Thomson, GA, USA
N777VG
BEECH 390
The purpose of the flight was to return employees of a vein care practice to their home base at Thomson-McDuffie County Airport (HQU), Thomson, Georgia. The pilot was the pilot flying, and the copilot was the pilot not flying. (The National Transportation Safety Board [NTSB] notes that although the copilot is referred to as such in this report, his role in the cockpit is not required by federal regulations.) The departure from John C. Tune Airport, Nashville, Tennessee, and en route portions of the flight were uneventful. During the flight, the copilot reminded the pilot about a speed restriction and also reminded the pilot to adjust his altimeter. The pilot responded to the altimeter reminder by stating, "say, I'm kinda out of the loop or something. I don't know what happened to me there but I appreciate you lookin' after me there." About 4 minutes later, on approach to HQU, the pilot lowered the landing gear, and the ANTI SKID FAIL message illuminated in the cockpit; the copilot commented on the illumination. The pilot continued the approach; he did not respond to the copilot and did not refer to the Abnormal Procedures section of the Federal Aviation Administration (FAA)-approved Abbreviated Pilot Checklist to address the antiskid system failure message. The airplane touched down on runway 10 about 2005, and about 7 seconds later, the pilot initiated a go-around. (In postaccident interviews, neither the pilot nor the copilot recalled the reason for the go-around.) The airplane lifted off near the departure end of the 5,503 ft-long runway. According to enhanced ground proximity warning system (EGPWS) data, when the airplane was about 63 ft above ground level, the left wing struck a utility pole, which was 72 ft high and about 1,835 ft from the runway threshold, severing the outboard portion of the wing. The airplane continued another 925 ft before crashing in a wooded area. Examination of the wreckage revealed no evidence of any preimpact failures or malfunctions of the engines or flight controls. The reason for the antiskid system malfunction could not be determined due to the general destruction of the wreckage. For an antiskid inoperative condition, the Abbreviated Pilot Checklist only provides landing distance values for flaps up and flaps 10 degrees. The pilot should have selected one of those two flap settings for landing and determined the landing distance required. The first data recorded by the EGPWS showed that the airplane was configured at flaps 30. The flaps were transitioning through flaps 15 at the time of impact. When the antiskid system fails, the landing distance required for full stop increases greatly: according to the Abbreviated Pilot Checklist, the landing distance would increase about 130 percent with flaps up and 89 percent with flaps 10. Thus, the required landing distance for the weather conditions that prevailed at HQU at the time of the accident with flaps up was 7,066 ft, and the required landing distance with flaps 10 was 5,806 ft. HQU runway 10's available runway length for landing was 5,208 ft, which did not meet the flaps up or flaps 10 performance penalty requirements with an antiskid system failure, thus requiring a diversion to a longer runway. It is likely that after touchdown, the pilot recognized that the airplane was not slowing as he expected and might not stop before the end of the runway. Rather than risk a high-speed overrun, he elected to conduct a go-around. The NTSB determined that at the time the airplane struck the utility pole, the landing gear was extended, the flaps were in transit (retracting) toward the 10-degree position, and the lift dump system was deployed. Lift dump is a critical system to assist in stopping the Beechcraft 390 Premier (Premier 1A) during landing. Section 3A of the airplane flight manual (AFM) (Abnormal Procedures) included the following warning: "Extending lift dump in flight could result in loss of airplane control leading to airplane damage and injury to personnel. Continued safe flight with lift dump extended has not been demonstrated." The wreckage examination as well as drag estimates based on recovered EGPWS data indicate that the lift dump remained extended during the airplane's go-around attempt. The airplane drag associated with lift dump, flaps, and landing gear likely resulted in only marginal climb performance. While Beechcraft does not publish a procedure for a go-around after touchdown, aerodynamic data for the 390 Premier (Premier IA) suggest that if the airplane were configured with lift dump retracted and flaps 10 degrees or less, it would have been capable of a significantly higher climb rate after the failed landing attempt. The pilot displayed a lack of systems knowledge of the accident airplane. First, the pilot demonstrated a lack of understanding of the antiskid system. Although the pilot had received antiskid system failure training during his recurrent simulator training on January 4, 2013, he stated in postaccident interviews that he did not think they needed the antiskid system for the landing at HQU and that the performance penalty would only apply if you were "trying to make your numbers." Because of this faulty belief, when the antiskid failure illumination occurred, the pilot did not take action. Second, the pilot selected