The catastrophe was recorded by a number of surveillance cameras, some located not far from the point of impact. Video showed the airplane airborne, initially drifting left, then yawing left to an extreme sideslip angle before rapidly rolling into an inverted dive. The sequence took just a few seconds. Once the left wing had dropped, the low altitude made recovery impossible.

The crew had not reported any trouble to the tower. National Transportation Safety Board (NTSB) investigators reconstructed the event by analyzing surveillance videos and the sound spectrum of the engines captured as background noise by the cockpit voice recorder, as well as extracting data from the airplane’s ADS-B and terrain awareness warning systems. They concluded the critical left engine had spooled down for some reason, and the pilot had reacted by pressing on the left rudder pedal rather than the right. Only the combination of asymmetric thrust with added rudder, the NTSB found, could bring the airplane to the extreme yaw angle observed in the videos, as asymmetric thrust alone would not have been sufficient.

The only communications between the two pilots recorded during the accident sequence were an exclamation of “What in the world?” by the pilot flying and the copilot’s statement, three and a half seconds later, that “You just lost your left engine.” (The King Air is a single-pilot airplane. The copilot frequently flew with the pilot to gain experience, but was not permitted to touch the controls when passengers were aboard.)

The NTSB suspected the spooldown of the left engine might have been caused by a faulty friction setting on the left power lever, which could have allowed it to creep backward during the takeoff roll. This is a known susceptibility of King Airs; the power levers are spring-loaded toward idle, each has its own friction knob, and they rely on positive friction to keep them from drifting. The power quadrant was too badly damaged in the post-crash fire to allow investigators to tell anything about the position of the left power lever or the friction settings. Uncommanded power rollbacks on the PT6-series engines can have other causes, however, which would not necessarily be detectable in a severely burned wreckage, and so the attribution to the friction setting remained speculative.

The quadrant frictions are a checklist item, but the CVR recording disclosed no pre-takeoff briefing and none of the expected checklist or V-speed callouts. According to other pilots who had flown with him, the pilot, 71, a 16,450-hour ATP, was “not strong on using checklists” and “just jumped in the airplane and went.” He was, on the other hand, “super strong” on knowledge of the airplane, in which he had logged 1,100 hours. According to the pilot who administered his most recent proficiency check, he had performed well on the simulated engine failure on takeoff. The check ride took place in the airplane, however, not in a simulator, and so as a safety precaution the engine cut, which had been briefed in advance, did not occur until the airplane was safely airborne and climbing. A successful performance under such controlled circumstances did not guarantee success in exigent ones.

The NTSB’s reconstruction of the takeoff showed the pilot had rotated at 102 kias, slightly below the V1 (go/abort) speed of 106 kias and 8 knots below the calculated rotation speed of 110 knots. The airplane was fully airborne at 106 kias and was at around 110 kias when the power began to roll back. The airplane drifted left, reaching a maximum altitude of 100 feet. Three seconds later, it was at 70 feet and the airspeed was 85 knots. One second later, it plunged through the hangar roof.

The standard procedure for loss of an engine in the King Air 350 is to establish a positive rate of climb with a pitch angle of 10 degrees, retract the landing gear, and feather the propeller on the inoperative engine while maintaining V2 (minimum safe climb speed with an engine out) to 400 feet agl. Above 400 feet, the airplane is allowed to accelerate, the flaps are retracted, and the climb continues at 125 kias.

None of this happened, however, because the pilot, in spite of his lifetime of flying experience and countless successful proficiency checks, stepped on the wrong rudder pedal.

• READ MORE: Objection Overruled

There was a time when the NTSB often cited fatigue as a contributing factor in accidents, but at some point it must have become obvious that plenty of well-rested pilots crashed too, so unless a pilot literally fell asleep at the wheel, fatigue could never be proved to have been a link in a causal chain. In this case, the pilot had a history of severe sleep apnea. To the extent that the FAA was aware of it, the agency had taken no action, although in principle the condition could have been disqualifying. The NTSB turned its back on this opportunity to invoke fatigue. “No evidence,” the agency wrote, “indicates that the pilot’s medical conditions or their treatment were factors in the accident.”

