Atlanta, GA, USA
N826JH
BEECH 400A
The second-in-command (SIC) was the pilot flying for most of the flight (takeoff, climb, cruise, and descent) and was in the left seat, while the pilot-in-command (PIC) was the pilot monitoring for most of the flight and was in the right seat. Before takeoff, the PIC calculated reference speed (Vref) for the estimated landing weight and flaps 30-degree extension was 120 knots, with a calculated landing distance of 3,440 ft. Further, before takeoff, there were no known mechanical difficulties with the brakes, flaps, antiskid, or traffic alert and collision avoidance (TCAS) systems. After takeoff and for most of the flight, the PIC coached/instructed the SIC, including instructions on how to set the airspeed command cursor, a request to perform the after-takeoff checklist, and a comment to reduce thrust to silence an overspeed warning aural annunciation. When the flight was northwest of Dekalb Peachtree Airport (PDK), Atlanta, Georgia, on a right base leg for a visual approach to runway 20L with negligible wind, air traffic controllers repeatedly announced the location and distance of a Cessna airplane (which was ahead of the Beech 400A on a straight-in visual approach to runway 20R). Because the Beech 400A flight crew did not see the other airplane, the controllers appropriately instructed them to maintain their altitude (which was 2,300 ft mean sea level [msl]) for separation until they had the traffic in sight; radar data indicated the Beech 400A briefly descended to 2,200 ft msl then climbed back to 2,300 ft msl. According to the cockpit voice recorder (CVR) transcript, at 1004:42, which was about 12 seconds after the controller instructed the Beech 400A flight crew to maintain altitude, the on board TCAS alerted "traffic traffic." While the Beech 400A did climb back to 2,300 ft msl, this was likely a response to the air traffic control (ATC) instruction to maintain altitude and not a response to the TCAS "traffic traffic" warning. At 1004:47, the CVR recorded the SIC state, "first degree of," likely referring to flap extension, but the comment was not completed. The CVR recorded an immediate increase in background noise, which was likely due to the landing gear extension. The PIC then advised the local controller that the flight was turning onto final approach. The CVR did not record any approach briefing or discussion of runway length or Vref speed. The PIC stated in a postaccident interview that he took control of the airplane during the base leg on approach to PDK. This likely occurred at 1005:05, when the CVR recorded the PIC state, "let me see a second"; however, the transfer was not explicitly verbalized. According to the CVR transcript, at 1005:08, the controller advised the Cessna pilot that the Beech 400A had just flown over his airplane, which the Cessna pilot confirmed; about that time, radar data indicated that the Beech 400A was at 2,400 ft msl, and the Cessna was at 1,800 ft msl. However, both the SIC and the PIC of the accident airplane erroneously believed the Cessna was 300 ft above them. The PIC of the accident airplane reported that because of the perceived location of the traffic conflict, he initiated a right turn and descent for the runway without seeing the Cessna and contrary to the instructions from the controller. During the approach, the enhanced ground proximity warning system (EGPWS) sounded the aural caution "sink rate sink rate" and also the aural warning "pull up pull up" several times. The CVR did not record comments from either flight crewmember about the cautions or warnings; they performed no maneuvers in response to the cautions or warnings and elected to continue the approach to the runway rather than perform a go-around, which is what they should have done after they evaluated the situation and per the Flight Manual Supplement. At the last recorded EGPWS position (.5 nautical mile [nm] from the displaced threshold and 153 ft above the displaced threshold elevation of runway 20L), the calculated groundspeed was 194 knots, and the descent rate was greater than 2,150 ft per minute. During postaccident interviews, neither flight crewmember could recall the airspeed during the approach; however, the PIC reported that he believed the airplane was high and fast on approach, which is consistent with his comment of "way too fast" recorded on the CVR. Witnesses, including PDK tower controllers, reported that the airplane appeared to be fast on approach, and the touchdown point on the runway was consistently reported to be about abeam the very high frequency omnidirectional range/distance measure equipment navigation aid on the airport, which allowed for about 2,970 ft of runway remaining. After touchdown, an unidentified crewmember called for deployment of the thrust reversers, and the SIC called for deployment of the speed brakes. The PIC reported applying the wheel brakes, but the airplane did not decelerate as expected. He stated that he released and then reapplied the wheel brakes with maximum force, again without effect. During a postaccident interview, he