Deborah A.P. Hersman
National Transportation Safety Board
Corporate Aviation Safety Seminar (CASS) 2006
May 10, 2006
This afternoon I am going to present the Board’s findings on two accidents: Montrose and Stuart. But first, I will quickly run through our on-going investigations without spending a lot of time discussing them.
The Montrose accident occurred on November 28, 2004, about 0958 Mountain Standard Time, when a Canadair CL-600 “Challenger” collided with the ground during take-off at the Montrose Regional Airport, Montrose, Colorado. The on-demand Part 135 charter flight was on an instrument flight rules flight plan, and instrument meteorological conditions prevailed. 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. Impact forces and a post-crash fire destroyed the airplane. Before the accident flight, the airplane had arrived at Montrose from Van Nuys, California. It taxied to the ramp and was parked for about 40 to 45 minutes with its auxiliary power unit running. The airplane was refueled during this time. A lineman stated that fluffy, wet, snow flurries were falling. A witness who was preparing his airplane for flight stated that there appeared to be snow on the accident airplane’s wings, but he could not tell how much. Although de-icing services were available and a lineman was on the ramp de-icing other airplanes, the accident fight crewmembers did not request de-icing services for the airplane. A witness stated he did not observe either the captain or the first officer conduct a tactile examination of the wing surfaces. One of the passengers stated that slushy clumps of snow slid off the fuselage and past his window while the airplane taxied for takeoff. The passenger seated on the right side of the cabin stated that during takeoff, the airplane lifted off and climbed 20 to 50 feet. He said the left wing then dropped abruptly and banked to an angle 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, then the airplane fell straight onto its nose. The airplane’s impact ground scar originated in the grass about 44 feet from the right edge of the runway.
Montrose Regional Airport sits at an elevation of 5,759 feet. The weather consisted of a few clouds at 500 feet, 900 feet overcast ceiling, visibility 1-1/4 mile, light snow and mist and calm winds. The temperature was 30 degrees Fahrenheit and the dew point was 28 degrees Fahrenheit. Snow began falling on the airport about 0730 and a NOTAM was issued advising that all surfaces had ¼-inch wet snow. About 0830, braking action was reported as fair.
The investigation found that there were no airframe, systems, or engine malfunctions. The safety issues identified during the investigation were the flight crew’s failure to follow the appropriate winter weather operating procedures as outlined by the operator, the airplane flight manual, and Federal regulations, and the flight crew’s apparent lack of understanding of the seriousness of the winter weather hazards that were present. The report also addressed the issue of crew resource management deficiencies, which were identified during the investigation, but were not directly causal to the accident.
Analysis of the available data for the accident airplane clearly shows the accident involves a case of upper wing surface ice contamination. Upper wing ice can take many forms, but all seriously degrade the lifting capability of an airplane.
The results of the performance study showed that the takeoff roll and acceleration of the accident airplane were consistent with a normal take-off. The timing of the 80-knot and V1 airspeed callouts recorded on the CVR were consistent with normal operation. The performance study also showed that the airplane had attained the proper speed at lift-off and theairplane lifted off between 4,000 – 4,600 feet down the runway, as expected in normal operations. The airplane had the proper pitch at liftoff, however the airplane then experienced an aerodynamic stall as the pitch was increased to the point of the stick pusher activation. During the onset of the stall, the airplane experienced a loss of roll control.
A Challenger airplane had experienced a similar take-off accident at Birmingham Airport in the United Kingdom in January of 2002, which was investigated by the United Kingdom Air Accident Investigations Board. This aircraft had a flight data recorder and the performance of the airplane in the Birmingham accident was very similar to the circumstances determined in the Montrose accident. The data showed that the take-off roll was normal, and immediately after lift-off the airplane rolled to the left despite a full right aileron and rudder input. The AAIB determined that the roll had resulted from the left wing stalling at an abnormally low angle of attack due to flow disturbance resulting from frost contamination of the wing.
The sparse ice is what we are most concerned about. This type of small, hard-to-see accumulation can result in aerodynamic penalties similar to those resulting from large accumulations. This type of small accumulation may worry some pilots; others, however may not see this a threat. Even smaller accumulations, the size of salt grains, have been shown to be capable of reducing lift enough to affect the take-off performance of airplanes. This type of accumulation is very hard to see, does not appear threatening, yet is still a danger. This type of accretion is best detected by using a tactile inspection of the wing.
