Charleston, WV, USA
N246PS
BOMBARDIER CL600
Cockpit voice recorder (CVR) information revealed that the flight crew began a personal conversation (that is, a conversation not pertinent to the operation of the airplane) during departure delay. The flight crewmembers continued the nonpertinent conversation throughout the entire taxi, which was not in accordance with company procedures and Federal regulations regarding sterile cockpit. CVR information also revealed that, although the flight crew completed all of the required checklist items during the taxi, each item was read and responded to in a very quick and routine manner. About 1609, the captain called for flaps 20 and then for the Taxi checklist. Flight data recorder (FDR) data indicated that, 1 second later, the flaps moved from the flaps 0 to the flaps 8 position. Further, while conducting the checklist, the first officer stated, “flaps 8” and “eight degrees,” indicating that he had selected the flap handle to the flaps 8 position, not to the flaps 20 position as called for by the captain. However, the captain responded, “set” and “eight,” respectively, indicating that he did not notice the incorrect flap setting. The rapid and perfunctory manner in which the flight crew conducted the Taxi checklist resulted in the captain not visually comparing the airplane’s flap position with the aircraft communications addressing and reporting system data, which was his normal practice. After rapidly completing the Taxi checklist, the flight crew continued the nonpertinent conversation until the captain called for the Before Takeoff checklist. After the flight crew rapidly conducted this checklist, without including a proper takeoff briefing, the flight was cleared for takeoff. The takeoff was normal until the airplane reached an airspeed of about 120 knots. At this time, FDR data showed the flaps beginning to move from the flaps 8 to the flaps 20 position. Shortly thereafter, the first officer stated, “V one [the takeoff decision speed],” which was 127 knots. The CVR then recorded the sound of the airplane master caution and flaps and spoilers configuration aural alerts. The captain initiated a rejected takeoff (RTO) about 5 seconds after he started moving the flaps and when the airplane was at an airspeed of about 140 knots, which was 13 knots above V1. Bombardier computed the total distance required for the incident airplane to accelerate stop using data from the FAA-approved Airplane Flight Manual and the planned takeoff performance data (including configuration, weight, altitude, and reduced thrust takeoff). The calculations indicated that the airplane would have stopped about 5,730 feet from the beginning of the takeoff roll if the deceleration had been initiated at the planned V1 (127 knots). Given that the runway was 6,300 feet long and that FDR data indicated a normal deceleration during the RTO, sufficient runway distance would have existed for the airplane to stop on the runway surface if the captain had initiated the RTO immediately after he identified the misconfigured flap setting instead of reconfiguring the flaps. The captain should have called for an RTO as soon as he recognized the flaps were in the wrong position. As a result of the captain’s decision to attempt to reconfigure the flaps and delay the RTO, the airplane overran the runway end and entered the engineered materials arresting system (EMAS) at an airspeed of about 50 knots. The airplane stopped 128 feet into the EMAS arrestor bed with about 277 feet of arrestor bed remaining. Before the installation of the EMAS in September 2007, the runway end safety area for runway 23 was only 120 feet long. If this incident had occurred before the installation of the EMAS, the airplane most likely would have traveled beyond the length of the original safety area and off the steep slope immediately beyond its end.