attributed the inability to stop the airplane to be a malfunction of the normal brake system; however, both passengers in the accident airplane reported hearing sounds consistent with brake application during the landing roll. Further, skid marks alternating light and dark in color were found on the runway, which are indicative of brake application and antiskid release. The airplane departed the end of the runway and came to rest about 800 ft from the departure end of the runway adjacent to the airport boundary fence. The PIC reported in a postaccident interview that after the accident, he set the airplane back to takeoff configuration. Given the observed touchdown point, the retracted flaps position, and the excessive speed during the approach, the airplane would not have been able to stop on the runway. Although the PIC reported that he positioned the flap selector to the 30-degree position during the approach and it was found in that position during the investigation, postaccident inspection of the flap system components indicated that the flaps were retracted. The CVR recorded the SIC begin a command to extend the flaps to the first notch; however, the PIC did not verbally respond to the incomplete command for flaps to be set, the before-landing checklist was not verbalized, and there was no discussion of flap position. While the speed during the final portion of the approach and at touchdown could not be determined, it is unlikely the airplane decelerated to or below the maximum 30-degree flap extension speed of 165 knots before touchdown, given that the airplane's groundspeed was 194 knots when the airplane was .5 nm from the displaced runway threshold. Further, operation of the airplane with 30 degrees of flaps extended at speeds in excess of the maximum allowable speed would have resulted in noticeable vibration; the passengers reported that they did not notice anything unusual about the flight until landing. The estimated high airspeed at landing reported by witnesses also indicated that the flaps were not extended because the flaps set in the 30 degree position would have resulted in aerodynamic deceleration. Additionally, no evidence of preimpact failure or malfunction of the flap system components was noted. Therefore, the as found position of the flap selector most likely occurred after the airplane came to rest and not during flight as reported by the PIC. Calculations by the airplane manufacturer indicate that in the configuration of the airplane on approach (flaps retracted), any speed greater than 142 knots would have resulted in an inadequate distance remaining to stop the airplane from the observed touchdown point. Postaccident examination and testing of the brake and antiskid system components revealed no evidence of preimpact failure or malfunction, even though the PIC reported that the inability to stop the airplane was caused by a malfunction of the wheel brake system. Further, alternating light and dark-colored marks on the runway indicated braking action and antiskid release of brake pressure consistent with normal operation of both systems. The lack of deceleration was most likely the result of the airplane being at an excessive airspeed with the flaps retracted, rendering a light weight-on-wheels condition and, thus, reduced wheel braking. While the light weight-on-wheels condition could have prevented the deployment of the thrust reversers and speed brakes, it is also possible that the flight crew did not deploy the thrust reversers and speed brakes, despite the comments recorded on the CVR. The PIC's intentional action of setting the airplane in takeoff configuration after the accident prevented the conclusive determination of the thrust reverser and speed brake settings. The deployment of the speed brakes would have increased weight on wheels, resulting in increased braking action. In a postaccident interview, the PIC stated that he did not consider performing a go around because he did not see the Cessna that was landing on runway 20R. However, several factors should have necessitated a go-around. First, the accident airplane's excessive airspeed was characterized by both the PIC and witnesses as fast. The investigation could not determine the accident airplane's airspeed at touchdown; however, the as-found position of the horizontal stabilizer pitch trim closely matched the position it would have been set to at the last groundspeed value recorded by the EGPWS (194 knots, determined at a point .5 nm from the displaced runway threshold), which was in excess of the calculated Vref speed of 120 knots. At 1005:28, the CVR recorded the PIC state that the airplane was "way too fast," indicating his awareness of the excessive airspeed. Second, the excessive rate of descent that caused the EGPWS to sound the sink rate alarm indicated an unstabilized approach. Third, Flight Manual Supplement 206 to the Airplane Flight Manual states that when an aural "pull up" warning occurs, the flight crew should level the wings, add maximum power, increase pitch to 15 degrees nose up, retract flaps if extended, and