Learjet 60 runway overrun at CAE
Fatal Columbia SC accident report stresses the need for crew resource management training.
By Greg Feith
Contributing Writer
On a Friday night in September 2008, a Bombardier Learjet 60 (N999LJ) operating for Global Exec Aviation under a Part 135 certificate overran Rwy 11 at CAE (Columbia SC).
Once the facts of the accident became clear, it was evident that the sequence of mis-steps started before the airplane ever left the ramp, and escalated quickly thereafter from an abnormal event to an emergency.
The cockpit voice recorder (CVR) transcript told the story of 2 pilots who prepared the airplane for flight and initiated the taxi without understanding clearly the instructions for taxiing to Rwy 11.
At one point, the ground controller told the crew they were going in the wrong direction on a taxiway. In an effort to correct the situation, the controller provided instructions for the crew to back taxi on Rwy 11 and cleared them for departure once they arrived at the west end of the runway.
Following a few clean-up items, the captain provided an abbreviated rejected takeoff (RTO) briefing and stated to the copilot that they had plenty of runway, so they’d abort takeoff if they were below 80 kts after V1 and before V2, on engine failure, fire malfunction, or loss of directional control.
As a side note, nothing in the Flight Safety Intl (FSI) or Global Exec Aviation procedures referenced any RTO criteria after V1.
Although the briefing ended without a discussion regarding specific tasks for the copilot (pilot monitoring) to accomplish during an RTO, the copilot did make a comment that seemed to get lost in the conversation and could have been a hint to the captain. Referencing the RTO items, the copilot stated, “If the runway is long, I abort.
If it is short, I kinda do a different briefing, depending on the length of the runway, but we’re pretty heavy, so it’s probably not a bad idea.”
Unfortunately, we will never know the true context of that statement, but it would appear that, because the airplane was heavy, the copilot was compensating for the heavy weight and longer ground roll, and that he was aware that the remaining stopping distance might be similar to operating on a short runway.
Nonetheless, the captain initiated the takeoff, and, as the airplane accelerated through V1, the CVR recorded the sound of a loud rumbling, followed immediately by the copilot saying, “Go.” The captain responded, after which the copilot said, “Go, go, go.”
The airplane continued to accelerate through V1 and was approached VR (145 kts) when the captain asked the copilot, “Go?” while at the same reducing the thrust, then increasing the thrust again, followed by a total reduction in thrust that coincided with the copilot’s answer of “No” to the captain’s question.
Although neither crew member knew the nature of the problem, they were confronted with a situation that required a split-second decision to either continue the takeoff or perform a high-speed RTO and risk the airplane overrunning the runway.
Crew resource management
It is evident that the captain and copilot reacted differently to the same airplane performance and controllability cues, with the copilot immediately reverting to his training and the operational procedures of continuing the takeoff after V1.
Conversely, the captain, had the additional cue of tactile feedback and likely perceived that the controllability of the airplane was compromised, which prompted her to initiate the RTO rather than take a sick airplane into the air.
Despite both pilots knowing that a high-speed RTO was a risky action that would likely result in a runway overrun, was this the result of poor preflight preparation?
Perhaps it was just bad aeronautical decision-making, inadequate communications, poor situational awareness, bad leadership, poor training, or just plain bad crew resource management (CRM) under challenging circumstances.
By its definition, CRM is supposed to provide the basic foundation for pilots to develop their respective decision-making and leadership skills and knowledge so that, rather than acting as one of 2 pilots in the cockpit, both of them can work effectively and efficiently as one.
It is evident that, in this accident, the copilot reverted immediately to his training and standard operating procedures (SOPs) and was decisive with his input, telling the captain, “Go, go, go.” However, the captain was indecisive and initiated an unannounced RTO after briefly considering continuing the takeoff.
The combination of extended time and indecision cost the lives of the 2 pilots and 2 passengers – but how did 2 professional pilots who were trained in RTOs and emergency procedures fail to maintain their operational discipline? This is something that should have been ingrained in them during training.
As in all major National Transportation Safety Board (NTSB) investigations, the operations group explored various aspects of the flightcrew’s background and training, as well as the operational performance of the accident aircraft.
One prominent subject discussed in the report was CRM, including a dissection of the pilots’ actions and inactions during the accident flight, and the specific factors that influenced the decision to perform a high-speed RTO.
CRM was born in the late 1970s and early ’80s, based on lessons learned from accidents and serious incidents where crew performance was either inadequate, deficient, or the subject of intense scrutiny.
CRM aimed to provide a pathway for the aviation industry to develop education and training programs that addressed human performance and how important it is that 2 pilots operating in the cockpit environment must focus on situational awareness, aeronautical decision-making, leadership, communications, and workload management in harmony rather than autonomously.
These training programs have been very successful, for the most part, as long as crew members employ and execute the principles of CRM without exception. However, while CRM has improved operational discipline and safety vastly, humans are not infallible, and errors do occur.
Errors can be deterministic, because you can’t predict when an error is going to occur. Errors are also probabilistic, meaning we can identify the likely phases of flight when certain types of error could occur, based on statistics and trends.
While safety has improved, year after year there are still aircraft accidents and serious incidents attributed to CRM issues involving dual- and single-pilot crews.
The crash of the Learjet 60 at CAE provides clear examples of CRM going wrong.
In its report, NTSB identified numerous errors and omissions committed by the pilots, both as individuals and as a crew.
These errors include – but are not limited to – (1) the captain’s indecision, (2) the captain’s failure to following training protocols and SOPs, (3) the failure to make a clear RTO call that was coordinated and agreed upon by both pilots, (4) the copilot’s acceptance of a simplified RTO briefing that did not identify who would perform specific tasks, and (5) the captain’s lack of assertiveness and leadership at the onset of the situation.
The report further discusses several issues related to the maintenance of the airplane and the severely under-inflated tires that failed and shed tire debris into the wheel well, damaging the hydraulic system and causing the brakes and thrust reversers to fail.
In fact, the damage to the air-ground switch caused the thrust reversers to return to a stowed position, providing forward thrust when the captain was attempting to use the brakes and thrust reversers to stop.
Summarizing
Pilots cannot perform autonomously in aircraft operations requiring 2 pilots, but rather in a complementary manner to ensure the highest levels of operational safety.
This begins with training and reinforcing policy and procedures so they become second nature, ensuring there is no indecision or ambiguity between crew members during a high-stress, high-anxiety situation, or miscommunications or information misinterpretation that could delay or inhibit a pilot from reacting and performing with clarity and efficiency.
Training is a critical part of a CRM program, because it provides the environment to redirect pilot thinking in order to ensure clear and concise communication, improve aeronautical decision-making, develop and hone leadership skills, and empower an individual to participate with equality, regardless of cockpit position or rank.
These are the qualities that will move the needle from individualistic thinking and behavior to thinking and performing as a crew with coordination and effective operational discipline, and are absolutely necessary to reduce errors and enhance flight safety.
Training should be used by pilots to develop their individual skills and learn to use tools that can be effective in recognizing imprecision in things such as procedural briefings, or further develop their assertiveness to ensure that the input provided in the crew environment is being heard and considered by the other pilot, especially under the most challenging of circumstances.
Finally, training reinforces standardization and emphasizes the need to maintain the highest levels of operational discipline at all times. Train with purpose so you can execute with purpose.