Aviation Accident Summaries

Aviation Accident Summary ERA19FA248

Elizabethton, TN, USA

Aircraft #1

N8JR

Textron Aviation Inc 680A

Analysis

The pilots were conducting a visual flight rules cross-country flight with three passengers onboard. The preflight, departure, and cruise portions of the flight were uneventful. During the initial approach to the airport, the flight crew discussed having some difficulty visually acquiring the airport. They also discussed traffic in the area and were maneuvering around clouds, which may have increased the pilots' workload. As the approach continued, the airplane crossed a ridgeline at 710 ft above ground level (agl), which triggered a terrain awareness and warning system (TAWS) alert. Further, the flight crew made several comments about the airplane flying too fast and allowed the airspeed to increase well above the reference speed (Vref) for the approach. At 1535:57 (about 1 minute 52 seconds before landing), the pilot pulled back the throttles to idle, where they stayed for the remainder of the approach. In an attempt to slow the airplane for landing, the pilot partially extended the speedbrakes when the airplane was below 500 ft agl, which is prohibited in the airplane flight manual (AFM). Five seconds before touchdown, the airplane's descent rate was 1,500 ft per minute (fpm), which exceeded the maximum allowed for landing per the AFM of 600 fpm. When the airplane first touched down, it was traveling about 18 knots above Vref. The pilot did not extend the speedbrakes upon touchdown, which the landing checklist required, but instead attempted to deploy the thrust reversers immediately after touchdown, which was a later item on the landing checklist. However, the thrust reversers did not unlock because the airplane bounced and was airborne again before the command could be executed, which was consistent with system design and logic: the thrust reversers will not unlock until all three landing gear are on the ground. The airplane touched down four times total; on the third touchdown (after the second bounce), when all three landing gear contacted the runway, the thrust reversers unlocked as previously commanded during the first touchdown. Although the pilot subsequently advanced the throttles to idle, which would normally stow the thrust reversers, the airplane had bounced a third time and had already become airborne again before the thrust reversers could stow. When the airplane became airborne, the system logic cut hydraulic power to the thrust reverser actuators; thus the reversers would not stow. The thrust reversers were subsequently pulled open due to the aerodynamic forces. The pilot attempted to go around by advancing the throttles when the airplane was airborne. However, the electronic engine controls prevented the increase in engine power because the thrust reversers were not stowed. When the airplane touched down the fourth and final time, the pilot attempted to land straight ahead on the runway; the airplane touched down hard and the right main landing gear then collapsed under the wing. The airplane departed the paved surface and came to rest about 600 ft beyond the runway threshold. The passengers and crew eventually evacuated the airplane through the main cabin door, and the airplane was destroyed in a postaccident fire. A postaccident examination of the airplane systems, structure, powerplants, and landing gear revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The airplane's approach was unstabilized: its airspeed during the approach and landing well exceeded Vref and its descent rate exceeded the maximum allowed for landing just seconds before touchdown. Both the pilot and copilot commented on the airplane's high speed several times during the approach. During short final, the pilot asked the copilot if he should go around, and the copilot responded, "no." Although the copilot was the director of operations for the flight department and the direct supervisor of the pilot, the pilot stated that the copilot's position did not influence his decisions as pilot-in-command nor did it diminish his command authority. Neither the pilot nor copilot called for a go-around before landing despite awareness that the approach was unstabilized. As the airplane touched down, the pilot failed to follow the AFM guidance and used the thrust reversers before the speedbrakes. According to the airplane manufacturer's calculations, the airplane could have stopped within the length of runway available if the airplane had not bounced and the speedbrakes and wheel brakes were used at the point of the first touchdown. After the third touchdown, when the airplane became airborne again, the pilot attempted a go-around; the AFM prohibits touch-and-go landings after the thrust reversers are deployed. It is critical for pilots to know the point at which they should not attempt a go-around; a committed-to-stop (CTS) point is the point at which a go-around or rejected landing procedure will not be initiated and the only option will be bringing the aircraft to a stop. Establishing a CTS point eliminates the ambiguity for pilots making decisions during time-critical events. The FAA issued Information for Operators 17009, "Committed-to-Stop Point on Landings," to inform operators and pilots about the importance of establishing a CTS point; however, the director of operations was not aware of the concept of a CTS point during landing.