climb at the best angle of climb speed. The flight crew did not take these actions in response to the warning. Finally, the runway distance remaining (of about 2,970 ft) at the touchdown point was inadequate for the airplane to stop based on the PIC's preflight calculations and postaccident calculations. Based on the airplane configuration at touchdown, any speed greater than 142 knots would have resulted in a landing overrun. While the PIC recognized the excessive airspeed, neither pilot responded to the excessive airspeed, excessive rate of descent, the EGPWS system alarms, or the insufficient runway remaining to land and called for a go around, even though the airplane had sufficient altitude and airspeed to safely do so. The flight crew also demonstrated poor crew resource management (CRM), evidenced by poor communication, lack of crew monitoring, and lack of situation awareness. Regarding poor communication, the PIC's statement of "let me see a second" likely indicated the point when he took control of the airplane from the SIC and deviated from the standard "my airplane" transfer of control command. Further, the flight crew's actions while on the base leg, including the flight crew's failure to adhere to instructions from air traffic controllers not to descend until the Cessna traffic was in sight, show a lack of crew monitoring and cross-checking between the PIC and SIC, important concepts of CRM to ensure the highest levels of safety. Although the SIC reminded the PIC that they were not to descend, the PIC did not respond, and the SIC briefly descended then returned to the appropriate altitude. Further, the PIC and SIC both exhibited poor situation awareness throughout the accident flight. First, they were not able to accurately visualize their position in relation to the Cessna, despite repeated communication from the controller announcing the location and altitude of the Cessna. The PIC and SIC apparently did not realize that the tower transmission to the Cessna of "five eight echo that previous traffic's a mile off your right side [2,300 msl] indicated" was a reference to them since they were at the altitude the transmission described. Second, the on board TCAS issued an audible and visual alert regarding the Cessna, but neither the PIC nor the SIC was able to accurately determine the Cessna's altitude and location despite the information that the TCAS and ATC provided. This lack of situation awareness was likely caused by the SIC's lack of proficiency in the airplane during the accident flight. His lack of proficiency (evidenced by his inability to locate and set the airspeed command cursor, his failure to perform the after-takeoff checklist, the overspeed warning exceedance after takeoff, and his inability to get the vertical speed command to work during the descent) led the PIC to coach/instruct him for most of the flight, which likely distracted the PIC from his pilot monitoring duties, reducing his situation awareness. Further, the flight crewmembers demonstrated unprofessional behavior, evidenced by a lack of checklist usage. The SIC's lack of experience in the make and model airplane demanded extra vigilance regarding the use of checklists, which did not occur. Before departure, the CVR did not record the use of a before-takeoff checklist; the CVR recorded the pilots stating some individual pre-takeoff items but not as part of a clear challenge/response checklist. In addition, the approach and before-landing checklists and the transfer of control of the airplane from the SIC to the PIC were not explicitly verbalized. Further, the SIC asked for the descent checklist, to which the PIC responded, "hang on a second"; the complete checklist was not verbalized, and there was no challenge and response. Although not required for Part 91 flights, checklists are universally recognized as basic safe aviation practices.
HISTORY OF FLIGHTOn June 18, 2012, about 1006 eastern daylight time (EDT), a Beechcraft Corporation 400A, N826JH, collided with terrain following a landing overrun on runway 20L at Dekalb-Peachtree Airport (PDK), Atlanta, Georgia. The airline transport pilot and copilot sustained serious injuries, and the two passengers sustained minor injuries. The airplane was substantially damaged. The airplane was registered to and operated by N79TE, LLC, under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as an executive/corporate flight. Visual meteorological conditions (VMC) prevailed for the flight, which operated on an instrument flight rules (IFR) flight plan. The flight originated at Northeast Alabama Regional Airport (GAD), Gadsden, Alabama, about 0943 EDT (0843 central daylight time [CDT]). The accident occurred during the first flight of the day, the purpose of which was to transport the airplane owner and an employee of the airplane owner's company to Atlanta for business. The second-in-command (SIC) was the pilot flying for most of the flight and was in the left seat, while the pilot-in-command (PIC) was the pilot monitoring for most of the flight and was in the right seat. (The PIC stated in a