Aviation Accident Summaries

Aviation Accident Summary ANC04FA026

Ft. Lauderdale, FL, USA

Aircraft #1

N24RZ

Gates Learjet 25B

Analysis

The captain and first officer were conducting a CFR Part 135 on-demand charter flight, returning two passengers to the accident airplane's base airport. The multi-destination flight originated from the accident airport, about 16 hours before the accident. On the final leg of the flight, the flight encountered stronger than anticipated headwinds, and the first officer voiced his concern several times about the airplane's remaining fuel. As the flight approached the destination airport, the captain became concerned about having to fly an extended downwind leg, and told the ATCT specialist the flight was low on fuel. The ATCT specialist then cleared the accident airplane for a priority landing. According to cockpit voice recorder (CVR) data, while the crew was attempting to lower the airplane's wing flaps in preparation for landing, they discovered that the flaps would not extend beyond 8 degrees. After the landing gear was lowered, the captain told the first officer, in part: "The gear doors are stuck down.... no hydraulics." The captain told the first officer: "Okay, so we're gonna do, this is gonna be a ref and twenty...All right, probably not going to have any brakes..." According to a ATCT specialist in the control tower, the airplane touched down about midway on the 6001-foot long, dry runway. It continued to the end of the runway, entered the overrun area, struck a chain link fence, crossed a road, and struck a building. During a postaccident interview, the captain reported that during the landing roll the first officer was unable to deploy the airplane's emergency drag chute. He said that neither he nor the first officer attempted to activate the nitrogen-charged emergency brake system. The accident airplane was not equipped with thrust reversers. A postaccident examination of the accident airplane's hydraulic pressure relief valve and hydraulic pressure regulator assembly revealed numerous indentations and small gouges on the exterior portions of both components, consistent with being repeatedly struck with a tool. When the hydraulic pressure relief valve was tested and disassembled, it was discovered that the valve piston was stuck open. The emergency drag chute release handle has two safety latches that must be depressed simultaneously before the parachute will activate. An inspection of the emergency drag chute system and release handle disclosed no preaccident mechanical anomalies.

