NTSB Identification: ERA12LA401
14 CFR Part 91: General Aviation
Accident occurred Monday, June 18, 2012 in Atlanta, GA
Probable Cause Approval Date: 02/19/2014
Aircraft: BEECH 400A, registration: N826JH
Injuries: 2 Serious,2 Minor.
NTSB investigators may have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
The second-in-command (SIC) was the pilot flying for most of the flight (takeoff, climb, cruise, and descent) and was in the left seat, while the pilot-in-command (PIC) was the pilot monitoring for most of the flight and was in the right seat. Before takeoff, the PIC calculated reference speed (Vref) for the estimated landing weight and flaps 30-degree extension was 120 knots, with a calculated landing distance of 3,440 ft. Further, before takeoff, there were no known mechanical difficulties with the brakes, flaps, antiskid, or traffic alert and collision avoidance (TCAS) systems. After takeoff and for most of the flight, the PIC coached/instructed the SIC, including instructions on how to set the airspeed command cursor, a request to perform the after-takeoff checklist, and a comment to reduce thrust to silence an overspeed warning aural annunciation. When the flight was northwest of Dekalb Peachtree Airport (PDK), Atlanta, Georgia, on a right base leg for a visual approach to runway 20L with negligible wind, air traffic controllers repeatedly announced the location and distance of a Cessna airplane (which was ahead of the Beech 400A on a straight-in visual approach to runway 20R). Because the Beech 400A flight crew did not see the other airplane, the controllers appropriately instructed them to maintain their altitude (which was 2,300 ft mean sea level [msl]) for separation until they had the traffic in sight; radar data indicated the Beech 400A briefly descended to 2,200 ft msl then climbed back to 2,300 ft msl. According to the cockpit voice recorder (CVR) transcript, at 1004:42, which was about 12 seconds after the controller instructed the Beech 400A flight crew to maintain altitude, the on board TCAS alerted "traffic traffic." While the Beech 400A did climb back to 2,300 ft msl, this was likely a response to the air traffic control (ATC) instruction to maintain altitude and not a response to the TCAS "traffic traffic" warning. At 1004:47, the CVR recorded the SIC state, "first degree of," likely referring to flap extension, but the comment was not completed. The CVR recorded an immediate increase in background noise, which was likely due to the landing gear extension. The PIC then advised the local controller that the flight was turning onto final approach. The CVR did not record any approach briefing or discussion of runway length or Vref speed.
The PIC stated in a postaccident interview that he took control of the airplane during the base leg on approach to PDK. This likely occurred at 1005:05, when the CVR recorded the PIC state, "let me see a second"; however, the transfer was not explicitly verbalized. According to the CVR transcript, at 1005:08, the controller advised the Cessna pilot that the Beech 400A had just flown over his airplane, which the Cessna pilot confirmed; about that time, radar data indicated that the Beech 400A was at 2,400 ft msl, and the Cessna was at 1,800 ft msl. However, both the SIC and the PIC of the accident airplane erroneously believed the Cessna was 300 ft above them. The PIC of the accident airplane reported that because of the perceived location of the traffic conflict, he initiated a right turn and descent for the runway without seeing the Cessna and contrary to the instructions from the controller. During the approach, the enhanced ground proximity warning system (EGPWS) sounded the aural caution "sink rate sink rate" and also the aural warning "pull up pull up" several times. The CVR did not record comments from either flight crewmember about the cautions or warnings; they performed no maneuvers in response to the cautions or warnings and elected to continue the approach to the runway rather than perform a go-around, which is what they should have done after they evaluated the situation and per the Flight Manual Supplement. At the last recorded EGPWS position (.5 nautical mile [nm] from the displaced threshold and 153 ft above the displaced threshold elevation of runway 20L), the calculated groundspeed was 194 knots, and the descent rate was greater than 2,150 ft per minute.