postaccident interview that he took control of the airplane from the SIC during the base leg on approach to PDK and became the pilot flying.) The flight crew received their IFR release from a Birmingham air traffic control tower (ATCT) controller while on the ground at GAD. The flight was released for departure about 0942 and was told to report airborne. At 0942:50, the cockpit voice recorder (CVR) recorded the PIC announce on the GAD common traffic advisory frequency that the flight was on a straight-out departure from runway 6. Before departure, the CVR did not record the use of a before-takeoff checklist; the CVR recorded the pilots stating some individual pre-takeoff items but not as part of a clear challenge/response checklist. At 0943:32, the CVR recorded the PIC ask the SIC, "who's flying the airplane?" The SIC responded, "I'm flying the airplane," to which the PIC replied, "you say I fly the airplane you take care of the checklists." At 0944:42, the CVR recorded the PIC ask the SIC, "what you want your speed on," to which the SIC initially responded with the maximum continuous thrust setting; when questioned a second time by the PIC, the SIC responded, "two fifty." The SIC then asked the PIC how to set the airspeed command cursor, and at 0945:00, the PIC stated, "turn it turn it turn it…don't fly…stall. two fifty down there." At 0945:16, the PIC advised the Birmingham ATCT that the flight was out of 3,000 feet for 4,000 feet; the controller cleared the flight to 5,000 feet and indicated that they should advise when the flight was established on victor airway 325, which the PIC acknowledged. At 0945:52, the PIC asked the SIC if he forgot anything, to which the SIC replied, "I don't know—checklist—after takeoff checklist." The PIC immediately called out some items from the after-takeoff checklist, including landing gear, flaps, autopilot, maximum continuous thrust setting, and ignition. He instructed the SIC that he needed to call for the checklist. At 0946:33, the CVR recorded a sound similar to an overspeed warning that lasted for 13.9 seconds. About 6 seconds after the sound of the overspeed warning began, the PIC advised the SIC to reduce thrust. The CVR recorded the airplane owner on the cockpit area microphone (CAM) asking if there was a problem and stating, "I was thinking are we fixing to crash?" The PIC advised the airplane owner that the warning was a reminder that "…you're going too fast." About 0947, the PIC advised the controller that the flight was established on the victor airway and level at 5,000 feet, and air traffic control (ATC) communications were then transferred to the Atlanta air route traffic control center (ARTCC). The flight remained in contact with the Atlanta ARTCC from about 0947 to 0956. During that time, the flight was cleared to climb to 13,000 feet mean sea level (msl) and was given an altitude crossing restriction. The PIC instructed the SIC how to achieve the crossing restriction. About 0956, the Atlanta ARTCC controller transferred the flight to Atlanta approach control, which the PIC acknowledged. The PIC established contact with Atlanta approach control, and during that initial contact, the controller advised the flight crew of the altimeter setting, instructed them to descend and maintain 5,000 feet, and asked them to advise when they had automated terminal information service (ATIS) information India. About 0956, the controller advised the flight crew to expect a visual approach to runway 20L, and the CVR recorded the flight crew obtaining ATIS information Juliet and discussing setting the cabin pressurization for landing. At 0957:04, the SIC asked for the descent checklist, to which the PIC responded, "hang on a second." The complete checklist was not verbalized, and there was no challenge and response to the checklist items. The PIC stated during a postaccident interview that they performed the descent, approach, and before-landing checklists but not aloud. At 0958:48, the controller instructed the flight crew to descend and maintain 4,000 feet, which the PIC acknowledged, and at 0959:05, the CVR recorded the SIC state, "I can't get vertical speed to work at all"; the PIC advised him to disconnect the autopilot, and the CVR recorded a sound consistent with autopilot disconnect. The PIC then stated, "now try your vertical speed. It wasn't on." About 1002, the controller instructed the flight crew to descend and maintain 3,000 feet and to advise when PDK was in sight; the PIC immediately advised the controller that the flight was descending and would advise when the airport was in sight. At 1003:15, the PDK approach controller was being relieved from position. During the position relief briefing, the departing controller advised the relieving controller that the Beech 400A (the accident airplane) was inbound to land and that a Cessna airplane (N3558E) was at 2,300 feet msl on a straight-in approach to runway 20R. The relieving controller asked the departing controller if the Cessna pilot knew about the Beech 400A; the reply was no. At this time, the Cessna was north of PDK flying in a