Factual Information

HISTORY OF FLIGHT On February 20, 2004, about 2157 Eastern standard time, a Gates Learjet 25B airplane, N24RZ, sustained substantial damage when it struck a fence and building during a runway overrun while landing at the Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The airplane was being operated by Skylink Jets, Fort Lauderdale, as a Title 14, CFR Part 135, on-demand charter flight returning two flight nurses to Fort Lauderdale when the accident occurred. Of the four people aboard, the airline transport captain sustained serious injuries, the airline transport first officer sustained minor injuries, and the two flight nurses were not injured. Visual meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan was filed. The accident leg of the flight originated at the Luis Munoz Marin International Airport, San Juan, Puerto Rico, about 2033 Atlantic standard time. According to the two flight nurses aboard, the flight originated at the Fort Lauderdale Executive Airport about 0530, on the day of the accident. The flight flew to Providenciales, Turks and Caicos Islands, and to Barbados, where a patient was picked up and flown to Caracas, Venezuela. After delivering the patient to Caracas, the flight flew to San Juan, Puerto Rico, where the airplane was refueled for the return flight to the Fort Lauderdale Executive Airport. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on February 20, about 2300, a Fort Lauderdale Executive Airport Air Traffic Control Tower (ATCT) specialist reported that as the accident airplane passed through Miami Approach Control's airspace, the crew requested to proceed direct to the Fort Lauderdale Executive Airport to avoid a low fuel situation. The flight was cleared direct to the Fort Lauderdale Executive Airport. The ATCT specialist said that as the accident airplane entered a left downwind for runway 08, the crew reported low fuel. The ATCT specialist instructed another airplane already on final approach to runway 08 to go around, and then immediately cleared the accident airplane for landing on runway 08. She said that as the accident airplane approached the runway, it touched down about midway on the 6001-foot long, dry runway. It continued to the end of the runway, entered the overrun area, struck a chain link fence, crossed a road, and struck a building. During an interview with the NTSB IIC on February 24, the captain of the accident airplane reported that after an uneventful takeoff from San Juan, the flight climbed to an initial en route altitude of 39,000 feet msl, and then to 41,000 feet msl as the flight progressed towards Fort Lauderdale. The captain said that while en route to Fort Lauderdale, the flight encountered stronger than anticipated headwinds, which reduced the flight's maximum fuel range. He said that as the flight neared the Fort Lauderdale Executive Airport, the flight's destination airport, the first officer voiced his concern about the airplane's remaining fuel condition. The captain said the first officer was mostly concerned about a 300 pound discrepancy between what the airplane's fuel gauges were reporting, and what the airplane's cockpit mounted fuel totalizer was reporting. The captain said that he assured the first officer that they had enough fuel to reach Fort Lauderdale. The captain said that as they maneuvered the airplane into a left downwind for landing on runway 08, they overheard the ATCT specialist clear a Cessna 172 for a long final approach for runway 08. The captain said he was now concerned about having to fly an extended downwind leg in order to provide adequate spacing, so he had the first officer tell the ATCT specialist the flight was low on fuel, in order to obtain immediate landing priority. The captain said that as his airplane entered a left base, he instructed the first officer to extend the airplane's wing flaps to 8 degrees. He then instructed the first officer to extend the airplane's wing flaps to 20 degrees, followed shortly thereafter by a request to lower the airplane's landing gear. He said that after the flaps were extended and the landing gear lowered, the first officer reported, "three greens, and two reds," indicating that the landing gear was safely down and locked, but the inboard landing gear doors had remained open during the landing gear extension. As the captain turned the airplane from a left base to final approach, he instructed the first officer to apply full flaps. He said that as the first officer applied full flaps, the first officer stated, "I think we only have 8 degrees flaps," followed by the first officer's comment concerning either low, or no hydraulic pressure. The captain said that he placed the auxiliary hydraulic pump to the "on" position, and continued the approach. He said that after touchdown, as he applied the brakes, the brakes failed to respond. He then instructed the first officer to activate the airplane's emergency drag-chute, but the first officer was unable to pull the handle up in order to release the drag-chute. He said that the airplane tracked down the centerline on the runway until reaching the end, and he then veered the airplane slightly to the left to avoid obstructions at the end of the runway. The airplane continued for an additional 1,748 feet beyond the end of the runway before striking a fence, crossing a four lane road, and hitting a concrete building. The captain reported that during the landing roll, neither he nor the first officer attempted to activate the nitrogen-charged emergency brake system. During the on scene