a flap position (flaps 30) that was prohibited by the antiskid failure procedures in the AFM. Third, he performed a go-around with the lift dump extended. Both the AFM and a placard in the cockpit warned against extending the lift dump in flight. When the pilot decided to go around, he should have immediately retracted the lift dump per the AFM restriction for lift dump extension in flight. The utility pole (Pole 48) that was struck was erected, along with several others, in 1989 by Georgia Power. Although Georgia Power did not notify the FAA about the poles after they were constructed, the information about the obstructions was available to the FAA through other sources. After the accident, Georgia Power submitted FAA Forms 7460-1 for four utility poles east of the airport, including Pole 48. The FAA conducted aeronautical studies on the poles and, on May 31, 2013, determined in its initial findings that Pole 48 did not comply with FAA obstruction standards and was "presumed to be a hazard to air navigation." The study also stated that if the pole were lowered to a height of 46 ft or less, it would comply with obstruction standards. After the FAA issued the preliminary obstruction determinations, Georgia Power requested that the FAA conduct further study on the four obstructions to determine if a favorable determination could be achieved. On August 12, 2013, the FAA published public notices announcing the four aeronautical studies and invited interested parties to submit relevant comments before September 18, 2013. According to an FAA official, the final determinations for the four obstructions were not completed at the time of this report. Since the initial aeronautical studies were conducted, the FAA Flight Data Center issued several notices to airmen to alert pilots about obstructions and also to amend the approach and departure procedures at HQU accordingly. Although the FAA has deemed the pole a presumed hazard, the pilot's attempted flight with the extended lift dump made airplane control and continued safe flight unlikely. In evaluating the pilot's performance, the NTSB considered that the pilot experienced a sleep restriction, a circadian disruption the night before the accident, and long duty hours and extended wakefulness. The pilot normally slept about 8 hours per night; however, he only slept 5 hours the night before the accident (February 19). Further, the pilot awoke about 0200 on the morning of the accident, which was significantly earlier than his normal waking time of about 0600. On the day of the accident, he reported that upon arrival in Nashville, he slept for about 4 hours in a chair in the pilot lounge. However, his cell phone activity indicated outgoing calls during that time, suggesting interruptions to his sleep, which would have fragmented any sleep the pilot did obtain and degrade its restorative quality. Additionally, the accident took place about 2006, indicating an extended period of wakefulness based on the early awakening. Based on the available evidence, the pilot was likely suffering from fatigue at the time of the accident. Research indicates that fatigue associated with sleep loss, circadian disruption, and long duty hours can lead to increased difficulty in sustaining and directing attention, memory errors, and resultant lapses in performance. An NTSB safety study found that flight crewmembers who were awake for more than 12 hours made more procedural errors, tactical decision errors, and errors of omission than those awake less than 12 hours (NTSB. 1994. A Review of Flightcrew-Involved Major Accidents of U.S. Air Carriers, 1978 through 1990. SS-94/01. Washington, DC). Twice during the accident flight, the copilot gave the pilot reminders (one about the speed restriction and one about the altimeter). The pilot responded by indicating that he was "out of the loop." Further, the pilot did not refer to the Abbreviated Pilot Checklist for the antiskid system failure (for which the copilot commented on the illuminated light) or retract the lift dump when he elected to go around. Had the pilot not been fatigued, he likely would have paid closer attention to the flight and not had lapses in performance. Both pilots survived, with serious injuries, and all five passengers, who were seated in the back, died. Postaccident examination showed that the seat buckles in the back were not fastened and the shoulder harnesses were not attached or pulled out. According to the copilot, the "fasten seatbelt" sign was on (the seatbelt chime was recorded by the cockpit voice recorder), but he did not remember giving a briefing on seatbelts. The pilot indicated that he did not remember seeing if the passengers had their seatbelts on. All six of the passenger seats had been forcibly detached from the airplane fuselage, and three were consumed by fire. All of the passengers sustained multiple traumatic injuries. Although proper use of restraint systems in survivable accidents can dramatically lessen or prevent serious injuries to occupants, due to the high impact forces and fragmentation of the cabin in this accident, it is unknown whether the use of restraints would have affected the survivability of the passengers. Member Sumwalt filed a concurring statement that can be found in the public docket for this accident. Member Weener joined the statement.
