Brotherly Distractions Produce An Overrun

With few exceptions, turbojet-powered civilian airplanes are certified to be flown by two pilots, and operators staff accordingly. However, on occasion, a pilot-in-command (PIC) has to find a replacement for the regular second-in-command (SIC). And while such replacements may be qualified according to FAR Part 61.55, they may not actually be ready to serve as effective crewmembers.

It’s up to the PIC to make a wise and well-informed judgment about the new SIC’s true qualifications for the position, however temporary. When that substitute is a relative or a friend, that judgment can be fraught with risk. It is very likely the dynamic between two familiar, close-knit acquaintances on the flight deck will differ from the more formal interaction of two pilots connected in a strictly professional capacity.

Friends and family members will tend to act casually, use slang terms, communicate non-verbally and have less focus on the command and subordinate roles. The more experienced of the two may try to compensate for the relative inexperience of the other.

Proper application of crew resource management (CRM) can go a long way toward allowing the replacement pilot to fit into your planned operation. CRM, or the application of team management concepts to the flight deck, emphasizes interpersonal communications, leadership and decision-making. Good CRM provides a common mental model of the way the mission is going to be conducted. Such training has long been required at Part 121 airlines, but it is still a somewhat uncertain idea in many Part 91 operations.

A replacement pilot’s misunderstanding of CRM and lack of proficiency contributed to an accident on June 18, 2012.

The owner of a Beechjet 400A (N826JH) had called his pilot who also managed his aircraft and asked him to schedule a flight from their home base of Gadsden, Alabama, to Atlanta and then on to Jacksonville, Florida, leaving two days later at around 0900. The pilot maintained a list of qualified SICs who regularly flew the airplane, but none were available on short notice. The PIC’s brother, who had obtained a BE-400 type rating with “SIC privileges only” in 2007, was available but had not flown the plane regularly in recent years. Nevertheless, the PIC decided to go ahead and fly the trip with his sibling in the right seat.

Two days later, upon touching down at 1006 at Atlanta’s DeKalb-Peachtree Airport (KPDK), the Beechjet overran the end of Runway 20L, crossed an airport service road, veered to the left and struck an airport perimeter fence before coming to a stop — upright, fortunately. The airplane was heavily damaged, both pilots were seriously injured, and the two passengers suffered injuries as well, but comparatively minor.

The NTSB determined the probable cause of the accident was the pilots’ failure to obtain the proper airspeed for landing, which resulted in the jet touching down too fast with inadequate runway remaining to stop. Contributing to the mishap was the failure of either pilot to call for a go-around, their poor CRM and lack of professionalism.

The Flight

The flight departed Northeast Alabama Regional Airport (KGAD) in Gadsden at 0942 that Monday with the SIC flying from the left seat and the owner and one of his employees aboard. The jet was equipped with a cockpit voice recorder (CVR), and the PIC can be heard giving his brother dual instruction before and during the flight using a question and answer style.

To begin, the CVR did not record the use of a clear challenge and response checklist before takeoff. The PIC asked the SIC, “Who’s flying the airplane?” to which the brother replied, “I’m flying the airplane.” But the PIC corrected, “You say, ‘I fly the airplane; you take care of the checklists.’” Shortly after takeoff, the PIC asked, “What you want your speed on?” and the SIC replied, “Uh, ninety six.” At that, the PIC repeated the question, and the brother said, “Two fifty.” The PIC replied, “All right, dial it in over there,” and the SIC asked, “Is that it — outside or inside,” and the PIC said, “Nope, right there. Two fifty. Turn it to the right — turn it, turn it, turn it. Don’t fly * stall — two fifty down here.” Shortly thereafter, the PIC asked, “You forgetting anything?” and the SIC responded, “I don’t know — checklist — after-takeoff checklist.” The PIC performed after-takeoff items and reminded the SIC he must call for the after-takeoff checklist.

The flight was cleared to maintain 5,000 ft. and intercept Victor 325. As the airplane approached the airway and the altitude, the PIC said “Capture that nav right there — take your range — take your hands off of that.” At 0946:33, the CVR recorded an overspeed warning that lasted 13.9 sec. The PIC told the SIC to reduce thrust. He told the passengers, “That’s my fault; no problem guys,” but the owner said, “Oh, I thought we had a problem,” and “I was thinking are we fixing to crash?” To the SIC, the PIC said, “See how quick it’ll get away from you?” and then, “Scan . . . scan.” Atlanta Center next cleared the flight to climb to and maintain 13,000 ft. and the two pilots had a discussion about the use of the vertical speed mode of the autopilot. The PIC said, “You get above 10,000 — you’re fixing to overspeed again.”