Other decisions by the flight crew regarding winter weather operations were questionable, but they did not lead directly to this accident. For example, upon arriving in Montrose, the captain elected to upload 400 gallons of additional fuel into the airplane’s fuel tanks. Refueling increased the amount of time that the airplane remained parked on the ground, allowing for contamination to accumulate on the upper surfaces of the wing and horizontal stabilizer. This allowed cold-soaked fuel to come in contact with the upper wing surface when it was filled into the main wing tanks, further increasing the possibility that contamination could adhere to the wing upper surfaces.
Review of the cockpit voice recorder transcript indicated that the flight crew initially planned to depart from runway 35, which was a 10,000-foot long runway. However, because of snow removal operations on runway 35, the captain elected to depart from runway 31, which was a 7,500-foot long runway. Initially, the first officer informed the captain that the required runway length for take-off was about 8,000 feet. When the captain realized that runway 31 was not long enough, he asked the first officer to look up the required take-off runway length for the airplane in various configurations. Even though the airplane flight manual required that engine bleed air for anti-icing should be used in the conditions present at the time of the accident, the crew decided that, with no engine bleed air systems in use, the required runway length was 7,2000 feet. Even after the planning discussions, right before take-off roll, the captain changed the airplane’s configuration again, and did not discuss new performance data regarding this change. At no time did the flight crew consult the contaminated runway data. The presence of runway contamination increases the takeoff runway length required. Had the flight crew used the contaminated runway data as required by the company, with the appropriate airplane configuration, the take-off distance required would have been about 11,513 feet. In that case, the airplane would not have been permitted to take off from either runway until the runway contamination was cleared.
The captain and first officer were each trained and qualified under part 135 to perform their respective duties. The captain and first officer had also received instruction regarding winter weather operations during company indoctrination training within the last year. However, the captain and first officer had little or no experience operating airplanes in winter weather conditions such as those experienced on the day of the accident. In fact, a review of captain’s flight from 2000-2004, showed only 18 instances of operating in the northern half of the U.S. during winter months and a review of the weather data showed no precipitation similar to circumstances of the accident on those 18 days.
Review of CVR data revealed that both pilots failed to adhere to federal regulations and company policies. Specifically, the flight crew failed to confirm that a proper preflight inspection was conducted of the upper wing surfaces of the airplane for ice contamination. Further, the captain failed to have the airplane de-iced prior for takeoff; he failed to use the appropriate bleed air systems; he failed to use the contaminated runway data; he failed to confirm that take-off on the shorter runway was within the performance specifications of the airplane; and he failed to provide a required takeoff briefing, thus not maintaining the safety margins built into the briefing procedures that reinforce crew coordination and awareness of operational hazards.
The first officer failed to challenge the captain’s non-compliance with company procedures and federal regulations, thus failing to provide an independent evaluation and monitoring function by a second pilot that was required of his position. Part 135 operators are not required to train flight crewmembers in CRM.
On December 2, 2005, as a result of the investigation of the October 25, 2002 King Air crash near Eveleth, Minnesota that killed Senator Paul Wellstone, the NTSB issued a recommendation to the FAA to require that Part 135 on-demand charter operations establish and implement an FAA-approved CRM training program for their flight crews.
The FAA responded to the recommendation on April 12, 2004, that an aviation rulemaking committee was revising and improving Part 135, including requiring CRM training, and that the rulemaking committee had a 2-year charter with a notice of proposed rulemaking targeted for fiscal year 2005. The rulemaking has not yet been issued. The recommendation was therefore reiterated in the Montrose report and the status was changed to, “Open – Unacceptable Response”.
In the wake of the Montrose and Teterboro accidents, the issue of operational control, wet leases, and charter brokers have been addressed by FAA and DOT through various publications and meetings.1 The Safety Board has also dealt with appeals of FAA enforcement actions resulting from such activities that were deemed to be unsafe by FAA (Administrator v. Darby Aviation dba Alphajet International, Inc.). While FAA and DOT are making efforts to address several areas of concern, much of their guidance is not mandatory.
Under sanctioned FAA practices, certificate business names, or DBAs (“doing business as”) are permitted as long as they list the alternate names in their Operations Specifications (OpsSpecs). A review of the docket reveals that there are several DBAs associated with Air Castle, including Global Airways, Global Aviation, and California Airways. Air Castle was owned by a Winfair Aviation Group, which also owned several other companies including Hop-a-Jet. Hop-a-Jet leased the accident aircraft to Air Castle dba Global Aviation. In fact, an LA Times article on the accident 2 quoted an Air Castle official stating that Air Castle was a “paper company” owned by Jet Alliance, and a Hop-a-Jet official stated that the accident aircraft was leased to Jet Alliance. After the accident, all aircraft were removed form the Air Castle operating certificate and placed on another certificate issued to Worldwide Jet Charter, LLC. Jet Alliance is listed as a dba of Worldwide Jet. This recitation of corporate structure may not be entirely accurate because contained in the docket for this investigation, are three organizational charts, all of them different. The only thing that is clear is that it is all very confusing. This confusion does not mean that Air Castle was not safe; investigators, in fact, found that Air Castle was generally a safe operator. But it begs the question whether the FAA has the resources and the ability to oversee these complex business arrangements.