HISTORY OF FLIGHTOn February 20, 2013, about 2006 eastern standard time (EST), a Beechcraft Corporation 390 Premier (Premier IA), N777VG, collided with a utility pole, trees, and terrain following a go around at Thomson-McDuffie County Airport (HQU), Thomson, Georgia. The airline transport-rated pilot and copilot were seriously injured, and the five passengers were fatally injured. The airplane was registered to the Pavilion Group, LLC, and was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a business flight. Night visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight originated at John C. Tune Airport (JWN), Nashville, Tennessee, about 1827 central standard time (1927 EST). On the morning of the accident, the pilot and copilot left their respective homes in South Carolina about 0230 for the 1-hour drive to HQU (where the airplane was based) to fly five passengers, who were employees of Vein Guys®, to JWN. (The National Transportation Safety Board [NTSB] notes that while the copilot is referred to as such in this report, his role in the cockpit is not required by federal regulations.) The airplane departed HQU about 0406 and arrived at JWN about 0459. (Although JWN is located in the central time zone, all subsequent times in this report are in EST unless otherwise noted.) Both pilots stated in postaccident interviews that the flight to JWN was uneventful and the weather was good. They reported that at the JWN terminal, they slept in the crew break room, completed paperwork, and worked on the computer. They left for a late lunch about 1500 and returned to the airport about 1630. According to security camera footage from the JWN terminal, both pilots were observed walking toward the airplane about 1913, and about 1918, the five passengers were seen walking toward the airplane while one crewmember performed an external walk-around inspection. About 1923, the airplane taxied from the parking area and departed JWN at 1927. The pilot was the pilot flying and was in the left cockpit seat. About 1927, the flight crew contacted departure control while climbing through 3,500 ft mean sea level (msl) and requested an IFR clearance to HQU. About 1930, the flight crew contacted the Memphis air route traffic control center (ARTCC) while climbing through 14,000 ft msl, and about 1933, the flight was cleared to climb and maintain a cruising altitude of flight level (FL) 270. According to flight crew interviews, the en route weather was good, and a tailwind in excess of 70 knots was observed. About 1948, the flight crew contacted the Atlanta ARTCC and was cleared to descend to FL240. About 1953, the flight crew was given a further descent clearance to 11,000 ft msl along with the Athens, Georgia, altimeter setting. About the same time, the copilot tuned in the HQU automated weather observation system (AWOS) to receive the most current weather at the destination airport. The AWOS at 1935 reported calm wind, temperature 10 degrees C, 10 statute miles visibility or greater, scattered clouds at 12,000 ft, and an altimeter setting of 30.13 inches of mercury. The pilot then set up the flight management guidance system for a visual approach to runway 10 at HQU with a 3.4-degree descent to the runway from a 5-mile final approach. The copilot tuned the instrument landing system for runway 10 as a backup. About 1956, the flight crew advised the Atlanta ARTCC that they were descending through 18,500 ft, and 2 minutes later, they cancelled their IFR flight plan. About 1958, the copilot stated to the pilot, "ten thousand comin' up captain and you blowin' through." About 1959, the copilot told the pilot to adjust his altimeter. The pilot responded, "say, I'm kinda out of the loop or something. I don't know what happened to me there but I appreciate you lookin' after me there." The flight crew was then directed to contact Augusta approach control, and about 2000, the flight crew contacted Augusta approach control and advised that they were descending out of 8,400 ft and had HQU in sight. About 2002, the flight crew advised Augusta approach control that they would switch to the local HQU advisory frequency. Concurrently, the pilot began to perform an "S" turn along the final approach path to the runway. About 1 minute later, the enhanced ground proximity warning system (EGPWS) aural alert announced that the airplane was 1,000 ft above the ground, and the pilot lowered the landing gear. According to the cockpit voice recorder (CVR), after the landing gear was lowered, about 2004, the copilot noted that the "ANTI SKID FAIL" annunciator light illuminated. The pilot continued the approach, and, about 2005, the airplane touched down on runway 10. Witnesses reported that after the airplane touched down, they heard or saw it go around. According to the CVR, the takeoff warning horn sounded about 0.3 seconds before the pilot stated that he was performing a go-around. The airplane lifted off near the departure end of the runway. The copilot directed the pilot to increase pitch. According to EGPWS data, as the airplane climbed to an altitude of about 63 ft above the ground, about 9 seconds after liftoff, the left wing struck a utility pole located about 0.25 miles east of the departure end of the runway. The airplane continued about 925 ft before colliding with trees and terrain. It was destroyed by impact forces and a postcrash fire. During a postaccident interview, when asked about the approach, landing, and go-around at HQU, the pilot recalled checking the airplane's landing light switches to prepare for the landing. The next thing