southerly direction toward PDK, while the Beech 400A was about 8 nautical miles (nm) west northwest of PDK flying in an easterly direction toward PDK. About 1003, the PIC of the Beech 400A advised the approach controller that PDK was in sight. At that time, the flight was northwest of PDK on a right base leg flying in an easterly heading. About 7 seconds later, the controller advised the Beech 400A flight crew that the flight was cleared for a visual approach to runway 20L and to contact the PDK ATCT on 120.9 MHz, which the PIC immediately acknowledged. At 1003:40, the PIC contacted the PDK ATCT and advised the controller that the flight was on the frequency. The CVR recorded the local controller immediately advise the flight crew that "…traffic's a Cessna five mile final for the right side. Runway two zero left clear to land. That traffic is at [2,200] indicated." The PIC acknowledged the landing clearance but not the traffic information. According to the CVR, at 1003:53, the local controller advised the Cessna pilot that the Beech 400A was off his right side about 4 miles, at 3,300 feet msl descending for PDK, and cleared the Cessna to land on runway 20R. The Cessna pilot did not immediately respond, and the local controller again contacted the Cessna pilot, advised him of the location of the Beech 400A (3 o'clock, 3 miles, at 2,700 feet), and cleared the Cessna to land. The Cessna pilot acknowledged the landing clearance but advised the controller that the Beech 400A was not in sight. According to the CVR, at 1004:23, the local controller advised the Beech 400A flight crew that the previously called traffic was at its 12 o'clock position and 2.5 miles, at 2,000 feet msl indicated, to which the PIC stated, "…we're looking." The CVR indicated that at 1004:30, the controller advised the flight crew to maintain its present altitude until the traffic was in sight, which the PIC acknowledged. (The Beech 400A was at 2,300 feet msl.) Radar data indicated that the flight crew briefly descended to 2,200 feet msl, then climbed back to 2,300 feet msl. At 1004:37, the PIC told the SIC, "alright. 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 Beech 400A was "a mile off your right side [2,300 msl] indicated." The PIC stated during a postaccident interview that the traffic alert and collision avoidance system (TCAS) was working normally and that the 10-mile range was selected. At 1004:42, the CVR recorded, "traffic traffic"; the PIC reported during a postaccident interview that a blinking yellow target ahead of their position was depicted on the TCAS display. The SIC reported during a postaccident interview that he did not see the TCAS display because he was looking outside the cockpit. At 1004:47, the SIC stated, "first degree of" followed immediately by the sound of increased background noise; however, the communication was not completed. According to the CVR, at 1004:54, the PIC advised the local controller that the flight was turning from base to final for runway 20L. The National Transportation Safety Board (NTSB) radar study indicated that at that time, the Cessna was at 1,800 feet msl and was nearly due east of the position of the Beech 400A, which was at 2,400 feet msl. The CVR indicated that at 1004:57, the local controller asked the Beech 400A flight crew if they had the Cessna traffic in sight, to which the PIC advised the controller, "negative contact." About that time, the Beech 400A was at 2,400 feet msl, and the Cessna was at 1,800 feet msl. According to the CVR, at 1005:05, the PIC stated, "let me see a second," to which the SIC responded that he thought the other airplane was "…going to the left side." The PIC stated during a postaccident interview that he took the controls from the SIC during the base leg but did not verbalize that exchange of airplane control. (The SIC stated that it is common on every trip to switch pilot-flying and pilot-monitoring duties; however, he indicated that to further clarify the change of control procedures, the PIC would state "my airplane" and take control.) According to the CVR, at 1005:08, the controller advised the Cessna pilot that the Beech 400A had just flown over his airplane, which the Cessna pilot confirmed and reported the Beech 400A in sight. The Cessna pilot later indicated in a written statement that the Beech 400A was in a steep descent to runway 20L after passing over his position. Both flight crewmembers later reported that they thought the Cessna was 300 feet above them. The PIC stated during a postaccident interview that he heard a radio call of "traffic 300 feet above" and decided to perform an evasive maneuver by performing a right descending turn to avoid the traffic that he did not yet see. The radio call of "traffic 300 feet above" was not recorded by the CVR, nor was it on the ATC transcript. The NTSB radar study indicated that at 1005:12, the Beech 400A was at 2,300 feet msl, and at 1005:13, the Cessna was at 1,800 feet msl. According to the CVR, at 1005:14, the controller cleared the Beech 400A to land, which the PIC acknowledged, and about 7 seconds later, the