I would have expected the NTSB’s finding of “probable cause” to be something like “…the pilot’s inappropriate reaction to a loss of power in the left engine, which resulted in loss of control.” Instead, it blamed “the pilot’s failure to maintain airplane control,” which seems rather vague and generic. Among the contributing factors, “failure to conduct the airplane manufacturer’s emergency procedure” is a little misleading, since he did begin to execute the procedure but bungled it. The agency added his “failure…to follow the manufacturer’s checklists during all phases of operation,” even though the only link between checklists and the crash was the hypothetical faulty friction setting for which there was no material evidence. Two King Air pilots with whom I discussed the accident were skeptical of the friction theory because they said matching torques on two PT6s during takeoff involves enough fiddling with the power levers that it would be impossible for the pilot to be unaware of a sloppy-feeling lever.

I suspect the NTSB wanted to blame the accident on the pilot not being a by-the-book kind of person. None of his associates the NTSB interviewed suggested he was reckless or incompetent—quite the opposite. The problem with pinning the accident on a personality trait of the pilot is that the mistake of stepping on the wrong rudder pedal is not connected in any obvious way to that. It seems more like one of those random human mistakes we all sometimes make—but hope we will never make at a critical moment.

Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the August 2023/Issue 940 print edition of FLYING.

The post King Air 350 Accident Proved to Be Fatal Misstep appeared first on FLYING Magazine.

“You’ve been watching, and you still want to go?” the briefer asked.

“Baby needs a wash,” joked the pilot, 66, a recently retired judge who was known for his “well-honed” sense of humor.

“Oh, he’s going to get a wash job,” the briefer said. “We do have a lot of rain and convective activity. It’s becoming pretty solid. I can’t see you doing much dodging trying to get around.”

“It looks like it subsides as it goes east,” the pilot suggested, and then added, “Question mark.”

“Well, yeah, question mark,” said the briefer. “If you take a line drawn directly north, it’s heavy precipitation until you get over to about Bowling Green (Kentucky), and that’s when the thunderstorms start again. But all this is moving northeast about 34 knots, so you head east as it is heading east, and then you get blocked off, and it’s building behind so…you have to go today?”

“Well, maybe not.”

“We will have some rain tomorrow, but at least it will break up enough and begin to move to where, you know, that Arkansas and Missouri area won’t be getting so smashed.”

“I might just go up and take a look at it and see what it looks like out of the windshield,” the pilot mused. “I don’t have anything better to do today.”

“Well,” said the briefer, “think of a good reason to go.”

He issued the required “VFR not recommended” warning—under the circumstances it was hardly necessary—and the pilot filed an IFR flight plan, estimating 2 hours and 15 minutes for the 520 nm trip.

His airplane was a Lancair Legacy, a small, very fast two-seat retractable homebuilt with a 310 hp engine. After climbing VFR to 6,000 feet, the pilot contacted Memphis Approach at 9:50 a.m. The controller asked whether he wanted to continue on his present heading of 356 degrees or deviate eastbound to try to go around the weather. The pilot said he would like to avoid the weather, and the controller gave him a vector of 060. The pilot, however, asked to continue on his present heading for a couple of minutes, and the controller agreed.

A minute later, the pilot came back. “The route ahead, as far as I can see, looks VMC. I can’t be sure on that, but I’d appreciate your input.”

“All right,” the controller replied, “stay on course and let me know if that weather starts to become a problem for you.”

Four minutes later, the controller said, “You are just going to run into about a 10-mile-wide band of showers that’s crossing in front of you. The quickest way through the weather, if you want a direct 90-degree cut, is about a 330 heading. There’s a lot of rain for about 10 miles, and then it should clear up on the other side.”

“All right, thanks,” replied the pilot. “We’ll go to 330, and we’ll slow down a little bit.” Two minutes passed.

“Looks like you are getting an updraft there,” the controller said. “I don’t have any targets around your altitude. Do what you can to hold it, but just take care of yourself through that weather. You’ve got another 10 miles before you’re going to clear it up a little bit.”

