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Crash During Attempted Go-Around Reveals Safety Shortcomings

Thu, May 12, 2011 — David Evans

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The fatal crash of a business jet points to the need for decision points during landing that are analogous to those in takeoff.

For example, there is V1 in takeoff, the critical engine failure speed at which there is enough runway remaining to stop the airplane. Beyond V1, the takeoff must be continued on the remaining engine(s). Indeed, there are a host of speed thresholds used during takeoff (VR, V4, etc.) and for the cruise portion of flight (VA, VS, etc.). The definitions of these V speeds is not important for purposes of this discussion; the essential point is that there are not equivalent speeds used in landing. In the case of this accident, the need for either a speed at which one must stop (VS) or stay on the ground (VG) might have prevented the late decision to go-around, which led to the crash.

The case involves a July 2008 fatal accident of an East Coast Jets business aircraft, a Hawker Beechcraft 125-800A, at Owatonna, MN. The two pilots and six passengers aboard were killed. The tragedy was recently the subject of a National Transportation Safety Board (NTSB) hearing.

The accident airplane

“This is the fourth major accident in three years in which the pilots could not stop after landing,” declared NTSB Chairman Deborah Hersman.

From the cockpit voice recorder, the flight crew appeared hurried; an approach briefing was not conducted and the before-landing checklist was only partially completed. Flaps were not deployed, and neither pilot called out “FLAPS – SET”. The captain was the pilot flying and the first officer was performing pilot monitoring duties, but in this case that responsibility was not executed. The first officer was engaged in radio calls to the Owatonna fixed base operator (FBO) when the aircraft was below 10,000 feet altitude. Such nonessential activity is a violation of the sterile cockpit rule. There was no landing distance assessment before landing on the wet runway. The wet, ungrooved pavement increased the distance at which the airplane could be safely brought to a stop. An 8 knot tailwind also contributed to the difficulty in slowing the aircraft.

According to the NTSB’s Malcolm Brenner, neither pilot had adequate sleep the night before, and the poor cockpit resource management, decision-making, coordination and late decisions during landing were symptoms consistent with fatigue. He noted that the Federal Aviation Administration (FAA) published a proposed rule on pilot fatigue, but this initiative addressed rest and duty requirements for Part 121 scheduled airline pilots only. The proposed rule does not cover Part 135 operations of the type flown by East Coast Jets. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)

The airplane was not equipped with engine thrust reversers. A lift-dump function would extend the flaps to 75º, thereby increasing drag, but the captain delayed moving the airbrake handle beyond the OPEN position, which was necessary to engage lift-dump.

Rolling rapidly to the end of the runway, at 17 seconds after touchdown the captain initiated a go-around. The airplane lifted off the runway, struck a localizer antenna, and the airplane skidded to a halt about 2,100 feet past the runway end.

“If they had stayed on the ground and overrun the tarmac 100 to 300 feet, there probably would not have been fatalities,” Hersman observed.

If the captain had stayed on the ground, an overrun would have occurred which was probably survivable

According to the NTSB:

“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.”

Of the 14 recommendations issued by the NTSB to the FAA as a result of this accident, the very first one dealt with a committed-to-stop distance for all jets, not just small business/charter aircraft, to include transport-category airliners:

“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.”

On takeoff, beyond V1 speed the airplane should be gotten airborne as there is not sufficient runway to stop after that threshold is passed. There is no equivalent for landing, such as VG for “stay on the ground” because it is too late for a go-around. The absence of such cues on landing – equivalent to such lifesaving V speeds on takeoff – raises an obvious question: what other basic safety provisos are missing and awaiting an accident to be revealed?


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