July 31, 2008
NTSB Number AAR-11/01
NTIS Number PB2011-910401
Adopted March 15, 2011
On July 31, 2008, about 0945 central daylight time, East Coast Jets flight 81, a Hawker Beechcraft Corporation 125-800A airplane, N818MV, crashed while attempting to go around after landing on runway 30 at Owatonna Degner Regional Airport, Owatonna, Minnesota. The two pilots and six passengers were killed, and the airplane was destroyed by impact forces. The nonscheduled, domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 135. An instrument flight rules flight plan had been filed and activated; however, it was canceled before the landing. Visual meteorological conditions prevailed at the time of the accident.
The National Transportation Safety Board determines that the probable cause of this accident was the captain's decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing to the accident were (1) the pilots' poor crew coordination and lack of cockpit discipline; (2) fatigue, which likely impaired both pilots' performance; and (3) the failure of the Federal Aviation Administration (FAA) to require crew resource management (CRM) training and standard operating procedures (SOPs) for 14 CFR Part 135 operators.
The safety issues discussed in this report relate to the following: flight crew actions; lack of SOPs requirements for Part 135 operators, including CRM training and checklist usage; go-around guidance for turbine-powered aircraft; Part 135 preflight weather briefings; pilot fatigue and sleep disorders; inadequate arrival landing distance assessment guidance and requirements; Part 135 on-demand, pilot-in-command line checks; and cockpit image recording systems. Safety recommendations concerning these issues are addressed to the FAA.
As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:
Require manufacturers of newly certificated and in-service turbine-powered aircraft to incorporate in their Aircraft Flight Manuals a committed-to-stop point in the landing sequence (for example, in the case of the Hawker Beechcraft 125-800A airplane, once lift dump is deployed) beyond which a go-around should not be attempted. (A-11-18)
Require 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and Part 142 training schools to incorporate the information from the revised manufacturers' Aircraft Flight Manuals asked for in Safety Recommendation A-11-18 into their manuals and training. (A-11-19)
Require 14 Code of Federal Regulations Part 135 and 91 subpart K operators to establish, and ensure that their pilots adhere to, standard operating procedures. (A-11-20)
Require principal operations inspectors of 14 Code of Federal Regulations Part 135 and 91 subpart K operators to ensure that pilots use the same checklists in operations that they used during training for normal, abnormal, and emergency conditions. (A-11-21)
Require manufacturers and 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to design new, or revise existing, checklists to require pilots to clearly call out and respond with the actual flap position, rather than just stating, "set" or "as required." (A-11-22)
Work with the National Weather Service to revise Advisory Circular 00-24B, "Thunderstorms," by including explanations of the terms used to describe severe thunderstorms, such as "bow echo," "derecho," and "mesoscale convective system." (A-11-23)
Revise regulations and policies to permit appropriate use of prescription sleep medications by pilots under medical supervision for insomnia. (A-11-24)
Require 14 Code of Federal Regulations Part 135 and 91 subpart K pilots to receive initial and recurrent education and training on factors that create fatigue in flight operations, fatigue signs and symptoms, and effective strategies to manage fatigue and performance during operations. (A-11-25)
Review the policy standards for all common sleep-related conditions, including insomnia, and revise them in accordance with current scientific evidence to establish standards under which pilots can be effectively treated for common sleep disorders while retaining their medical certification. (A-11-26)
Increase the education and training of physicians and pilots on common sleep disorders, including insomnia, emphasizing the need for aeromedically appropriate evaluation, intervention, and monitoring for sleep-related conditions. (A-11-27)
Actively pursue with aircraft and avionics manufacturers the development of technology to reduce or prevent runway excursions and, once it becomes available, require that the technology be installed. (A-11-28)
Inform operators of airplanes that have wet runway landing distance data based on the British Civil Air Regulations Reference Wet Hard Surface or Advisory Material Joint 25X1591 that the data contained in the Aircraft Flight Manuals (and/or performance supplemental materials) may underestimate the landing distance required to land on wet, ungrooved runways and work with industry to provide guidance to these operators on how to conduct landing distance assessments when landing on such runways. (A-11-29)
Require that 14 Code of Federal Regulations Part 135 pilot-in-command line checks be conducted independently from other required checks and be conducted on flights that truly represent typical revenue operations, including a portion of cruise flight, to ensure that thorough and complete line checks, during which pilots demonstrate their ability to manage weather information, checklist execution, sterile cockpit adherence, and other variables that might affect revenue flights, are conducted. (A-11-30)
Require 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to ensure that terrain avoidance warning system-equipped aircraft in their fleet have the current terrain database installed. (A-11-31)
As a result of its investigation of the October 25, 2002, accident in which an Aviation Charter, Inc., King Air A100 airplane lost control and impacted terrain in Eveleth, Minnesota, the National Transportation Safety Board issued the following safety recommendation to the Federal Aviation Administration (FAA) on December 2, 2003:
Require that 14 Code of Federal Regulations (CFR) Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement an [FAA]-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. (A-03-52)
Safety Recommendation A-03-52 (previously classified "Open-Unacceptable Response") is classified "Closed-Acceptable Action" in this report, and this classification is discussed in section 2.3.1.