At 0951:16, Atlanta Center cleared the flight to cross CARAN at 8,000 ft. The SIC did not hear the clearance, prompting the PIC to ask, “How’s your headset working?” Atlanta Center then revised the clearance to cross 13 west of DALAS at 8,000 ft.. Over the next 4 min. the pilots had a more or less continuous conversation, with the PIC coaching his brother on how to use the vertical speed control and set the power to manage the descent, but the SIC was having difficulty. During the descent the PIC said, “You hear me? All right, do something with that vertical speed if you’re gonna go back to 8,000.” And 24 sec. later, the PIC cautioned, “I wouldn’t power up in a descent. Pull power; pull power back.”

At 0955:45, the flight checked in with Atlanta Approach and was cleared to descend farther to 5,000 ft. The PIC did not include the ATIS on his initial call, so Approach Control said, “Advise when you have information India.” During the next 30 sec., as the PIC attempted to listen to the ATIS, his brother interrupted him four times with questions.

At 0959:05, after receiving further clearance to 4,000 ft., the SIC said “I can’t get vertical speed to work at all,” and after another verbal exchange the PIC said, “Disconnect the autopilot and hand-fly.” At 1002:58, the PIC said, “I want you to learn how. When you say it’s not working, you gotta look around.”

The flight was cleared direct to the airport and down to 3,000 ft. and asked to call the airport in sight. At 1003:22, the PIC called the airport in sight, received clearance for a visual approach to Runway 20L, and was instructed to contact the tower. Upon initial contact, the tower said, “Traffic’s a Cessna 5-mi. final for the right side — Runway 20 left clear to land. That traffic is at 2,200 indicated.”

In the next 2 min. and 20 sec. before the end of the CVR recording, there were 48 verbalizations or warnings — 10 tower transmissions, four calls from the Cessna, one TCAS warning, five TAWS warnings, six radio calls from the Beech crew and 22 crew statements — on average, one every 3 sec.

At 1004:23, the tower said, “Beech Juliet Hotel previously called traffic 12 o’clock two and a half miles 2,000 indicated,” then, “November Six Juliet Hotel advise maintain present altitude until you have that aircraft in sight — he’s at 2,000.” The PIC replied, “Six Juliet Hotel we’re looking — no joy.”

At 1004:37, the PIC told the SIC, “All right. What do you want? Don’t speed up now you’re fixing to land,” followed immediately by the SIC stating they were instructed to maintain altitude. At 1004:41, the controller advised the Cessna pilot that the Beechjet 400A was “a mile off your right side 2,300 indicated.” At 1004:42, the CVR recorded, “traffic, traffic.” The PIC saw a blinking yellow target ahead of their position on the TCAS display, but the SIC did not see the TCAS display because he was looking outside the cockpit.

Despite never seeing the Cessna, the Beechjet crew continued their descent on base leg, crossing over the top of the other airplane. At 1005:05, the PIC said “let me see a second,” and took control of the airplane without verbalizing doing so. At 1005:21, the SIC said “before-landing checklist,” but he was interrupted by an aural caution “sink rate, sink rate.” The PIC replied “done.” However, the airplane was not fully configured for landing.

The TAWS announced either “sink rate” or “pull up” warnings multiple times as the airplane approached the runway. The PIC said “way too fast” but continued the approach. The tower controller said in an interview that he saw the airplane touch down abeam the VOR/DME station.

After touchdown, the PIC applied the wheel brakes, but the airplane did not decelerate as expected. He was startled by the fact that the brakes were ineffective, and did not deploy the speed brakes or thrust reversers. When he saw the airplane would not stop by the end of the runway, he steered it away from the localizer antenna to avoid a fire. The CVR recorded the sound of the airplane touching down at 1005:55 and the sound of impacts at 1006:12.

The Investigation

The 66-year-old PIC held an airline transport pilot (ATP) certificate with an airplane multiengine land rating and type ratings in the CE-500, BE-300, BE-400, MU-300 and HS-125. He held a first-class medical certificate with the limitation “must wear corrective lenses” and received a special issuance due to sleep apnea, high blood pressure and related medications.

His reported total flight time was 10,800 hr., which included 1,500 hr. as PIC in the BE-400. He reported having 25 flight hr. in the previous 30 days and 100 hr. in the previous 90. He completed a BE-400 recurrent PIC course at Simcom on Dec. 22, 2010, and a Hawker 800XP initial at FlightSafety International on Sept. 25, 2011.

A contract pilot, he also provided flight and aircraft management services through his own company. He had managed the accident airplane for five years and a King Air for the same company before that. He stated he had received normal rest in the three days before the accident.

The SIC was 68, held an ATP with an airplane multiengine land rating and type ratings with SIC privileges only for the BE-300, BE-400 and MU-300. He held a second-class medical certificate with a limitation to have glasses available for near vision. On his most-recent medical examination he had failed the normal color vision test but passed on the basis of a statement of demonstrated ability that had been administered in 1997.

He stated he had 3,500 hr. of flight time and 150 hr. in the BE-400, and he also said he had flown 9.7 hr. in the Beechjet the month before the accident. He estimated he had made 15-20 landings in that airplane. However, he could provide no logbook verification.