“Thank you, sir,” the pilot said.

Twenty seconds later, the controller asked the pilot whether he was OK. There was no reply. The controller’s transmissions became increasingly urgent.

“You’re going through a heavy area of weather, sir. If you can hear me, you, climb, altitude whatever, deviate, reverse course is also approved, sir…Radar contact is lost 30 miles northeast of Memphis, sir…You’ve got another 15 or 20 miles in that weather. If you can hear, sir, suggest a heading northwest bound to get through the weather. You’re in a level 4 and level 5 cell in that area, sir.”

The controller was not long in guessing what had happened. “I think he might have crashed,” he told a colleague.

Three hours later, searchers in a helicopter spotted fragments in a rain-soaked field. The recovery team found the engine and propeller buried almost 9 feet below the surface.

About an hour before the flight took off—but after the pilot’s conversation with the weather briefer—the National Weather Service had issued a SIGMET for the area through which the flight would pass. It warned of severe thunderstorms with tops to 38,000 feet, possible 50-knot gusts and 1-inch hail. The pilot most likely never saw the SIGMET. A retrospective analysis of Doppler weather radar recordings confirmed that at the time of the crash the pilot was just crossing the leading edge of a level 5 storm.

The National Transportation Safety Board limited its finding of “probable cause” to the trivial insight that the pilot had lost control of the airplane. A factor in the accident, it added, was “insufficient information” provided by the controller, who did not convey the storm’s intensity level to the pilot until he was already in it. Exactly how and why the loss of control occurred was not discussed. The wreckage was too badly fragmented for forensic analysis, and significant portions of it were not recovered at all. It did not appear that the airplane had broken up in flight, however. The wreckage was confined to a small area among plowed fields where more widely scattered debris would have been easy to find.

• READ MORE: The Road Not Taken

This accident occurred in 2004. In the intervening years, the NTSB has moved away from mechanistic analyses such as “loss of control” and toward more judgment-oriented ones signaled by the phrase, “the pilot’s decision to…” Today, I think, the finding of probable cause would put more emphasis on decision-making on the parts of both the pilot and controller, although the board’s investigations seldom satisfactorily dissect the nuances of decisions made by two people unconsciously influencing one another. The pilot’s assertion that it looked like VMC ahead probably affected the controller’s interpretation of his own weather display. The controller’s mention of 10 miles of “showers”—two and a half minutes in the Legacy—probably alleviated the pilot’s concern about the storm.

At the risk of venturing into groundless speculation, I am inclined to note that, as a judge, the pilot was accustomed to being the final arbiter of complex questions. As the builder-pilot of a beautiful—the word he used when filling in the “color” field in his flight plan—high performance airplane, he also probably experienced a little of the feeling of untouchable power that comes with fast airplanes and fast cars. The weather briefer hinted, warned, cajoled—but his objections were overruled.

This review first appeared in the July 2023/Issue 939 print edition of FLYING.

The post Objection Overruled appeared first on FLYING Magazine.

• READ MORE: NTSB Preliminary Report on Kentucky Fatal Crash Released

• READ MORE: Death by Time Builder

The post Instructing Isn’t for Everyone, but It Gives You Great Skills appeared first on FLYING Magazine.

Time builders are the flight instructors who, although they hold an instructor certificate, are focused on building their hours, not teaching. They may not know how to teach beyond the test because that’s how they were trained. This is particularly common if they went through an accelerated program where the focus is get ’em, get ’em out.

Rote learning, as opposed to understanding, application, and the level where we seek correlation often doesn’t happen. Correlation requires the learner to perform real-world tasks and exhibit in-depth knowledge by problem-solving rather than responding by rote.

It is coming back to bite us. The number of time builders teaching to the rote level is manifesting at the private pilot level as the failure rate for private pilot applicants on the check ride, which is higher than 50 percent in some places. They are being pushed through the pipeline just as many of their instructors were. The experience boxes have been checked and endorsements given, but even if the applicant passes the check ride, that doesn’t mean they are ready for the real world. This is particularly true of instructor applicants.