History of Flight On January 19, 2010, the flight crew of PSA Airlines, doing business as US Airways Express flight 2495, rejected the takeoff of a Bombardier CL-600-2B19, N246PS, which subsequently ran off the runway end and then stopped in the engineered materials arresting system (EMAS) installed in the runway end safety area at Yeager Airport (CRW), Charleston, West Virginia. None of the 31 passengers (including one lap-held child) or 3 crewmembers sustained injuries, and the airplane received minor damage. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121, and its intended destination was Charlotte Douglas International Airport, Charlotte, North Carolina. The incident flight was the fifth flight for the flight crewmembers in the first day of a 3-day trip sequence, and they were scheduled to be on the ground at CRW for about 30 minutes. The first officer stated that, during that time, he completed a walk-around inspection of the airplane and received the takeoff performance data via the aircraft communications addressing and reporting system (ACARS). The ACARS performance data included the following: takeoff weight 44,400 pounds, takeoff flap setting 20, FLEX 33 takeoff thrust setting (reduced thrust takeoff), V1 (takeoff decision speed) of 127 knots, and Vr (rotation speed) of 128 knots. The captain was the flying pilot for the incident flight. According to cockpit voice recorder (CVR) information, the flight crew completed the Before Start checklist at 1554:25. (All times in this report are eastern standard time based on a 24-hour clock.) At 1558:51, the captain made a public address announcement indicating that the departure would be delayed about 15 minutes. At 1602:35, the first officer notified the local controller (LC) that the airplane was ready to taxi, and the LC instructed the flight crew to hold the airplane on the ramp. About 1 minute later, the flight crew started a personal conversation (that is, a conversation not pertinent to the operation of the airplane) after setting the parking brake, and this conversation continued until 1607:32 when the LC instructed the flight crew to taxi to runway 23. (The LC was working both the ground and local positions.) Flight data recorder (FDR) data indicated that, 1 second later, the parking brake was released and the airplane began to taxi. At 1607:40, the captain continued the nonpertinent conversation. At 1608:44, the captain stated, “flaps twenty,” and then called for the Taxi checklist. FDR data indicated that, 1 second later, the flaps moved from the flaps 0 to the flaps 8 position. At 1609:02, the first officer began the Taxi Checklist, during which he stated, “flaps eight,” and the captain responded, “set.” At 1609:08, the first officer continued the checklist, stating, “flaps trims eight degrees,” and the captain responded, “eight.” The first officer completed the Taxi Checklist at 1609:13. The captain continued the nonpertinent conversation from 1609:19 to 1611:47 when he called for the Before Takeoff checklist. At 1612:01, the first officer began the Before Takeoff checklist. At 1612:05, the LC cleared the airplane for takeoff, and the first officer acknowledged the instruction. (FDR data indicate that the airplane continually taxied from its initial taxi clearance at 1607:38 until its takeoff clearance at 1612:05.) At 1612:18, the first officer continued the Before Takeoff checklist, stating, in part, “takeoff briefing. No questions.” The first officer completed the checklist at 1612:27. FDR data showed the airplane heading aligning with the runway heading and the engine thrust increasing to takeoff thrust at 1612:50. Three seconds later, the captain asked, “we’re cleared to go right?” and the first officer responded, “yup.” At 1613:06, the captain stated, “set thrust,” and the first officer responded, “thrust set.” Four seconds later, the captain stated, “eighty knots,” and the first officer responded, “checked.” FDR data showed that, at 1613:20, the flaps position began moving from the flaps 8 toward the flaps 20 position and the speed was about 120 knots. At 1613:21, the first officer stated, “V one,” at which time, the airspeed was about 127 knots. Two seconds later, the CVR recorded the sound of the airplane master warning and then the flaps and spoilers configuration aural alerts. FDR data showed that, at 1613:25, both engine fan speeds began decreasing, the flight and ground spoilers were extended, and both of the captain’s brake pedals were depressed. The airplane reached a maximum airspeed of about 143 knots at 1613:26. At 1613:36, the first officer contacted the LC, stating, “rejecting…off the end of…runway two three.” At 1613:38, the airplane entered the engineered materials arresting system (EMAS) at an airspeed of about 50 knots, and, about 3 seconds later, it stopped about 128 feet into the EMAS arrestor bed (178 feet from the runway end). (The EMAS is set back 50 feet from the runway end.) Damage to Aircraft The flaps, landing gear, and landing gear doors received minor damage. Personnel Information The captain, age 38, was hired by PSA Airlines on June 21, 1999. He held an airline transport pilot certificate with airplane multiengine land, Dornier DL 328, and CL-65 ratings. (CL-65 is the rating given for CL-600 series airplanes.) The captain held a first-class medical certificate dated April 3, 2009, with a limitation that he must “wear corrective lenses.” PSA Airlines records