Factual Information

HISTORY OF FLIGHTOn August 15, 2019, about 1537 eastern daylight time, a Textron Aviation Inc. 680A, N8JR, was destroyed when it was involved in an accident near Elizabethton, Tennessee. The pilot and copilot were not injured and the three passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. In postaccident interviews and written statements, the pilot and copilot reported that the purpose of the flight was to drop off one of the three passengers at Elizabethton Municipal Airport (0A9), Elizabethton, Tennessee, before continuing the flight to San Antonio, Texas. The flight departed Statesville Regional Airport (SVH), Statesville, North Carolina, at 1519 and climbed to 12,500 ft mean sea level (msl). The preflight, departure, and en route portions of the flight were routine. Unless otherwise noted, the following sequence of events was derived from the download and review of data from onboard data and voice recording systems, and all speeds are indicated airspeed. At 1527 (about 8 minutes after takeoff), the airplane began a descent from 12,500 ft msl to 5,400 ft msl; during the descent, the airplane turned right to varying headings between 325º and 342º. During this time, the flight crew discussed clouds in the area and the best ways to maneuver around them as well as traffic in the area and landmarks, including ridgelines, to help them identify 0A9. About 1530, the copilot announced via the airport's common traffic advisory frequency their intention to land on runway 24. At 1532:11, the pilot stated, "well it wouldn't hurt to slow down." About 33 seconds later, the descent resumed, and the airspeed decreased to 200 knots with the autothrottle engaged. At 1533:00, the airplane began to turn left, and the crew conversation indicated that they had some difficulty visually acquiring the airport; the airplane then turned right and began to climb. At 1535:02, the descent resumed, and 10 seconds later the terrain avoidance and warning system (TAWS) excessive closure rate caution and warning alerts sounded in the cockpit as the airplane crossed a ridge at 710 ft above ground level (agl). The copilot asked the pilot if he saw the terrain, and the pilot responded, "yeah, I got it." At 1535:27, the airplane began a shallow left turn to an extended final. As the approach to landing resumed, the descent rate increased; the autothrottle positioned the throttles to their minimum, 6º throttle lever angle, and the airspeed increased to 220 knots. At 1536:12, the pilot asked the copilot to position the flaps to the flaps 1 setting. The crew then manually positioned the throttles to 0º throttle lever angle, which disengaged the autothrottle; the throttles were not moved for the remainder of the approach. At 1536:29, the pilot stated, "slow down." At 1536:31, the pilot asked the copilot to lower the landing gear, and the copilot responded that he would after the airplane slowed down more. At 1536:36, the speedbrake lever was partially extended to a 33º lever angle, and the TAWS excessive descent rate caution alert sounded about 5 seconds later. (See figure 1 for the accident airplane's flight path until the first touchdown.) At 1536:47, about 3 nautical miles from touchdown and at 2,783 ft msl (781 ft agl), the speedbrake lever was extended to 41º for a total of 21 seconds then retracted after the airspeed decreased to 205 knots. At 1536:50, the landing gear were extended, and 7 seconds later, flaps 2 (15°) was selected; these actions were performed when the airplane reached the maximum speeds to perform those functions (205 knots and 195 knots, respectively). Figure 1 : N8JR's approach, including speed and use of speedbrakes (in yellow ), landing gear, and flaps. As the flaps were extending, the TAWS forward looking terrain alert rate of terrain closure caution alert sounded twice (at 1536:59 and at 1537:09), then a warning alert sounded (at 1537:11). The airplane was at an altitude of 2,159 ft msl (471 ft agl). Following these alerts, the copilot selected full flaps and the descent rate and airspeed decreased. At 1537:26, the copilot stated, "and I don't need to tell ya, we're really fast," and the pilot responded, "I'm at idle." Six seconds later, the pilot asked, "do I need to go around?" and the copilot responded, "no." At 1537:31, about 270 ft agl, the speedbrakes were partially extended for 5 seconds (to 140 ft agl). The pilot then stated, "I got the speed brakes out," to which the copilot responded, "well you should get rid of those because we don't wanna get a CAS [Crew Alerting System] m- or a thing sent to ya." Eight seconds before touchdown, at 1537:41, the pilot stated, "alright, I'll be on the T-Rs [thrust reversers] quickly." For the computed airplane weight, the reference speed (Vref) for the final approach was 108 knots; the airplane's airspeed at the runway's displaced threshold was 126 knots. Five seconds before touchdown, the airplane's descent rate was over 1,500 ft per minute (fpm). According to airport surveillance video and recorded data, the airplane first briefly touched down with a bounce on the runway designator about 240 ft past the displaced threshold with about 3,860 ft of paved surface remaining. The airplane then touched down two more times, bouncing each time, then continued airborne over the runway until it touched down a fourth time with about 1,120 ft of paved surface remaining. See figure 2 for a depiction of the bounced landing detailing the landing gear touchdowns, vertical acceleration, and thrust reverser actions (the speedbrakes were not extended after