Currently, the instructor community at large is talking about a particular crash—I cannot in good conscience call this one an accident—that happened in Kentucky last week involving a time builder instructor with an affinity for social media and an 18-year-old private pilot candidate. I can’t call it an accident because there were so many blatant mistakes and failures to identify and address. I have been a CFI for 20 years, and I have never seen one like this before.

Details

On September 27, the Piper Warrior belonging to Eagle Flight Academy in Owensboro, Kentucky, was supposed to make a night flight from Owensboro/Daviess County Regional Airport (KOWB) to Bowling Green-Warren County Regional Airport (KBWG) in Kentucky.

Aboard were Connor Quisenberry, a private pilot candidate, and flight instructor Timothy McKellar Jr., 22.

The events of the evening were documented by McKellar on Snapchat. That’s right. The flight instructor decided to document the flight. It is clear that Quisenberry is not a regular student of McKellar’s, because McKellar’s Snapchat story begins with him talking to the camera and shaking his head along with the caption, “me and this student should not get along if he was my full-time student. I’ve seen faster at the Special Olympics.”

If that blatant smear isn’t enough to turn the viewer away, it gets worse. The camera angle is then reversed to show Quisenberry, flashlight in hand, performing what appears to be the preflight inspection of the Warrior. McKellar impatiently taps his fingers on the outside of the aircraft.

McKellar expresses impatience with Quisenberry who “wanted to have a conversation” when the instructor wants to get the flight over with because he has to be up at 4:30 a.m. McKellar refers to Quisenberry as “Forrest Gump.” The time stamp of the Snapchat shows 8:39 p.m. as McKellar is heard saying, “C’mon.” He posts that the pair have a three-hour flight ahead. The video continues showing the night takeoff and in-flight cruise.

McKellar makes a second reference to Quisenberry as Forrest Gump, stating that he is “just giving it to him straight up,” to which Quisenberry allegedly replies to the criticism by saying, “I don’t mind you being hard on me. I know I need it.”

The final Snapchat posted by McKellar shows a preview of the flight path from Bowling Green to Owensboro over top radar showing severe storms heading toward them.

McKellar circles the storms and writes, “headed are [sic] way like a group of pissed off hornets.”

It has not escaped the instructor community that McKellar, who was critical of the intellectual capacity of Quisenberry, uses “are” instead of “our” in his post. And continued the flight into a thunderstorm.

The TAFs and METARs from the area at the time of the flight showed severe weather in all quadrants. The question is asked:  Given this information as noted by Snapchat, why did the flight continue?

The Last Moments

You cannot visually see thunderclouds at night, but apparently the flight continued into them as FlightAware shows the aircraft made some extreme altitude fluctuations, and McKellar asked for an IFR clearance and was told to head east before contact was lost.

According to local law enforcement, the wreckage was found spread out over three-quarters of a mile in mountainous terrain. The National Transportation Safety Board is expected to release a preliminary report on the accident in a few weeks.

Aftermath

McKellar’s behavior will likely be used as a case study for future flight instructor candidates. Frustration on the part of both the instructor and learner is a normal part of the flight training process, and both must learn to deal with it.

The flight instructor is supposed to be able to compartmentalize it, or at the very least restrain themself from publicly shaming their learner on social media. It goes the other way too. Learners who do this to their instructors will likely find themselves ostracized from the flight school. Remember the phrase “praise in public, criticize in private”—and make that criticism constructive.

McKellar’s friends and family have defended him on social media, insisting “Junior was a jokester and just messing with his student” and suggesting people view McKellar’s YouTube channel.

There is a lot of aviation there, including a video where McKellar appears to sip 100LL from a sump cup then jokes how he will smell like fuel for the rest of the day.

McKellar was a relatively inexperienced instructor. His social media shows he soloed in October 2020 at a small flight school then did the bulk of his training at ATP Flight School, the largest accelerated training program in the U.S. He earned his commercial and flight instructor certificates in May 2023. It is not clear how many hours of dual instruction he had accrued before the last flight.