SIC stated, "before landing checklist"; however, that command was followed 1 second later by an aural caution "sink rate, sink rate" from the enhanced ground proximity warning system (EGPWS). Simultaneous to the sink rate caution, the PIC stated, "done." The PIC reported in a postaccident interview that before landing, he configured the airplane by calling for flaps, then the landing gear, and then additional flap extension; however, he set the flap selector to the 30-degree position himself and verified the flap position. The CVR did not record any call by the PIC for landing gear or flaps. During the approach and landing phases, the CVR did not record an approach briefing by the PIC or SIC to include reference speed (Vref) or runway length. The PIC stated in a postaccident interview that he could not recall the airspeed maintained during the approach but indicated that he believed the airplane was high and fast. At 1005:28, the CVR recorded the EGPWS aural caution/warning "sink rate sink rate pull up," followed by the PIC stating, "way too fast." At 1005:32, the CVR recorded the EGPWS aural warning "pull up pull up," followed by an expletive by the PIC. About 2 seconds later, the CVR recorded the EGPWS aural warning "pull up pull up," which was repeated 3 seconds later. The NTSB radar study indicated that from 1005:03 to 1005:36 (the time of the last recorded radar target), the airplane traveled about 1.74 nm at an average ground speed of 190 knots. The last radar target indicated the airplane was at 1,200 feet msl and about 0.68 nm from the runway 20L displaced threshold. The EGPWS last recorded position was at 1005:40, and at that time, the airplane was located about .5 nm from the runway 20L displaced threshold. The data indicated that the ground speed was 194 knots, the GPS altitude was 1,136 feet (about 153 feet above the runway 20L displaced threshold elevation), and the vertical speed was 2,153 feet feet per-minute down. Witnesses reported that the Beech 400A appeared to be flying at a high rate of speed or fast on final approach, with several witnesses reporting that the touchdown point on runway 20L was near or abeam the very high frequency omnidirectional range/distance measure equipment (VOR/DME) navigation aid, which was 2,031 feet from the displaced threshhold. The tower local controller reported observing the accident airplane touch down about "…midfield at a very high speed and run off the end of the runway." At 1005:55, an unidentified crewmember stated, "reverse reverse," followed 4 seconds later by "speedbrakes" from the SIC. About 1 second later, an unidentified crewmember stated, "they're out." At 1006:01, the local controller stated to the Beech 400A flight crew, "…not a lot of runway left." The airplane owner, who was seated in the last row of forward-facing seats, reported that on touchdown, the airplane appeared to be aligned, and he felt deceleration from brake application for about 5 seconds; however, about 3 to 5 seconds after touchdown, the airplane suddenly veered hard to the right, then back to the left. He also reported hearing squealing at various times during the landing roll, which was also reported by the other passenger. Several PDK ATCT controllers reported that they saw the airplane roll off the departure end of runway 20L, then lost sight of it. The airplane came to rest mostly on airport property, adjacent to the airport boundary fence. There were no ground injuries. About 15 seconds after the start of the communication from the controller regarding the lack of remaining runway, the sound of an emergency locator transmitter was heard on the tower frequency. The airplane owner reported that after the airplane stopped, both engines continued to operate, and the cabin door was initially stuck but was then able to be opened. The airplane owner noticed fuel leakage, and both flight crewmembers were in a daze. He then yelled for them to secure the engines. The PIC reported during a postaccident interview that after the airplane owner yelled to them that the engines were still running, he secured the airplane, shut down the engines, closed the firewall valves, and put the airplane back to takeoff configuration. He then reported turning off the master switch, and the airplane owner reported that he assisted the PIC and SIC out of the airplane; the PIC was at the cabin door when he helped him out of the airplane. All occupants were taken to local hospitals for treatment of their injuries. The PIC reported in a postaccident interview that he did not consider executing a go around because it would involve a climbout and he did not see the traff
The flight crew's failure to obtain the proper airspeed for landing, which resulted in the airplane touching down too fast with inadequate runway remaining to stop and a subsequent runway overrun. Contributing to the accident were the failure of either pilot to call for a go-around and the flight crew's poor crew resource management and lack of professionalism.
Source: NTSB Aviation Accident Database
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