Intersection Takeoff Leaves No Margins

The following information provides an awareness of problems that might be avoided in the future. The information is based on final reports by official investigative authorities on aircraft accidents and incidents.

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Jets

Commander ‘Overruled’ Copilot

Boeing 777-300. No damage. No injuries.

While preparing for a flight to Mumbai, India, the evening of Aug. 30, 2016, both pilots completed performance calculations for takeoff from London Heathrow Airport’s Runway 27L. The commander’s calculations were based on using the full length of the runway. The copilot assumed that, due to taxiway closures, the takeoff would be initiated from an intersection. She found that a departure from the first available intersection could be conducted safely. The copilot’s calculations assumed different takeoff speeds and thrust and flap settings than those derived by the commander for a full-length takeoff.

The 777 was parked at a terminal south of Runway 27L. Portions of the parallel taxiway on that side of the runway were closed for construction. Thus, to use the full length of the runway, the crew would have had to taxi across the runway and use the parallel taxiway north of Runway 27L to reach the departure threshold, according to the report by India’s Ministry of Civil Aviation.

Although the commander decided to initiate the takeoff from the first available intersection south of the runway, he “overruled” the copilot and planned, for unspecified reasons, to use the performance calculations he had derived for a full-length departure, the report said. “The commander was much senior to the copilot,” the report noted.

Runway 27L was 12,001 ft (3,658 m) long, and 8,495 ft (2,589 m) of the runway was available for takeoff from the intersection. Investigators determined that the aircraft required a takeoff distance of 10,899 ft (3,322 m) using the performance parameters the commander had calculated for a full-length takeoff. The use of these parameters for the intersection departure did not meet regulatory requirements for a rejected or continued takeoff following an engine failure, the report said.

During the takeoff roll, the captain pulled his control column back at the predetermined rotation speed, 165 kt, but then applied a “more aggressive pull one second later,” the report said. The 777 lifted off “just 311 ft [95 m] from the end of the runway” and crossed the departure threshold at 13 ft (22 ft below the minimum required screen height).

There was no damage to the aircraft and no injury to the 231 passengers and 15 crewmembers, but the event was classified as a serious incident. “The incident may or may not [have been] survivable had there been a rejected takeoff for any reason,” the report said.

‘Catastrophic’ Engine Failure

Bombardier CRJ700. Substantial damage. No injuries.

The CRJ was en route at Flight Level 340 (approximately 34,000 ft) on a scheduled flight from Cincinnati, Ohio, U.S. to Denver the morning of Nov. 29, 2016, when the flight crew heard a loud noise and saw indications that the left engine had flamed out. The crew declared an emergency, diverted to St. Louis and landed the airplane without further incident. None of the 73 occupants was hurt.

Examination of the airplane revealed that the General Electric CF34-8C engine had experienced a catastrophic failure, said the report by the U.S. National Transportation Safety Board (NTSB). Investigators determined that the failure was precipitated by a fatigue crack emanating from a corrosion pit in the second-stage high-pressure turbine, which caused the separation of several turbine blades.

“The corroded areas contained elements including sulfur, sodium, potassium and phosphorous,” the report said. “The source of the corrosive elements could not be identified.” The report noted that the operator of the CRJ had performed CF34-8C engine water washes every 1,200 flight hours, compared with GE’s recommendation of 1,600 hours.

‘So Tired I Can’t See Straight’

Bombardier Global 5000. No damage. No injuries.

Acute fatigue and ineffective crew communication factored in the flight crew’s failure to recognize that they had descended more than 1,300 ft below the prescribed minimum altitude during an instrument landing system (ILS) approach to Hong Kong International Airport the night of Nov. 15, 2016, according to a report by the U.K. Air Accidents Investigation Branch.

The report said that the commander commented several times during the positioning flight from Beijing that he was tired, and the copilot made several mistakes, including incorrect clearance read-backs and altimeter settings. The commander told investigators that he had found the copilot’s explanations of the mistakes confusing.