portion of the investigation, the airplane's cockpit voice recorder (CVR) was recovered from the wreckage, and was forwarded to the NTSB laboratory in Washington, DC, for review. According to the CVR data, the captain was the flying pilot on the flight from San Juan, Puerto Rico to Fort Lauderdale, and the first officer was the non-flying pilot. At 2124, as the flight neared Fort Lauderdale, while in level cruise flight at 41,000 feet msl, the first officer asked the captain, in part: "Eight hundred pounds a side?" The captain responded: "Huh?" The first officer stated again: "Eight hundred pounds a side.... What? ... Hello...Are we doin' okay?" The captain then said: "Yeah, we're gonna come down like a bat out of hell and we're gonna cancel at eighteen." The first officer said: ".... get us in there...huh? ... It's too (expletive) close." The captain said: "Naw it's not, we're fine." The first officer said, again: "It's too (expletive) close." The captain then said: "We're gonna go down to idle pretty soon." At 2129, the first officer reported to the Miami ARTCC specialist on duty: "...Lear 24RZ is leaving 41,000 for 6,000." The sound of the airplane's engine's being reduced can be heard within the cockpit. The captain said: "You see, we're down to idle now." The first officer asked the captain: "Just ask (expletive) direct FXE right now?" The captain responded to the first officer's question by saying: "He's not going to give it to you, but you can ask him for it." At 2130, the first officer then contacts the Miami Center specialist, and said: "ah... Center, Lear 24RZ, we'd like to go direct, ah to request direct FXE at this time." The Miami Center specialist responded by saying: "24RZ uh, for now direct DEKAL (intersection), direct Fort Lauderdale Exec." The first officer responded by saying: "DEKAL direct Exec., Romeo Zulu." At 2131, the first officer tells the captain: "(expletive) 80 miles away.... Is it enough fuel?" The captain said: "What happened?" The first officer said: "Just want to see what fuel counters sum is... four, three, five, three." The captain said: "I think there's more fuel than what this is saying." At 2134, the captain contacted the Miami Center specialist, and said: "Sir, we are trying to avoid a minimum fuel situation... we'd like to get direct FXE. When we get below eighteen, we'll cancel and give you the airspace." The Miami Center specialist said: "24RZ, you are wanting into approach uh, VFR?" The captain said: "Uh, that's affirmative. Its, its VFR at Executive." The Miami Center specialist said: "...and November 24RZ, cleared direct to Executive." The first officer is then said: "He doesn't care, (expletive) it." At 2136, the captain tells the first officer: "It's called the art of the deal... Hey, we're fine...I think we got more in here than what this is saying." The first officer said: "You think?" The captain responded: "Yeah, by three hundred pounds." Between 2136 and 2139, the accident flight continued northbound towards the Fort Lauderdale Executive Airport, at 17,500 feet msl, and about 35 miles southeast of the airport. During this time, the flight was under control of Miami Center. The captain continued to monitor radio transmissions from Miami Center, and the first officer attempted to contact the Fort Lauderdale ATCT specialist using a second radio, but the tower personnel reported a very weak, unreadable radio signal. The captain contacted the Miami Center specialist and said: "24RZ cancel IFR, direct to Executive." The Miami Center specialist said: "N24RZ, roger on the cancellation. Maintain VFR. Remain on the present code for flight following." The first officer told the captain: "Looks like 7 minutes." At 2140, the captain again attempted to contact Fort Lauderdale ATCT specialist using a second radio, and said, in part: "Ah yes, is [runway] 26 available tonight?... We're about uh, thirty miles out, over the water, inbound VFR." The ATCT specialist said: "24RZ, understand you're 30 miles east VFR... What's your request? I can't, I can't understand you now. You have another radio you can try?" The captain said: "Uh, yeah, we're talking to Miami at this time. Uh, we're VFR at 17,500 inbound from San Juan. We're just wondering if runway 26 is available?... We could do a straight in." The ATCT specialist said: "I see you're requesting runway 26?" The captain replied: "Yes. that's affirmative." The ATCT specialist reports: "Learjet 24RZ approach, report (unintelligible) one five miles east of the airport for a straight in approach for runway 26. Wind 160 at 5, altimeter's 30.03." The captain said: "Okay, one five miles east for an approach to 26, Romeo Zulu." The captain told the first officer: "Okay, we got 26." While the captain continues to communicate with the Fort Lauderdale ATCT specialist on one radio, the first officer was simultaneously communicating with the Miami Center specialist on another radio. At 2141, the Fort Lauderdale ATCT specialist asked the captain: "Learjet 24RZ, do you require any assistance?" The captain then said: "Uh, negative, negative. Uh, we're just...Uh, the winds got beat to us... The winds beat us coming back from San Juan. We just don't want to have to declare minimum fuel, so we're just trying to get a shortcut, that's all." The ATCT specialist said: "Lear 24RZ, just be advised that your transmitter is unreadable um, I kind of understood that you are low on fuel. If yes, just click your mic twice." The captain then responds and said: "Negative, negative, negative. We're fine, we're just requesting that runway