It has been a long-standing practice in Part 121 operations to reveal to the consumer the name of the carrier with operational control. DOT requirements in this area have resulted in transparency in the relationships between commuter airlines and major carriers, as well as code share arrangements.
The need for greater transparency in the operations of Part 135 air charter service is crucial. While transparency by itself will not prevent an accident caused by crew inexperienced in flying in winter conditions, it could go a long way to exposing safety weaknesses of some operators within the industry and prevent them from finding shelter under diverse and undisclosed corporate names.
As a result of the Montrose accident, the Board issued three recommendations. First, to the FAA to develop training depicting small amounts of contamination. Second, to the DOT to require that information about the flight be provided to the passenger. Third, to the FAA, re-iteration and re-classification of the recommendation to require CRM training for Part 135 on-demand charter operations.
The final accident I’ll discuss today is the Martinsville/Stuart King Air accident. On October 24, 2004, about 1235 eastern daylight time, a Beech King Air 200, operated by Hendrick Motorsports, Inc., crashed into mountainous terrain near Stuart, Virginia, during a missed approach to Martinsville/Blue Ridge Airport. The Part 91 flight was transporting Hendrick Motorsports employees and others to a NASCAR event in Martinsville, Virginia. The two flight crewmembers and eight passengers were killed, and the airplane was destroyed by impact forces and a post-crash fire. Instrument meteorological conditions prevailed for the flight.
The airplane departed Concord, NC, approached Martinsville from the south, and crossed over the BALES locator outer marker at 3,900 ft. After turning outbound to the holding pattern, the flight crew was cleared for the localizer runway 30 approach, and radar services were terminated. The airplane then turned towards BALES, but remained at 3,900 ft. The airplane eventually reached the proper descent altitude, but at a point well beyond the airport. Seven miles beyond the Martinsville airport, the airplane initiated a straight-ahead climb. Approximately one minute later, the crew transmitted that they were executing a missed approach. The airplane impacted terrain 12 seconds after this transmission from the crew. The accident occurred on Bull Mountain at an elevation of about 2,400 feet and near the extended centerline of the runway. Bull Mountain is located about 10 miles northwest of Martinsville Airport.
The airplane crossed BALES at 3,900 ft; however, it should have been at 2,600 feet. The airplane crossed over the airport at 2,600 feet, where the airplane should have been at 1,300 feet in a position to land.
When the airplane was over the runway and a landing was not possible, the flight crew should have initiated the missed approach and a climbing right turn back to BALES. Instead, the airplane continued a straight-ahead descent to the minimum descent altitude. Seven miles beyond the airport, the flight crew initiated a straight-ahead climb.Again, the climb should have incorporated a turn, and should have started above the runway.
The investigation focused on why the flight crew did not follow the localizer runway 30 approach at the Martinsville airport. The airplane was equipped with a GPS receiver that was IFR capable, but not certified for IFR navigation. GPS course guidance could have been selected on the pilot’s navigation display.
Post-accident interviews with company pilots revealed that the GPS was used for backup navigation and position awareness only. On this approach, pilots would typically program BALES and the airport as waypoints. They would fly the airplane to the first waypoint, BALES, and then fly to the next waypoint, the airport. By design, the GPS would autosequence from BALES to the airport as the airplane passed BALES. Once the airplane flew over the BALES waypoint, the GPS would then provide distance and navigation information to the airport waypoint.
If the Board had made a recommendation, we would likely have addressed the issue of TAWS. Like the Kirksville accident, this accident also occurred in October 2004, six months prior to the FAA requirement for TAWS went into effect. Had the accident aircraft been equipped with enhanced ground prox, this accident could have been prevented.
It was a pleasure to be here today and I look forward to working with you to improve aviation safety, the reason we are all here today. Thank you.
1 The FAA has issued the following: “Wet Lease Policy Guidance,” (proposed, 70 Federal Register 61684), “Responsibility for Operational Control During Part 135 Operations and the Use of a DBA,” (notice issued June 10, 2005) and “The Role of Air Charter Brokers in Arranging Air Transportation.” (notice issued October 8, 2004).2 “High-Profile Business Plane Crashes Belie Safety”, Los Angeles Times, Ralph Vartabedian, December 12, 2004.