he remembered was waking up in the hospital on February 24, 2013. He did not recall any additional details about the approach, landing, or go-around or any airplane system anomalies, including any antiskid problems, during the flight. In postaccident interviews, the copilot did not recall anything unusual about the glidepath and recalled being about 1 or 2 knots above reference speed. The copilot thought that the airplane touched down on runway 10 within 200 ft of the 1,000-ft runway marker. As he began to reference the after landing checklist, he heard the pilot announce a go-around, but the copilot did not know the reason for the go-around. He stated that he began to monitor the airspeed indicator, saw that they were at 105 knots approaching the end of the runway, and thought "it was going to be close." The engines sounded like they always did on a normal takeoff. He thought something hit the airplane on his side and recalled seeing trees in the windshield. The next thing he remembered was seeing someone with a flashlight at the accident scene. He did not recall any alarm or aural caution before the go-around and indicated that everything looked normal. PERSONNEL INFORMATIONThe Pilot The pilot, age 56, held an airline transport pilot (ATP) certificate with a single pilot type rating on the Premier IA. (The 390 Premier is the same as the Premier I/IA series.) He also held a flight instructor certificate with airplane single engine land, airplane multiengine land, and instrument airplane privileges. He was the director of operations for Sky's the Limit, doing business as Executive Shuttle, a 14 CFR Part 135 operator based in Greenwood, South Carolina. He was hired by the Pavilion Group to provide private pilot services for their Premier IA under the provisions of 14 CFR Part 91. The pilot reported 13,319 hours total flying time, including 12,609 hours as pilot-in-command (PIC). He reported 198 hours, all as PIC, in the Premier IA. The pilot held a second-class Federal Aviation Administration (FAA) medical certificate, issued October 29, 2012, with a limitation to possess glasses for near/intermediate vision. According to interviews and training records, the pilot attended the FlightSafety Premier I Series (RA-390) initial training course at the FlightSafety Wichita Learning Center, Wichita, Kansas, from June 7, 2012, through June 22, 2012. The ground instruction consisted of 58 hours of ground training and 11.5 hours of briefing/debriefing. The pilot also attended flight simulator training, which consisted of 15 hours of simulator training. He was type rated on the Premier IA on June 22, 2012, following a 2.2-hour simulator session and a 2.5-hour oral/written examination. The pilot also attended the FlightSafety Premier I Series (RA-390) recurrent PIC course at the FlightSafety Greater Philadelphia/Wilmington Learning Center, Wilmington, Delaware, from January 3, 2013, through January 5, 2013. The ground instruction consisted of 12 hours of training and 4.5 hours of briefing/debriefing. The simulator portion of the training consisted of 7 hours of simulator time. A copilot who previously flew with the pilot stated that the pilot was experienced, professional, and possessed good flying skills. Both copilots who flew with the pilot, including the accident copilot, stated that they did not have a specific role on the flights they flew with him in the Premier IA. On February 15, the pilot flew the owner of Vein Guys® and his family to Orlando, Florida, and remained in Orlando until Monday, February 18. He did not use a copilot for the Orlando trip. On February 18, he flew the family to HQU and then drove to his residence, going to bed about 2100. On February 19, he awoke about 0500 for a 0930 flight to Olive Branch, Mississippi, with the accident copilot and Vein Guys® staff. The return flight landed at HQU about 1700 that evening. He arrived at his residence about 1820 and went to bed about 2100. On the day of the accident, the pilot awoke about 0200 and arrived at HQU about 0330 for the 0400 flight to JWN. He described February 20 as a "tough, tough day" because of the early departure time. After arriving at JWN, he slept for about 4 hours in a chair in the pilot lounge. He did not sleep again that day. A review of the pilot's cell phone records revealed three outgoing calls were made during his 4-hour sleep break. The pilot indicated that he normally slept about 8 hours per night and that he typically awoke about 0600. The Copilot The copilot, age 40, held an ATP certificate. He possessed no type ratings. He was employed by and flew charters for Executive Shuttle, which was owned by the accident pilot. He accompanied the accident pilot on the Premier IA flights at the pilot's request and estimated that he had about 45 flight hours in the Premier IA. He reported 2,932 hours total time, including 2,613 hours as PIC. The copilot held a second-class FAA medical certificate, issued February 12, 2013, with no limitations. The copilot received no simulator training in the Premier IA before the accident and did not complete formal training courses in the Premier IA. He received a 14 CFR 61.55 logbook endorsement on October 10, 2012, from the accident pilot, stating that he demonstrated the skill and knowledge required for safe operation of the Premier IA as second-in-command. On Monday, February 18, the copilot was at home and awoke between 0600 and 0630 and went to bed about 2200. On Tuesday, February 19, he awoke between about 0530 and 0600 and flew with the captain to Olive Branch. After returning to HQU, the