Had McKellar not chosen to Snapchat the ill-fated flight, this might have been viewed as just a bad accident. Rule No. 1 is keep the learner safe, noting the pilot in command (PIC)—in this case, the CFI—is responsible for the safety of the flight. McKellar was PIC, and he failed miserably at this task.

Is This One Age Related?

It has been suggested that age is a factor in this event. How mature were you at 22? Were you starting a business? Going to school? Still living off Mom and Dad? Starting a career? Trying to find a career? Maturity at any age runs the gamut. 

While there is a numeric quality to maturity, it very much depends on the person. There is no maturity test for flight instructors, which is unfortunate since, although it is an entry level position to a flying career, the stakes are quite high.

There are 18- to 20-somethings who work as CFIs as a means of building their hours and are good teachers. They listen to their learners and seek the counsel of more experienced instructors when they run into a challenge. They may even sit in on the ground schools taught by more experienced instructors because they want to improve their skills. They understand that telling a learner about something or demonstrating it in the aircraft doesn’t necessarily mean learning has taken place.

Much of this comes down to communication skills. As far as McKellar’s “giving it to [sic] the learner straight up,” direct communication can be accomplished without being insulting. When providing guidance to the learner, refer to the airman certification standards for the metrics they are measured to. “Your altitude sucks” or “you’re so rusty, we need a jack hammer” are neither professional nor helpful communication. All the learner may take from this is that they don’t want to fly with you again.

It is heartbreaking that Quisenberry allegedly accepted McKellar’s behavior as the norm. Connor, I know you can’t hear me when I say this, but I speak to all the other Connors out there: I am sorry this happened to you. Albeit, the concept of an instructor being hard on a learner can be a matter of perspective. If an instructor says your skills need some work, they don’t say it to be mean. The professional CFIs will pull out the ACS to show you where the soft spots in your skills are. Then they will help you shore them up. No CFI wants you to bend metal, get hurt or fail a check ride.

There is a big difference between “being hard” on a learner by holding you to the standards set forth in the ACS and being insulting or verbally abusive. If you had a little more life experience under your belt, you might have walked away from this CFI. And no one would have blamed you.

The post Death by Time Builder appeared first on FLYING Magazine.

A 2016 Flight Safety Foundation (FSF) study of 16 years of runway excursions determined that “83 percent could have been avoided with a decision to go around. In other words, 54 percent of all accidents could potentially be prevented by going around.” Failure to conduct a go-around is the number one risk factor in approach and landing accidents and a primary cause of runway excursions, the FSF added. The foundation also believes that while unstable approaches are a primary cause of landing excursions, “the global aviation industry’s rate of compliance with go-around policies is extremely poor with just 3 percent of unstable approaches resulting in a go-around.” Executing a go-around carries its own set of risks, such as exceeding flap and gear extended speeds and a failure to achieve a positive climb during the maneuver, because go-arounds are seldom practiced in the locations where they often occur.

The FSF also said, “Many aborted landing attempts have been investigated thoroughly over time, and much is known about contributing factors. What is lacking, however, is an understanding of the psychology of [pilot] noncompliance.” The foundation said the collective industry norm is to accept the non-compliance of go-around policies despite research indicating this contributes to abortive landing attempts. They added that the industry tends to focus on eliminating unstable approaches, mainly because pilots—management included—seem to have so little understanding of the risks involved in aborted landing attempts. Additionally, many pilots don’t see current go-around policies as realistic. The lessons learned in planning for an approach in turbine-powered aircraft can correlate closely to those necessary for the pilots of smaller GA airplanes.

On August 15, 2019, a Cessna Citation Latitude—a midsize business jet—crashed off the departure end of Runway 24 at Elizabethton, Tennessee (0A9), following an unstable VFR approach, a poorly executed landing, and a botched go-around attempt. The go-around decision by the pilot was made beyond the commit to stop point (CTS), a spot on the runway when a successful return to flight is not possible. The weather was good VFR with calm winds and the runway was dry. Neither pilot was injured, but all three passengers received minor injuries as they attempted to exit the aircraft after it burst into flames.