touchdown, although the landing checklist indicated they should be). Figure 2. Graph depicting the airplane's thrust reverser actions, landing gear touchdowns, and vertical acceleration (bold) during its bounced landing. When the airplane touched down initially at 1537:49, it was travelling 126 knots (18 knots above Vref) and had a descent rate of 600 fpm (the maximum allowed per the airplane flight manual [AFM]). All three landing gear registered "on-ground" simultaneously with a vertical acceleration of 1.4 gravitational acceleration (g), and thrust reverser deployment was commanded 0.4 second after the landing gear first touched the ground as the throttles were moved to the reverse idle position; however, the airplane bounced after touching down for 0.6 second and was airborne again before the thrust reverser command could be executed. When the airplane touched down a second time, 1.2 seconds later at 1.6 g, the nose landing gear touched down first, followed immediately by the right main landing gear. The left main landing gear never registered on-ground during the touchdown, and the airplane bounced and became airborne again after 0.4 second. The airplane touched down a third time, 1.8 seconds later at 1.7 g and about 1,000 ft down the runway with about 3,100 ft of paved surface remaining. The thrust reversers unlocked 0.4 second after all three landing gear registered on-ground because the reverser deployment command from the first touchdown was still active. Almost immediately after the thrust reversers unlocked, the pilot advanced the throttles to idle, sending a thrust reverser stow command at 1537:54; however, the landing gear status changed to "in-air" almost simultaneously when the command was executed. The airplane bounced after 0.6 second and became airborne a third time, and the in-air landing gear status triggered a cut in hydraulic power to the thrust reverser actuators, which is intended to prevent the airborne deployment of a thrust reverser. The cut in hydraulic power to the thrust reversers allowed the unlocked thrust reversers to be pulled open by aerodynamic forces. The amber "T/R UNLOCK CAS" message illuminated and the thrust reverser emergency stow switches began to flash. The pilot advanced the throttles to maximum takeoff power 0.7 second later in an attempt to go around; however, the thrust reversers reached full deployment 0.4 second after that. The airplane's full authority digital engine controls (FADEC), by design, prevented an increase in engine power while the thrust reversers were deployed. The red "T/R DEPLOY CAS" message was displayed in the cockpit, indicating that the thrust reversers were deployed, and the thrust reverser emergency stow switches continued to flash. The pilots later reported that they attempted to conduct a go-around; however, the engines did not respond as expected, so they landed straight ahead on the runway. While the airplane was airborne, the crew partially retracted the flaps as the airspeed decreased from 119 knots to 91 knots. The pilot retarded the throttles partially but not to idle, then pushed the throttles forward again with no effect because the FADEC continued to prevent an increase in thrust; the pilot then pulled back the throttles to idle. While airborne for 9.6 seconds, the airplane reached an altitude of about 24 ft agl. The stick shaker activated 0.5 second before the airplane touched down for the fourth and final time at 1538:03, warning of an imminent stall. The airplane touched down hard with a peak acceleration of 3.2 g on the left and right main landing gear, then the left main landing gear came off the ground then contacted the ground again. The nose gear contacted the ground about 0.5 second later. The left inboard wheel brake pressure increased to near maximum after the left main gear touched down; however, the left outboard and right wheel brake pressure did not increase significantly, indicating that only the left inboard tire was firmly contacting the runway. When all three landing gear touched down on the runway at 1538:06, the thrust reverser system was reenergized and the thrust reversers stowed 0.9 second later because the throttles were at idle. Airport surveillance video showed that the right main landing gear collapsed at 1538:04 and that the outboard section of the right wing contacted the runway immediately thereafter. The airplane then departed the 97-ft-long paved surface beyond the end of the runway and traveled through a 400-ft-long open area of grass, down an embankment, through a creek, through a chain-link fence, and up an embankment. Photographs of the accident scene showed that the airplane came to rest on the edge of a four-lane highway about 600 ft beyond the runway threshold. In postaccident interviews with the flight crew, they reported that they secured the engines after the airplane came to a stop and assisted the passengers with the evacuation through the main entry door as a postaccident fire erupted, which eventually destroyed the airplane. PERSONNEL INFORMATIONThe pilot, seated in the left cockpit seat and acting as the pilot-in-command, and the copilot, seated in the right cockpit seat, both held a type rating in the accident airplane. Both the pilot and copilot completed their most recent recurrent training together at TRU Simulation, Tampa, Florida. A review of the TRU Simulation syllabus for recurrent training revealed that the thrust reverser system was covered in ground training. In postaccident interviews, both the pilot and co-pilot reported that the thrust reverser system was adequately