During postaccident interviews, neither flight crewmember could recall the airspeed during the approach; however, the PIC reported that he believed the airplane was high and fast on approach, which is consistent with his comment of "way too fast" recorded on the CVR. Witnesses, including PDK tower controllers, reported that the airplane appeared to be fast on approach, and the touchdown point on the runway was consistently reported to be about abeam the very high frequency omnidirectional range/distance measure equipment navigation aid on the airport, which allowed for about 2,970 ft of runway remaining. After touchdown, an unidentified crewmember called for deployment of the thrust reversers, and the SIC called for deployment of the speed brakes. The PIC reported applying the wheel brakes, but the airplane did not decelerate as expected. He stated that he released and then reapplied the wheel brakes with maximum force, again without effect. During a postaccident interview, he attributed the inability to stop the airplane to be a malfunction of the normal brake system; however, both passengers in the accident airplane reported hearing sounds consistent with brake application during the landing roll. Further, skid marks alternating light and dark in color were found on the runway, which are indicative of brake application and antiskid release. The airplane departed the end of the runway and came to rest about 800 ft from the departure end of the runway adjacent to the airport boundary fence. The PIC reported in a postaccident interview that after the accident, he set the airplane back to takeoff configuration.
Given the observed touchdown point, the retracted flaps position, and the excessive speed during the approach, the airplane would not have been able to stop on the runway. Although the PIC reported that he positioned the flap selector to the 30-degree position during the approach and it was found in that position during the investigation, postaccident inspection of the flap system components indicated that the flaps were retracted. The CVR recorded the SIC begin a command to extend the flaps to the first notch; however, the PIC did not verbally respond to the incomplete command for flaps to be set, the before-landing checklist was not verbalized, and there was no discussion of flap position. While the speed during the final portion of the approach and at touchdown could not be determined, it is unlikely the airplane decelerated to or below the maximum 30-degree flap extension speed of 165 knots before touchdown, given that the airplane's groundspeed was 194 knots when the airplane was .5 nm from the displaced runway threshold. Further, operation of the airplane with 30 degrees of flaps extended at speeds in excess of the maximum allowable speed would have resulted in noticeable vibration; the passengers reported that they did not notice anything unusual about the flight until landing. The estimated high airspeed at landing reported by witnesses also indicated that the flaps were not extended because the flaps set in the 30 degree position would have resulted in aerodynamic deceleration. Additionally, no evidence of preimpact failure or malfunction of the flap system components was noted. Therefore, the as found position of the flap selector most likely occurred after the airplane came to rest and not during flight as reported by the PIC. Calculations by the airplane manufacturer indicate that in the configuration of the airplane on approach (flaps retracted), any speed greater than 142 knots would have resulted in an inadequate distance remaining to stop the airplane from the observed touchdown point.
Postaccident examination and testing of the brake and antiskid system components revealed no evidence of preimpact failure or malfunction, even though the PIC reported that the inability to stop the airplane was caused by a malfunction of the wheel brake system. Further, alternating light and dark-colored marks on the runway indicated braking action and antiskid release of brake pressure consistent with normal operation of both systems. The lack of deceleration was most likely the result of the airplane being at an excessive airspeed with the flaps retracted, rendering a light weight-on-wheels condition and, thus, reduced wheel braking. While the light weight-on-wheels condition could have prevented the deployment of the thrust reversers and speed brakes, it is also possible that the flight crew did not deploy the thrust reversers and speed brakes, despite the comments recorded on the CVR. The PIC's intentional action of setting the airplane in takeoff configuration after the accident prevented the conclusive determination of the thrust reverser and speed brake settings. The deployment of the speed brakes would have increased weight on wheels, resulting in increased braking action.