His most-recent training was a Beechjet 400A recurrent SIC course taught by his brother in April, two months before the accident. His name had not been entered in the aircraft logbook during that time. When asked what his CRM training involved, he said “V speeds, flap speeds, standard callouts, climb-outs.” He had normal rest before the accident flight and had no major health or personal issues. He was not a professional pilot but had been paid to fly on occasion.

The airplane was manufactured in 1993 and was certified under Part 25 for two crewmembers. Its total flight time was approximately 4,711 hr. The maximum flap extend speed for 10 deg. of flaps was 200 KIAS and the maximum flap extend speed for 30 deg. of flaps was 165 KIAS. An electrically powered anti-skid system was designed to release brake pressure when a skid was detected by a wheel speed transducer. The maximum deploy cycle time of the thrust reverser lever was 1.6 sec. at 100 KCAS.

Investigators found the nose and left main landing gear separated but close to the airplane and the right main landing gear separated but lodged between the aft wing root and fuselage. The fuselage was fractured at the front pressure bulkhead and aft abeam the engines. There was no evidence of fire. Both flaps were retracted, although the flap selector in the cockpit was at 30 deg. Both thrust reversers were stowed, the speed-brake switch was retracted, and the anti-skid was on. No failures were found in the flight control system. The horizontal stabilizer jackscrew was positioned at -3.6 leading-edge angle, which corresponded to 2.3 deg. from full nose-down trim. No failures were found in the flap system components. An examination and testing of the brakes and anti-skid system showed no evidence of failure.

An enhanced ground proximity warning system (EGPWS) was recovered from the aircraft, downloaded and evaluated by a specialist in the NTSB Vehicle Recorder Lab. In addition to the cautions and warnings already heard on the CVR, the EGPWS recorded data included airplane heading, GPS position, GPS altitude and vertical speed. Ground speed was derived from aircraft position information. The last recorded position was 0.5 nm from the displaced threshold of Runway 20L at KPDK. At that point, the airplane’s altitude was 153 ft. AGL, the calculated ground speed was 194 kt., and the descent rate was greater than 2,150 fpm. The stab trim position corresponded to the 194-kt. ground speed determined by the EGPWS data.

When investigators calculated the airplane’s weight and balance, they found the flight was within limits, the appropriate Vref for landing was 115 kt., and the unfactored dry runway landing distance was 3,505 ft. (The unfactored landing distance is not adjusted for any safety margin additives.) The winds were variable at 3 kt. and the visibility was 8 mi.

EGPWS Data

KPDK’s Runway 20L was concrete with diamond-ground grooves and had a positive gradient of 0.2%. The runway length was 5,001 ft. (excluding the displaced threshold), but the published landing distance was 4,801 ft. due to the proximity of the airport boundary fence. There was a two-light precision approach path indicator (PAPI) on the right side of Runway 20L, which provided a 3-deg. glidepath. A VOR/DME was located 2,031 ft. down the runway from the displaced threshold, resulting in 2,970 ft. remaining from abeam the VOR/DME to the departure end of Runway 20L. The airport director said an engineered materials arrestor system (EMAS) was to be installed in 2015.

Findings

Explaining the probable cause, the NTSB said the flight crew demonstrated poor CRM, evidenced by poor communication, lack of crew monitoring and lack of situational awareness. They did not perform a standard transfer of control, failed to adhere to ATC instructions, did not verbalize checklists, and failed to monitor and crosscheck each other. Furthermore, the brother-pilots were unable to visualize their position relative to the Cessna despite ATC assistance and onboard TCAS audible and visual alerts. The Safety Board further found the SIC’s lack of proficiency caused the PIC to coach/instruct him, which distracted the latter from his duties and reduced his situational awareness.

The PIC heard the “sink rate” and “pull up” warnings but ignored them. He knew he was “way too fast” on final approach but never checked to see if the flaps were down. He did not deploy the speed brakes, which, if deployed, would have put the weight on the wheels. He claimed the brakes malfunctioned, but intermittent skid marks showed the anti-skid system was working properly, applying and releasing the brakes in response to skidding. Had he deployed the thrust reversers, it might have reduced the airplane’s speed when it hit the fence, and lessened the resulting damage. He said he didn’t go around for fear of colliding with the Cessna, but he had quite deliberately crossed the Cessna’s flight path without seeing it just a few moments earlier.

The PIC overloaded himself by putting his very rusty brother in the left seat and continuing to give him instruction even when a collision was imminent, and then he continued the approach without any semblance of adherence to checklists, callouts, aural warnings or stabilized approach criteria. The brother belied any knowledge of CRM by failing to make callouts, run checklists or insist on a go-around.

The role of a replacement pilot is not just to support you in doing what you want to do, but also to monitor your actions, decisions and errors, and to call them out, forcefully if necessary. By doing so, that substitute may just save you from yourself.

Author’s note: I participated in this investigation as the group chairman for operational factors.