3/15/2011 12:00 AM
On March 15, 2011, the National Transportation Safety Board held a Board Meeting to discuss and adopt the Aviation Accident Report relating to the crash on landing of a Hawker Beechcraft BAE 125-800A in Owatonna, Minnesota on July 31, 2008.
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 investigation found that the pilots were properly certificated and qualified under federal regulations.
- The investigation found that the accident airplane was properly certificated, equipped, and maintained in accordance with federal regulations. Examinations of the recovered components revealed no evidence of any preimpact structural, engine, or system failures. The airplane was within normal weight and balance limitations.
- The accident was not survivable.
- The captain allowed an atmosphere in the cockpit that did not comply with well-designed procedures intended to minimize operational errors, including sterile cockpit adherence, and this atmosphere permitted inadequate briefing of the approach and monitoring of the current weather conditions, including the wind information on the cockpit instruments; inappropriate conversation; nonstandard terminology; and a lack of checklist discipline throughout the descent and approach phases of the flight.
- The flight crewmembers exhibited poor aeronautical decision-making and managed their resources poorly, which prevented them from recognizing and fully evaluating alternatives to landing on a wet runway in changing weather conditions, eroded the safety margins provided by the checklists, and degraded the pilots' attention; thus, increasing the risk of an accident.
- The airplane touched down within the target touchdown zone and at the recommended touchdown speed, and the captain likely applied sufficient pressure on the brakes during the initial part of the landing roll to take full advantage of the available runway friction, but he failed to immediately deploy the lift-dump system after touchdown in accordance with company procedures, which negatively affected the airplane's deceleration.
- If the captain had continued the landing and accepted the possibility of overrunning the runway instead of attempting to execute a go-around late in the landing roll, the accident most likely would have been prevented or the severity reduced because the airplane would have come to rest within the runway safety area.
- Establishing a committed-to-stop point in the landing sequence beyond which a go-around should not be attempted for turbine-powered aircraft would eliminate ambiguity for pilots making decisions during time-critical events.
- No evidence exists that reverted rubber or dynamic hydroplaning occurred.
- If, as a 14 Code of Federal Regulations Part 135 operator, East Coast Jets had been required to develop standard operating procedure and its pilots had been required to adhere to them, many of the deficiencies demonstrated by the pilots during the accident flight (for example, inadequate checklist discipline and failure to conduct an approach briefing) might have been corrected by the resultant stricter cockpit discipline.
- The first officer might have been used more effectively and the pilots might have performed better during the accident flight if they had received formalized crew resource management (CRM) training with stated standards like those required for 14 Code of Federal Regulations Part 121 operations, and, if the final rule, "Crew Resource Management Training for Crewmembers in Part 135 Operations," published on January 21, 2011, in 76 Federal Register 3831, had been in place before the accident flight, it might have addressed the CRM deficiencies exhibited by the flight crew.
- The Federal Aviation Administration (FAA) principal operations inspector for East Coast Jets was not familiar with the company's out-sourced training, and his oversight of the company could have been improved by communicating with Simcom and the FAA training center program manager for Simcom and ensuring that the checklists used during training were consistent with those used during operations.
- Maintaining consistency between the checklists used during training and those used during actual 14 Code of Federal Regulations Part 135 and 91 subpart K operations is essential to avoiding confusion about checklist usage and execution.
- Clearly stating and responding to the intended flap setting, rather than just stating, "set" or "as required," during all checklists would eliminate confusion about an airplane's configuration during critical phases of flight, such as landing.
- The captain did not obtain any forecast weather information for the flight route or the area surrounding Owatonna Degner Regional Airport (OWA); therefore, he did not have all of the weather information he needed to ensure that he could make a safe flight into OWA.
- If the captain had obtained a weather briefing from a National Weather Service-certificated weather briefer, the pilots would have had a more complete outlook of weather conditions along the flight route and at the destination airport, and they would have been alerted to the possibility that they would have to land on a wet runway in severe weather conditions.
- Guidance that explains terms related to severe thunderstorm conditions would help pilots better understand such conditions, which would allow them to make better-informed decisions regarding taking off or continuing flight when these types of conditions exist.
- Both pilots' performance was likely impaired by fatigue that resulted from their significant acute sleep loss, early start time, and possible untreated sleep disorders, and fatigue might have especially degraded the captain's performance and decision-making abilities when he had to decide while under time pressure whether to continue the landing or initiate a go-around.
- Although the first officer took a prescription sleep aid for which he did not have a prescription the night before the accident, because of the short duration of its effects for most individuals, it is unlikely that the use of this medication degraded the first officer's performance at the time of the accident, which occurred about 12 hours after he took the medication.
- Allowing civil aviation pilots who have occasional insomnia to use prescription sleep medications that have been proven safe and effective would improve these pilots' sleep quality and operational abilities.
- Educating and training pilots on fatigue-related issues could prevent pilots from operating flights while impaired by fatigue.
- Formal guidance on how pilots can be treated for common sleep disorders while retaining their medical certification could help mitigate fatigue-related accidents and incidents.
- The wet runway landing distances provided in aircraft flight manuals or performance supplemental materials that are based on the braking coefficients defined by the British Civil Air Regulations Reference Wet Hard Surface and Advisory Material Joint 25X1591 can be significantly shorter than the actual distances required to stop on some wet, ungrooved runways.
- Title 14 Code of Federal Regulations Part 135 pilot-in-command line-check requirements are not adequate because they allow more than one required inspection to be conducted simultaneously and do not require that the line checks be conducted on flights that truly represent typical revenue operations; thus, the efficacy of line checks to promote and enhance safety is minimized, and pilots have limited opportunities to demonstrate their ability to manage weather information, checklist execution, sterile cockpit adherence, and other variables that might affect revenue flights.
- Although the enhanced ground proximity warning system terrain database had not been updated to the most current version, the outdated database was not a factor in the accident.
- A lightweight recording system conforming to European Organization for Civil Aviation Equipment ED-155, "Minimum Operational Performance Specification for Lightweight Flight Recorder Systems," would have helped determine the flight crew's actions during the landing and subsequent go-around attempt, including, but not limited to, whether they silently conducted checklists (partially or completely), which flap settings they selected, and how much braking effort they made upon landing.
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 to require crew resource management training and standard operating procedures for Part 135 operators.
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.
- 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  into their manuals and training.
- 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.
- 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.
- 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."
- 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."
- Revise regulations and policies to permit appropriate use of prescription sleep medications by pilots under medical supervision for insomnia.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Require Part 121, 135, and 91 subpart K operators to ensure that terrain awareness and warning system-equipped aircraft in their fleet have the current terrain database installed. (A-11-XX)
Recommendation Classified in this Report:
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)
Safety Recommendation A-03-52 (previously classified "Open—Unacceptable Response") is classified "Closed—Acceptable Action."