In a postaccident interview, the PIC stated that he did not consider performing a go around because he did not see the Cessna that was landing on runway 20R. However, several factors should have necessitated a go-around. First, the accident airplane's excessive airspeed was characterized by both the PIC and witnesses as fast. The investigation could not determine the accident airplane's airspeed at touchdown; however, the as-found position of the horizontal stabilizer pitch trim closely matched the position it would have been set to at the last groundspeed value recorded by the EGPWS (194 knots, determined at a point .5 nm from the displaced runway threshold), which was in excess of the calculated Vref speed of 120 knots. At 1005:28, the CVR recorded the PIC state that the airplane was "way too fast," indicating his awareness of the excessive airspeed. Second, the excessive rate of descent that caused the EGPWS to sound the sink rate alarm indicated an unstabilized approach. Third, Flight Manual Supplement 206 to the Airplane Flight Manual states that when an aural "pull up" warning occurs, the flight crew should level the wings, add maximum power, increase pitch to 15 degrees nose up, retract flaps if extended, and climb at the best angle of climb speed. The flight crew did not take these actions in response to the warning. Finally, the runway distance remaining (of about 2,970 ft) at the touchdown point was inadequate for the airplane to stop based on the PIC's preflight calculations and postaccident calculations. Based on the airplane configuration at touchdown, any speed greater than 142 knots would have resulted in a landing overrun. While the PIC recognized the excessive airspeed, neither pilot responded to the excessive airspeed, excessive rate of descent, the EGPWS system alarms, or the insufficient runway remaining to land and called for a go around, even though the airplane had sufficient altitude and airspeed to safely do so.
The flight crew also demonstrated poor crew resource management (CRM), evidenced by poor communication, lack of crew monitoring, and lack of situation awareness. Regarding poor communication, the PIC's statement of "let me see a second" likely indicated the point when he took control of the airplane from the SIC and deviated from the standard "my airplane" transfer of control command. Further, the flight crew's actions while on the base leg, including the flight crew's failure to adhere to instructions from air traffic controllers not to descend until the Cessna traffic was in sight, show a lack of crew monitoring and cross-checking between the PIC and SIC, important concepts of CRM to ensure the highest levels of safety. Although the SIC reminded the PIC that they were not to descend, the PIC did not respond, and the SIC briefly descended then returned to the appropriate altitude. Further, the PIC and SIC both exhibited poor situation awareness throughout the accident flight. First, they were not able to accurately visualize their position in relation to the Cessna, despite repeated communication from the controller announcing the location and altitude of the Cessna. The PIC and SIC apparently did not realize that the tower transmission to the Cessna of "five eight echo that previous traffic's a mile off your right side [2,300 msl] indicated" was a reference to them since they were at the altitude the transmission described. Second, the on board TCAS issued an audible and visual alert regarding the Cessna, but neither the PIC nor the SIC was able to accurately determine the Cessna's altitude and location despite the information that the TCAS and ATC provided. This lack of situation awareness was likely caused by the SIC's lack of proficiency in the airplane during the accident flight. His lack of proficiency (evidenced by his inability to locate and set the airspeed command cursor, his failure to perform the after-takeoff checklist, the overspeed warning exceedance after takeoff, and his inability to get the vertical speed command to work during the descent) led the PIC to coach/instruct him for most of the flight, which likely distracted the PIC from his pilot monitoring duties, reducing his situation awareness.
Further, the flight crewmembers demonstrated unprofessional behavior, evidenced by a lack of checklist usage. The SIC's lack of experience in the make and model airplane demanded extra vigilance regarding the use of checklists, which did not occur. Before departure, the CVR did not record the use of a before-takeoff checklist; the CVR recorded the pilots stating some individual pre-takeoff items but not as part of a clear challenge/response checklist. In addition, the approach and before-landing checklists and the transfer of control of the airplane from the SIC to the PIC were not explicitly verbalized. Further, the SIC asked for the descent checklist, to which the PIC responded, "hang on a second"; the complete checklist was not verbalized, and there was no challenge and response. Although not required for Part 91 flights, checklists are universally recognized as basic safe aviation practices.
The National Transportation Safety Board determines the probable cause(s) of this accident to be: The flight crew's failure to obtain the proper airspeed for landing, which resulted in the airplane touching down too fast with inadequate runway remaining to stop and a subsequent runway overrun. Contributing to the accident were the failure of either pilot to call for a go-around and the flight crew's poor crew resource management and lack of professionalism. Full narrative available
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