Aircraft Accident Brief - Crash During Takeoff in Icing Conditions, Canadair, Ltd., CL-600-2A12, N873G

Montrose, Colorado
November 28, 2004

NTSB Number: AAB-06-03
NTIS Number: PB2006-108497
Adopted May 2, 2006
PDF

History of Flight

On November 28, 2004, about 0958 mountain standard time, a Canadair, Ltd., CL-600-2A12, N873G, registered to Hop-a-Jet, Inc., and operated by Air Castle Corporation doing business as Global Aviation Glo-Air flight 73, collided with the ground during takeoff at Montrose Regional Airport (MTJ), Montrose, Colorado. The on-demand charter flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135 on an instrument flight rules (IFR) flight plan. Instrument meteorological conditions prevailed, and snow was falling. Of the six occupants on board, the captain, the flight attendant, and one passenger were killed, and the first officer and two passengers were seriously injured. The airplane was destroyed by impact forces and postcrash fire. The flight was en route to South Bend Regional Airport (SBN), South Bend, Indiana.

Before the accident flight, the airplane had arrived at MTJ from Van Nuys Airport (VNY), Van Nuys, California, about 0910. Witnesses observed that the airplane had landed on runway 17, taxied to the ramp for fuel, and remained parked on the ramp at the fixed-base operator (FBO) for about 40 to 45 minutes with its auxiliary power unit (APU) running. According to a passenger, one of the pilots remained on board the airplane the entire time.

A pilot-certificated witness who was on the FBO ramp preparing his airplane for flight stated that he saw the accident airplane on the ramp. He stated that there appeared to be snow on the accident airplane's wings, but he could not tell how much. He made a comment about the contamination to his own co-pilot, and his co-pilot remarked to him that both the snow and the airplane's paint scheme were white. The pilot-certificated witness further stated he did not observe either the captain or the first officer conduct a tactile examination of the wing surfaces.

A lineman fueled the accident airplane at its single-point fuel filler port, which is located at the right-wing root, with 400 gallons of Jet A fuel; the fuel was pumped from a fuel truck that was kept outside and unheated. The lineman stated that he noticed ice on the airplane's nose landing gear area and slush-type ice on the wheels but did not look at the airplane's wings. The lineman stated that, while he fueled the airplane, one of its pilots stood near the wingtip. The lineman noted that the pilot seemed to be looking at the underside of the airplane near the right main landing gear but remained near the wingtip and then walked away when the fueling was completed. The lineman assumed the pilot left to go someplace warm because it was cold and "miserable" on the ramp. The lineman stated that fluffy, wet, snow flurries were falling and that he could see to only about the midfield point of the airport due to reduced visibility.

Personnel in the FBO office and a lineman who was on the ramp deicing other airplanes stated that the accident flight crewmembers did not request deicing services for the airplane and that none were provided. The FBO line service manager observed moderate snow was falling and melting upon contact with the ground.

According to the first officer's legal representative, due to the extent of his injuries, the first officer did not recall any of the circumstances or events regarding the accident flight and was unable to provide any information.

According to the cockpit voice recorder (CVR) transcript, while the airplane was parked on the ramp, at 0942:15, the captain asked the first officer, "how do you see the wings?" The first officer stated, "good," and the captain replied, "looks clear to me."

At 0949:02, during engine start procedures, the first officer asked the captain if he wanted engine bleeds open (on) or closed (off), and the captain replied that he wanted them open. The first officer stated, "yup. Okay so we need to a [sic] eight thousand foot of runway." The captain stated, "so it means [runway] three five."

The first officer announced over the airport's common traffic advisory frequency (CTAF) the crew's intention to taxi the airplane to runway 35. The airport operations manager, who was monitoring the frequency while operating a radio-equipped snowplow on that runway, advised the flight crew over the CTAF that snow removal was in progress on runway 35. The first officer asked how long it would take for the snow removal equipment to exit the runway, and the CVR recorded no reply. He repeated the question, and, again, no reply was recorded.

At 0953:31, the first officer stated, "oh well we gotta get out there anyway," and the captain replied, "well runway three one is here." According to the airport configuration diagram, the airplane was parked on the ramp adjacent to runway 31; the taxi distance from the airplane's parked location to runway 35 was approximately 1 mile.

At 0953:35, the first officer stated to the captain that runway 31 was 7,500 feet long, and the captain asked what length of runway would be needed for takeoff, "...let's say with the bleeds off." The first officer replied, "...that's seventy eight hundred [feet], I think...tenth [stage] closed." The captain asked, "six thousand [feet]?" The first officer replied, "seventy five ninety...seventy eight [hundred feet]."