Upon arrival in the Elizabethton area, the flying pilot (FP) never completely configured the airplane for a stable approach despite a number of nudges from the non-flying pilot (NFP) in the right seat. The Latitude touched down 18 knots above its calculated reference speed for the 5,001-foot Runway 24 that included a 902-foot displaced threshold . That left just 4,099 feet of usable runway remaining. Because of its excessive speed and a poorly executed flare, the Citation bounced the first time it touched down about 240 feet past the displaced threshold. It bounced two more times before finally touching down firmly on the fourth try. At that point there was just 1,120 feet of hard surface remaining.

According to the NTSB report ERA19FA248, during the first touchdown, “All three landing gear registered ‘on-ground’ simultaneously with a vertical acceleration of 1.4 Gs. Thrust reverser deployment was commanded 0.4 seconds after the landing gear first touched, however, the airplane bounced after being down for 0.6 second and became airborne again before the thrust reverser command could be executed.” The airplane touched down a second time on the nose gear first with a force of 1.2 Gs, followed immediately by the right main landing gear. The left main landing gear never registered on-ground this time as the airplane again became airborne 0.4 seconds later.

“On the third touchdown, the Latitude struck the runway with a force of 1.7 Gs. This time, the thrust reversers unlocked 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—perhaps to initiate a go around?—now sending a thrust reverser stow command. However, the landing gear status changed to ‘in-air’ that triggered a cut in hydraulic power to the reverser actuators to prevent their airborne deployment. The cut in hydraulic power to the reversers allowed the unlocked thrust reversers to be pulled open by aerodynamic forces.

“Moments later, an amber ‘T/R UNLOCK’ CAS message illuminated and the thrust reverser emergency stow switches began flashing. The pilot then advanced the throttles to maximum takeoff power in an attempt to go around just as the thrust reversers reached full deployment. The airplane’s full authority digital engine controls (FADEC), by design, prevented an increase in engine power while the reversers were deployed. The NTSB said 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 flashing.” The pilots later confirmed they attempted a go-around, but because the engines did not respond as expected, they elected to land straight ahead on the runway.

But in just a few seconds 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 fully to idle, but then pushed them forward again with no effect because the FADEC prevented the action. The FP never did extend the speed brakes after touchdown, which would have significantly helped slow the airplane. The stick shaker activated half a second before the airplane touched down for the fourth time, warning of an imminent stall. During the touchdowns, the aircraft reported a peak G load of 3.2. Once all three landing gear touched down on the runway, the thrust reverser system was again reenergized and the reversers stowed 0.9 seconds later because the throttles were now at idle.

During the final hard landing, the Latitude’s landing gear began to collapse and the airplane departed the 97-ft-long paved surface beyond the end of the runway, passed through a 400-ft-long open area of grass, down an embankment, through a creek, through a chain-link fence, and up an embankment before coming to rest on the edge of a four-lane highway. In post-accident interviews with the flight crew, they reported they quickly secured the engines and assisted the passengers with the evacuation through the main entry door as a post-accident fire erupted, which eventually destroyed the airplane.

Both pilots were experienced. The captain had logged about 5,800 hours total time, with 765 hours in make and model, while the NFP in the right seat had logged about 11,000 hours total time with 1,165 hours in make and model. The NFP also served as the flight department’s director of operations, making him the left-seat pilot’s immediate supervisor. The flying pilot said he did not believe flying with his boss caused him to make any decisions he wouldn’t also have made if he’d been flying with anyone else.

The NTSB’s docket on this accident includes both a transcript of the cockpit voice recorder (CVR), as well as copies of the individual post-accident interviews with the crew. One item that stood out was the crew’s apparent lack of preflight planning for the short 70-nm flight conducted at 12,500 feet between Statesville, North Carolina (KSVH), and Elizabethton. Within the world of flying, even jet flying, it’s not that unusual for pilots to fall into the potential trap of believing they can cope with most anything they encounter during such a short flight. In interviews, both pilots said they encountered nothing at all unusual during the approach, except the flying pilot’s admission that he failed to slow the aircraft, and also that he could have descended earlier.