for a shortcut." At 2144, the Fort Lauderdale ATCT specialist asked the captain: "Learjet 24RZ, I show you four miles southeast. Would you like a right downwind for runway 8 or would like to continue to 26?" The captain said: "Uh no, we're kinda dealing with Miami. If we can't do 26, we'll come around for [runway] 8. Its, its we're just trying to get a shortcut but uh, Miami's asking us to stay here now." At 2142, Miami Center specialist said: "All right, you've got to turn right 030, vectors for the descent." The captain then tells the first officer: "Uh... minimum, just tell him we'll have to declare minimum fuel." The first officer then told the Miami Center specialist: "Yes sir, and we'd like to request direct FXE at this time, or else we will have to have a minimum fuel situation." The specialist said: "A minimum fuel situation understood, proceed direct to Executive." At 2146, as the flight nears Fort Lauderdale, the crew is instructed to contact the Fort Lauderdale ATCT. After initial contact is confirmed with the Fort Lauderdale ATCT specialist, the first officer said, in part: "We just want to land right now. Uh come, we're passing through seven." The Fort Lauderdale ATCT specialist asked the first officer: "24RZ roger, traffic on a niner mile final for runway 8 is a Cessna descending out of 2,200. Are you gonna tear it back to the left or the right for landing?" The first officer said: "We're on a modified uh, left downwind for runway 8." The ATCT specialist instructs the crew to maintain at or above 3,000 feet msl for the Cessna traffic that was now on a 6 mile final, also landing runway 8. The first officer told the ATCT specialist: "Yes sir, we're declaring minimum fuel at this time. We wanna go straight in." The ATCT specialist instructed the landing Cessna to discontinue its approach to runway 8 with a left climbing turn, and cleared the accident airplane for landing on runway 8. At 2149, the crew began to configure the airplane for landing. The captain told the first officer: "...flaps eight.... gear down.... flaps twenty." The captain commented: "(unintelligible) the pumps." The first officer responded: "The pumps." The captain said: "...Huh...I see that." As the approach continues, the captain again said: "Flaps twenty." The first officer: "Uhh, (unintelligible).... the flaps are not coming down.... flaps not, no flaps." The captain told the first officer: "Yeah, the gear doors are stuck down.... no hydraulics." The first officer said: "Oh (expletive)...the gauges." The Captain asked that first officer: "We got three greens?" The first officer said: "We got three greens, you're landing, right?" The captain asked: "We got no flaps?." The first officer said: "NOPE." The captain asked the first officer: "Okay, what.... how much flaps can you give me?" The first officer said: "Actually, that...an, that's an eight...it looks like an eight?" The captain told the first officer: "Okay, so we're gonna do, this is gonna be a ref and twenty...All right, probably not going to have any brakes..." At 2151, a sound similar to the airplane touching down on the runway is heard. The captain said: "No brakes... Drag chute, drag chute, pull it [spoken in strained voice], straight up, but don't let go... Pull it, pull it, pull it, pull it." The first officer said: "Uuuuuuh, what the (expletive) [spoken in strained voice] The captain again said: "Pull it." The first officer said: "...it's not coming." At 2152, the captain said: "Hold on...Hold on" [spoken in a yelling voice] Sound of impact, and end of recording. FLIGHT CREW INFORMATION The captain and first officer declined to provide written statements to the NTSB. The NTSB IIC received pilot training and check ride information on both pilots from the operator's chief pilot, about 10 days after the accident. According to the chief pilot, all training and pilot records were kept off site, at the chief pilot's residence, located out of state. According to the FAA representative from the Fort Lauderdale Flight Standards District Office, all training and pilot records were to be kept on site, at the operator's base of operation. According to the FAA representative from the Fort Lauderdale Flight Standards District Office, neither the captain or first officer were qualified to act as flightcrew members, since both pilots failed to complete the FAA's initial hire training curriculum. Captain The captain held an airline transport pilot certificate with an airplane, single-engine and multiengine land ratings, and a type rating for Learjet aircraft. He also held commercial airplane pilot privileges for single-engine land and multiengine land. The captain's most recent first-class medical certificate was issued on September 19, 2003, and contained no limita

Probable Cause and Findings

The pilot in command's misjudged distance/speed while landing, and the flightcrew's failure to follow prescribed emergency procedures, which resulted in a runway overrun and subsequent collision with a building. Factors associated with the accident are the flightcrew's inadequate in-flight planning/decision making, which resulted in a low fuel condition; an open hydraulic relief valve, and inadequate maintenance by company maintenance personnel. Additional factors were an inoperative (normal) brake system, an unactivated emergency drag chute, the flightcrew's failure to engage the emergency brake system, and pressure placed on the flightcrew due to conditions/events.

 

Source: NTSB Aviation Accident Database

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