covered in initial and recurrent training. According to the copilot, who also served as the director of operations for the airplane operator, he and the pilot were the only pilots who flew the accident airplane. Both the pilot and copilot were qualified to act as pilot-in-command. The normal procedure for the crew was to "switch seats" often, with the pilot in the left seat always acting as pilot-in-command. As the director of operations, the copilot on the accident flight was also the direct supervisor of the pilot in the left seat. The pilot reported that this relationship neither influenced his decisions as pilot-in-command nor diminished his command authority. When asked if he thought there may have been repercussions from the copilot if he had discontinued the approach, the pilot responded "absolutely not." The pilot and copilot stated in postaccident interviews that they did not think that their maneuvers around clouds and traffic and identification of landmarks near 0A9 distracted them or increased their workload. In addition, the pilot and copilot said there was no pressure from the passengers to land rather than go around, and the copilot added that the airplane left SVH on time and that there were no other time constraints. The pilot recalled hearing the TAWS excessive closure rate warning alert on short final; however, he did not think that the alert contributed to the outcome. In retrospect, he felt the initial touchdown was too hard, possibly from an inadequate landing flare between final approach and touchdown, which would have slowed the descent rate and created a softer touchdown. When the copilot was asked in postaccident interviews if he thought the approach was stabilized, he responded "no." AIRCRAFT INFORMATIONThe airplane, also known as a Citation Latitude, had a low-wing, cruciform tail design with twin, fuselage-mounted engines. It was equipped with two cockpit seats and nine passenger seats. The pilots reported that the airplane departed SVH with about 1,312 gallons of fuel on board. According to the AFM, the maximum certified landing weight was 27,575 lbs, and the crew reported that the airplane weighed 27,508 lbs at the time of the accident and required 3,000 ft of runway for landing. According to the AFM, speedbrakes must be stowed before 500 ft agl and remain stowed until landing. The maximum landing descent rate was 600 fpm. The airplane was equipped with a cockpit voice recorder (CVR), a Garmin G5000 advanced integrated flight deck with flat screen displays and touch screen controls, a Textron Aircraft Recording System (AReS), and a Pratt and Whitney Canada FADEC on each engine. The CVR and G5000 memory card were removed from the airplane and sent for analysis to the National Transportation Safety Board (NTSB) Vehicle Recorder Division, Washington, DC. Textron reviewed the AReS data and provided a report to the NTSB. According to the airplane manufacturer, speedbrake extension at touchdown has a "significantly greater effect" than thrust reverser use. The manufacturer calculated the landing distance of the accident airplane model if it had been traveling at an airspeed of 126 knots at touchdown, which was 18 knots above Vref and was the speed of the accident airplane at the displaced threshold. According to the manufacturer's calculations, an airplane could have stopped within the length of runway available to the accident airplane if only speedbrakes and wheel brakes were used during the first touchdown and the airplane did not bounce. The AFM included three checklists to be completed during approach and landing: the approach checklist, the before landing checklist, and the landing checklist. The before landing checklist included lowering the landing gear, selecting full flaps, and confirming Vref; the landing checklist included extending speedbrakes at touchdown then deploying thrust reversers after nosewheel touchdown. AIRPORT INFORMATIONThe airplane, also known as a Citation Latitude, had a low-wing, cruciform tail design with twin, fuselage-mounted engines. It was equipped with two cockpit seats and nine passenger seats. The pilots reported that the airplane departed SVH with about 1,312 gallons of fuel on board. According to the AFM, the maximum certified landing weight was 27,575 lbs, and the crew reported that the airplane weighed 27,508 lbs at the time of the accident and required 3,000 ft of runway for landing. According to the AFM, speedbrakes must be stowed before 500 ft agl and remain stowed until landing. The maximum landing descent rate was 600 fpm. The airplane was equipped with a cockpit voice recorder (CVR), a Garmin G5000 advanced integrated flight deck with flat screen displays and touch screen controls, a Textron Aircraft Recording System (AReS), and a Pratt and Whitney Canada FADEC on each engine. The CVR and G5000 memory card were removed from the airplane and sent for analysis to the National Transportation Safety Board (NTSB)

Probable Cause and Findings

The pilot's continuation of an unstabilized approach despite recognizing associated cues and the flight crew's decision not to initiate a go-around before touchdown, which resulted in a bounced landing, a loss of airplane control, a landing gear collapse, and a runway excursion. Contributing to the accident was the pilot's failure to deploy the speedbrakes during the initial touchdown, which may have prevented the runway excursion, and the pilot's attempt to go around after deployment of the thrust reversers.

 

Source: NTSB Aviation Accident Database

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