indicated that the captain had accumulated 9,525 total flight hours, including 4,608 hours as pilot-in-command in the CL-65 airplane. In the 90 days, 30 days, and 24 hours before the incident, the captain had flown 169, 39, and 4 hours, respectively. He received his last proficiency check on February 25, 2009; his last line check on August 6, 2009; and his last recurrent ground training on August 24 and 25, 2009. The first officer, age 44, was hired by PSA Airlines on July 7, 2007. He held a commercial pilot certificate with airplane single and multiengine land and CL-65 (second-in-command privileges only) ratings. The first officer held a first-class medical certificate dated April 20, 2009, with no limitations. PSA Airlines records indicated that the first officer had accumulated 3,029 total flight hours, including 1,981 hours in the CL-65 airplane. In the 90 days, 30 days, and 24 hours before the incident, the first officer had flown 249, 103, and 4 hours, respectively. He received his last proficiency check on August 20, 2009, and his last recurrent ground training on August 27 and 28, 2009. Meteorological Information Visual meteorological conditions prevailed at the time of the accident. The CRW surface weather observation indicated the following: winds calm, visibility 10 statute miles, scattered clouds at 4,500 feet, broken clouds at 5,500 feet and 8,000 feet, and altimeter setting 29.91 inches of mercury. Airport Information CRW is located about 3 statute miles east of Charleston, West Virginia, and sits atop a plateau about 280 feet above the surrounding terrain. Runway 5/23 is grooved asphalt, and it is 6,300 feet long and 150 feet wide and has precision markings and distance remaining signs on the right side. The terrain at the end of runway 23 drops off sharply about 350 feet. An EMAS was installed at the departure end of runway 23 in September 2007. The EMAS is 170 feet wide and 455 feet long, including a 405-foot-long arrestor bed and a 50-foot-long setback from the runway end. Before installation of the EMAS, the runway end safety area was about 120 feet long. According to the EMAS manufacturer, the EMAS at CRW is less than 600 feet long, which is the standard Federal Aviation Administration (FAA) EMAS installation; however, it has a standard 70-knot predicted performance for airplanes of similar size and weight to the Bombardier CL-600 (that is, the EMAS at CRW is designed to stop such airplanes if they enter the EMAS bed at 70 knots or less). Flight Recorders The airplane was equipped with a solid-state L-3 Communications Fairchild model FA2100 1020 CVR. The CVR was in good condition, and the audio information was extracted from it normally. Although the CVR recording began at 1432:14, the transcript starts at 1554:07 as the flight crew was conducting the Before Start checklist. The airplane was equipped with an L-3 Communications Fairchild model FA2100 FDR. The recorder was in good condition, and the data were extracted from it normally. Medical Information In accordance with Federal regulations, the captain and first officer were tested by PSA Airlines for alcohol and five major drugs of abuse. Both pilots tested negative for drugs and alcohol. Tests and Research Accelerate-Stop Calculations Bombardier computed the total distance required for the incident airplane to accelerate-stop using data from the FAA-approved Airplane Flight Manual. The calculations indicated that the airplane would have stopped about 5,730 feet from the beginning of the takeoff roll if the deceleration had been initiated at the planned V1 (127 knots) assuming an airplane weight of 44,400 pounds, flaps 20, reduced thrust, no thrust reverser, 897 feet elevation, and altimeter setting 29.91 inches of mercury. As noted, runway 23 is 6,300 feet long. Additional Information Maintenance Inspections As a result of the incident, PSA maintenance personnel conducted the following inspections in accordance with the Airplane Maintenance Manual: rejected takeoff, pitot tubes, thrust reverser system, and takeoff configuration system. All system checks were normal. Sterile Cockpit Procedures The PSA Airlines Flight Operations Manual (FOM), Section 4.10.11, “Sterile Flight Deck,” states, in part, that, during critical phases of flight, flight crewmembers are prohibited from performing nonessential duties or activities. The FOM stated that critical phases of flight include all ground operations involving taxi, takeoff, and landing, and all other flight operations conducted below 10,000 feet mean sea level except for cruise flight. The FOM stated that essential duties and activities were required for the safe operation of the aircraft and that nonessential duties and activities were not required for the safe operation of the aircraft. Title 14 CFR 121.542, “Flight Crewmember Duties,” states, in part, the following: (a) No certificate holder shall require, nor may any flight crewmember perform, any duties during a critical phase of flight except those duties required for the safe operation of the aircraft… (b)No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft. (c) For the purposes of this section, critical phases of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight. Note: Taxi is defined as ‘movement of an airplane under its own power on the surface of an airport.’ FAA Aeronautical Handbook, FAA-H-8083-9A, Chapter 8, “Techniques of Flight Instruction, Sterile Cockpit Rule,” states, in part, the following: Commonly known as the ‘sterile cockpit rule,’ Title 14 of the Code of Federal Regulations (14 CFR) section 121.542 requires flight crewmembers to refrain from nonessential activities during critical phases of flight. As defined in the regulation, critical phases of flight are all ground operations involving taxi, takeoff, and landing, and all other flight operations below 10,000 feet except cruise flight. Nonessential activities include such activities as eating, reading a newspaper, or chatting. The captain stated that he and the first officer had “probably not” maintained a sterile cockpit during the incident taxi. The first officer stated that, when the airplane was moving, the flight crewmembers were not supposed to discuss anything not pertinent to the flight. He stated that he and the captain did not maintain a sterile cockpit. Flaps Procedures The PSA Airlines FOM, Section 4.6.5, “Taxi Check (Challenge & Response, FO Flow),” provides the following information: Once clear of the ramp area, the captain was to call for the flaps to be set and state what the flap setting should be. The F/O [first officer] was to perform the “Taxi Flow” prior to commencing the Taxi Checklist. The “Taxi Flow” called for the F/O to set the flaps to the takeoff setting. The second item on the Taxi Checklist called for both pilots to verify the flaps and trim were set for takeoff and state the flap setting and trim setting. The CL-600 is certified for takeoff flap settings of 8 or 20, and each flap setting has different takeoff performance data (that is, different airspeeds and distances). The captain stated that, during the Taxi checklist, the flap setting had to be verified by looking at the ACARS to see whether it indicated flaps 20 or flaps 8 and then looking at the Engine Indicating Crew Alerting System (EICAS) to verify that the flaps were properly set. He stated that he was not sure if he took these actions during the incident taxi and that he might have just repeated what the first officer said. The first officer stated that the captain called for flaps 20 and then the Taxi checklist, which he subsequently performed. He indicated that he was aware that a flaps 20 setting was used for takeoffs at CRW. He stated that, to verify the flap setting, he typically touched the flap handle, looked at the EICAS, and confirmed the ACARS information. He stated that the only time the flap setting was verified was during the Taxi checklist. Rejected Takeoff Guidance The PSA Airlines FOM, Section 7.1.2, “Rejected Takeoff,” states, in part, the following: If the takeoff is rejected with both engines operating, the Captain will retard the thrust levers to reverse while using maximum braking. PSA Airlines recommends an RTO [rejected takeoff] for any malfunction below 80 knots. Above 80 knots, an RTO is recommended for items such as: • Engine failure • Fire warning • Aircraft is considered unsafe or unable to fly • Loss of directional control. The FOM also stated that either pilot should call, “reject.” A chart in the manual directed the captain to bring the thrust levers to idle, apply maximum braking, and apply maximum reverse thrust consistent with directional control. The chart directed the first officer to make standard landing callouts and notify air traffic control. The PSA Airlines FOM, Section 7.8.4, “V1,” states, in part, the following: V1 is the maximum speed to which an aircraft can accelerate, lose an engine, and either stop or takeoff in the remaining distance. FAA Advisory Circular 120-62, “Takeoff Safety Training Aid,” defines V1 speed as follows: a. V1. The speed selected for each takeoff, based upon approved performance data and specified conditions, which represents: (1) The maximum speed by which a rejected takeoff must be initiated to assure that a safe stop can be completed within the remaining runway, or runway and stopway; (2) The minimum speed which assures that a takeoff can be safely completed within the remaining runway, or runway and clearway, after failure of the most critical engine at a designated speed; and (3) The single speed which permits a successful stop or continued takeoff when operating at the minimum allowable field length for a particular weight. The captain stated that the takeoff was normal until the 80-knot callout when he realized that the flaps were misconfigured. He stated that the incorrect flaps setting would have been a reason to abort the takeoff and that h
(1) The flight crewmembers’ unprofessional behavior, including their nonadherence to sterile cockpit procedures by engaging in nonpertinent conversation, which distracted them from their primary flight-related duties and led to their failure to correctly set and verify the flaps; (2) the captain’s decision to reconfigure the flaps during the takeoff roll instead of rejecting the takeoff when he first identified the misconfiguration, which resulted in the rejected takeoff beginning when the airplane was about 13 knots above the takeoff decision speed and the subsequent runway overrun; and (3) the flight crewmembers’ lack of checklist discipline, which contributed to their failure to detect the incorrect flap setting before initiating the takeoff roll. Contributing to the survivability of this incident was the presence of an engineered materials arresting system beyond the runway end.
Source: NTSB Aviation Accident Database
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