About 10 minutes out from 0A9, the crew can be heard on the cockpit voice recorder discussing what sounds like the pair trying to find a hole in order to get below the bases of some scattered to broken clouds to prepare for the visual approach. Nine minutes before the accident the NP asks the other whether any sort of approach aid was available to the runway, which it is not. Both pilots were however, well aware of the nearby terrain as they began their descent. Elizabethton airport is located at the southwest end of a valley with ridgelines that rise between 1,000 and 2,000 feet above 0A9′s field elevation.

During the flight, the CVR conversation between the two crewmembers seemed to indicate the FP was not entirely sure of his abilities as the flight approached OA9. Five minutes before touchdown, the NFP suggested, “It wouldn’t hurt to slow down.” Certainly, the flying pilot could be given the benefit of the doubt in that he interpreted the conversations more as gentle nudges from the right seater, such as when to start the descent, when to slow and a heading to find a hole in the clouds. The flying pilot did ask for confirmation of the location of a nearby ridgeline as he descended through the hole they apparently managed to locate. Both pilots mentioned some inbound traffic flying above them as they approached the airport. Two minutes prior to touchdown, the FP apparently had not yet sighted the airport as the NFP suggested, “Well, I wouldn’t turn. I wouldn’t turn to the right anymore. I would just climb right where you are.”

About 30 seconds later while on a seven-mile final for Runway 24, the crew received a Terrain Awareness and Warning System (TAWS) alert, “Terrain, Terrain,” followed shortly after by another warning, “Whoop, Whoop, Pull Up, Pull Up.” Less than a minute from touchdown, the aircraft was still flying beyond reference speed as the FP called for the landing gear. The NFP said he’d comply as soon as the airplane slowed below extension speed. Twenty five seconds before touchdown, the crew again received a TAWS, as well as another pull-up command. Fifteen seconds from touchdown, the NFP said, “And I don’t need to tell ya, we’re really fast.” About two seconds before touchdown, the FP asked his boss if he needed to go around, to which his boss replied, “No.” The FP then extended the speed brakes in an attempt to slow the Latitude, a violation of the aircraft’s limitations when the wheels are down. A few seconds after an apparently hard landing, the FP said, “sorry,” and “damn.” Seventeen seconds later, the flying pilot could only say, “hold *, hold *. hang on. hang on.” The NTSB deleted the expletives.

The final seconds of the flight were marked by decisions on the part of the flying pilot that seemed to indicate either a lack of understanding of how certain aircraft systems would function or a more adrenalin-charged series of near instantaneous, almost panicked reactions as nothing he tried seemed to slow the airplane before it left the runway.

Adding to the chaos, this accident nearly became fatal to all aboard as the aircraft slid to a stop. All landing gear eventually separated from the fuselage as the aircraft slid along on its right side The Latitude was equipped with an emergency exit at the right rear of the aircraft. Once the crew secured the engines, they tried to help one of the passengers who was unable to open the entrance door. Unfortunately the pilots were also unsuccessful in their attempts. Another passenger tried unsuccessfully to open the emergency escape door. The pilots were also unable to open that door as they saw heavy smoke and flames beginning to emerge from the rear of the airplane. The two pilots returned to the front door and this time were able to push it open just enough to allow for everyone to scurry to safety before the fire destroyed what was left of the airplane.

Investigators later found the entrance door handle was pushing against the ground on the outside making it difficult to open. Investigators found a fence post had impaled itself into the emergency escape hatch. The NTSB said, “Although there was extensive post-accident fire damage to the hatch, the latching pin was found in the closed and latched position. After investigators removed the hatch from its frame and the pole pinning it in place, the handle operated in a normal manner with full range of motion.”

The NTSB reported the probable cause of this accident as “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, landing gear collapse, and a runway excursion. Contributing to the accident was the pilot’s failure to deploy the speed brakes 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.”

The post Failure to Go Around Leads to Runway Excursion appeared first on FLYING Magazine.