The captain stated, "well we are between we are forty one thousand [pounds] so." The first officer replied, "sixty eight seventy five so right at seven thousand [feet], I guess. seventy two hundred [feet]?" The captain stated, "okay we can do that....okay. okay we'll go for [runway] three one, then. you agree?" The first officer then stated, "these number [sic] are always conservative anyway."

At 0954:54, the first officer contacted the Denver Air Route Traffic Control Center controller and received the flight's IFR clearance to SBN. The controller instructed the first officer to report back on his frequency after departure, the first officer acknowledged, and the controller received no further radio communication from the flight.

According to the passenger seated on the right side of the cabin, while the airplane taxied for takeoff, slushy clumps of snow and water slid down from the top of the fuselage and across his window. Another passenger stated he noticed water ran off the airplane's skin, "like it had taken a shower."

At 0957:32, the captain stated to the first officer, "you know what lets [sic] have the (engine) cowls and ah do a performance takeoff." At 0958:09, the captain stated, "set power." Ten seconds later, the first officer reported, "eighty knots." At 0958:32, the first officer stated, "there's vee one," followed by, "rotate." At 0958:39, the first officer asked, "want the gear up?" Immediately thereafter, the CVR recorded the sound of the stickpusher horn and the mechanical voice "bank angle" warning, followed by mechanical voice "five hundred" warning. The recording ended at 0958:46 with the sound of a loud rumble.

The passenger seated on the right side of the cabin stated that the airplane lifted off and climbed to about 20 to 50 feet, then the left wing dropped abruptly and banked to an angle he described as greater than the 7 o'clock position. He indicated that the right wing then dropped to about the 5:30 position, then the left wing dropped again. He stated that he heard a loud thump, his upper body was knocked into the aisle, and he was hanging by the seatbelt. He stated the airplane then fell straight onto its nose. Another passenger, who was seated on the left side of the cabin, estimated that the airplane had climbed to about 20 to 25 feet when the left wing initially "fell" as if "bricks had been dropped" on it, then it "violently slammed back to the right." He stated the left wing then banked back down and struck the ground, and the airplane's nose was down. He stated an explosion of dirt then came through the cabin from the front of the airplane.

One witness, who was west of the airport driving northbound on Highway 50, stated that he saw the airplane off to his right as it rolled on the runway. He indicated that the airplane was headed north but that the nose of the airplane turned sideways toward the right side of the runway and he then saw a flash of flame. He stated that the nose of the airplane faced east perpendicular to the direction of the runway and that the airplane slid along the ground in a northerly direction while smoke and flames came up behind it. Witnesses in a building near the departure end of the runway reported that they heard a loud "boom" and "whooshing" noise and that they looked out the window and saw the airplane on the ground in flames.

Probable Cause

The Board concludes that the probable cause of this accident was the flight crew's failure to ensure that the airplane's wings were free of ice or snow contamination that accumulated while the airplane was on the ground, which resulted in an attempted takeoff with upper wing contamination that induced the subsequent stall and collision with the ground. A factor contributing to the accident was the pilots' lack of experience flying during winter weather conditions.

Recommendations

For additional information on these recommendations, please refer to the safety recommendation letters.

New Recommendations

As a result of its investigation of this accident, the National Transportation Safety Board makes the following recommendation to the Federal Aviation Administration:

Develop visual and tactile training aids to accurately depict small amounts of upper wing surface contamination. Require all commercial airplane operators to incorporate these training aids into their initial and recurrent training. (A-06-42)

Also, the Safety Board makes the following recommendation to the Department of Transportation:

Require that, for 14 Code of Federal Regulations (CFR) Part 135 on-demand air taxi flights, the following information be provided to customers and passengers at the time the flight is contracted and at any point there is a subsequent change: the name of the company with operational control of the flight, including any "doing business as" names contained in the Operations Specifications; the name of the aircraft owner; and the name(s) of any brokers involved in arranging the flight. (A-06-43)

Previously Issued Recommendation Reiterated and Reclassified

As a result of its investigation of this accident, the National Transportation Safety Board reiterates the following recommendation, which was issued to the Federal Aviation Administration 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 a Federal Aviation Administration-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. (A-03-52)

On May 2, 2006, the Safety Board classified Safety Recommendation A-03-52 (previously classified "Open-Acceptable Response") "Open-Unacceptable Action."