copilot made the 1-hour drive to his home but was not certain what time he went to bed or fell asleep. The last cell phone activity that day occurred about 2148. On Wednesday, February 20, the copilot awoke between about 0200 and 0215 and drove with the accident captain to HQU for the flight to JWN. The copilot told investigators he was able to sleep for about 4 to 5 hours in the pilot lounge (awakening about 1000 central time). AIRCRAFT INFORMATIONThe Premier IA was a carbon fiber composite fuselage, metal low-wing airplane powered by two Williams FJ44-2A turbofan engines mounted on the aft fuselage each rated at 2,300 lbs of thrust. The Premier IA was not equipped with reverse thrust, and wheel braking was the primary means of stopping the airplane after landing. (The lift dump assists in putting weight on the wheels, which makes braking more effective.) The airplane was equipped with an electrically controlled antiskid system. According to the manufacturer, the system offered protection from skids and could provide consistently shorter landing rolls for all runway conditions. The ANTI SKID FAIL annunciator would illuminate if a malfunction existed in the system when the ANTI SKID switch was in the NORM (normal) position. Activation of the lift dump switch extended the three spoiler panels on each wing and overrode normal spoiler operation. A placard was located on the cockpit pedestal immediately aft of the lift dump switch that read, "WARNING DO NOT EXTEND IN FLIGHT." In addition, the Hawker Beechcraft Premier I/IA Model 390 Airplane Flight Manual (AFM), Section 3A—Abnormal Procedures, page A-25, states, "Do not extend lift dump in flight." Section 3A of the AFM (Abnormal Procedures) included the following warning: "Extending lift dump in flight could result in loss of airplane control leading to airplane damage and injury to personnel. Continued safe flight with lift dump extended has not been demonstrated." The airframe and engine maintenance logbooks were not located after the accident. Pavilion Group used CAMP Systems as their maintenance management provider, and the Hawker Beechcraft Service Center, Atlanta, Georgia, also provided maintenance services. The most recent record of maintenance performed on the airplane occurred on January 29, 2013, at Aeronautical Services, Greenwood, South Carolina. The maintenance included replacement of the left and right main tires, touching up exterior paint, and a battery capacity check. The total time on the airplane was not recorded at that time. The most recent maintenance record indicating aircraft total time was on January 4, 2013, when the airframe total time was 635.4 hours. The most recent comprehensive airframe and engine inspection was recorded on June 15, 2012. The 600-hour Schedule A inspection was accomplished at 503.3 hours total time and 565 total airframe cycles. METEOROLOGICAL INFORMATIONThe National Weather Service (NWS) reported no significant weather and no precipitation over the region. The area forecast applicable for HQU expected light wind and scattered to broken high cirrus clouds, with visibility unrestricted. The NWS also issued an airmen's meteorological information that was current at the time of the accident for moderate turbulence below 8,000 ft over the area. HQU was equipped with an AWOS that issued observations every 20 minutes. The HQU 1955 observation reported calm wind, visibility 10 miles or greater, sky clear, temperature 9 degrees C, dew point -4 degrees C, and altimeter setting 30.12 inches of mercury. The HQU 2015 observation reported wind from 240 degrees at 6 knots, visibility 10 miles or greater, broken ceiling at 12,000 ft above ground level (agl), temperature 11 degrees C, dew point -3 degrees C, and altimeter setting 30.15 inches of mercury. AIRPORT INFORMATIONThe Premier IA was a carbon fiber composite fuselage, metal low-wing airplane powered by two Williams FJ44-2A turbofan engines mounted on the aft fuselage each rated at 2,300 lbs of thrust. The Premier IA was not equipped with reverse thrust, and wheel braking was the primary means of stopping the airplane after landing. (The lift dump assists in putting weight on the wheels, which makes braking more effective.) The airplane was equipped with an electrically controlled antiskid system. According to the manufacturer, the system offered protection from skids and could provide consistently shorter landing rolls for all runway conditions. The ANTI SKID FAIL annunciator would illuminate if a malfunction existed in the system when the ANTI SKID switch was in the NORM (normal) position. Activation of the lift dump switch extended the three spoiler panels on each wing and overrode normal spoiler operation. A placard was located on the cockpit pedestal immediately aft of the lift dump switch that read, "WARNING DO NOT EXTEND IN FLIGHT." In addition, the Hawker Beechcraft Premier I/IA Model 390 Airplane Flight Manual (AFM), Section 3A—Abnormal Procedures, page A-25, s
The pilot's failure to follow airplane flight manual procedures for an antiskid failure in flight and his failure to immediately retract the lift dump after he elected to attempt a go-around on the runway. Contributing to the accident were the pilot's lack of systems knowledge and his fatigue due to acute sleep loss and his ineffective use of time between flights to obtain sleep. Member Sumwalt filed a concurring statement that can be found in the public docket for this accident. Member Weener joined the statement.
Source: NTSB Aviation Accident Database
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