Haze reduced surface visibility at Hong Kong to 3,800 m (less than 2 1/2 mi), and the crew was cleared to conduct the ILS approach to Runway 07L. Flying the approach manually, the commander descended below the minimum prescribed altitude of 1,700 ft while turning to intercept the localizer. The bank angle reached 44 degrees and the descent rate increased rapidly to 3,600 fpm during the turn. The aircraft was descending through 1,000 ft when the terrain awareness and warning system (TAWS) generated a “sink rate” warning. The commander reduced the descent rate to 1,900 fpm.

The copilot then said, “Just hold your altitude right there. Don’t descend any more.” After seven “gear” warnings sounded, the commander called for extension of the landing gear. The Global was descending through 760 ft when the copilot extended the gear. “The copilot asked the commander why they were still descending, and, although there was no response, the aircraft’s pitch attitude was adjusted and the rate of descent reduced,” the report said.

The airport traffic controller asked the crew to confirm their altitude about the same time the TAWS generated a warning that the aircraft was below the ILS glideslope. Shortly thereafter, the TAWS generated “terrain” and “pull up” warnings. The aircraft was at 390 ft when the commander initiated a climb. The copilot said, “Get it up to a thousand feet.”

“The aircraft continued to climb to 1,640 ft before intercepting the glideslope signal and [subsequently was landed] without further incident,” the report said. “During the final approach and again after landing, the commander said, ‘I’m so tired I can’t see straight.’”

The commander told investigators that he had gone to bed about midnight but did not sleep well before receiving a wake-up call at 0300. The aircraft departed from Beijing at 0645, and the crew initiated the ILS approach to Hong Kong nearly three hours later.

Overrun With Locked Wheels

Embraer Phenom. Substantial damage. No injuries.

The airplane was on a positioning flight the morning of Nov. 21, 2014, from Houston to Sugarland, Texas, U.S., where instrument meteorological conditions prevailed. The flight crew conducted the ILS approach to Runway 35, which was 8,000 ft (2,438 m) long.

Airspeed was 11 kt higher than prescribed when the Phenom crossed the runway threshold. The airplane, which was not equipped with spoilers or thrust reversers, touched down with a 7-kt tailwind. The pilot applied full wheel braking about eight seconds later. “The cockpit voice recorder recorded both pilots expressing concern that the airplane was not slowing,” the NTSB report said.

About 14 seconds after touchdown, the pilot engaged the emergency parking brake. “Wheel speed dropped to zero, and the airplane began to skid, which resulted in reverted-rubber hydroplaning,” the report said. “The airplane continued past the end of the runway, crossed a service road and came to rest in a drainage ditch.” Damage was substantial, but the pilots were not hurt.

Investigators determined that the Phenom could have been stopped on the runway if the pilot had continued applying maximum wheel braking; his engagement of the emergency parking brake decreased the airplane’s braking performance.

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Turboprops

Engine Fails on Initial Climb

Piper Cheyenne II. Destroyed. Four fatalities.

Night visual meteorological conditions prevailed when the Cheyenne departed from Elko, Nevada, U.S., on Nov. 18, 2016, for an air ambulance flight to Salt Lake City. Witnesses saw the airplane enter a 30-degree left bank on initial climb and then stop climbing as the bank angle abruptly increased. The Cheyenne descended onto a parking lot and burned. The patient, the two medical crewmembers and the pilot were killed.

Examination of the airplane revealed that the left engine was producing little or no power on impact. “The extensive fire and impact damage to the airplane precluded determination of the reason for the loss of left engine power,” the NTSB report said.

“In the two months before the accident, pilots had notified maintenance personnel three times that the left engine was not producing the same power as the right engine,” the report said. “In response, mechanics had replaced the left engine’s bleed valve three times, with the final replacement taking place three days before the accident. In addition, about one month before the accident, the left engine’s fuel control unit was replaced during troubleshooting of an oil leak.”

Open Breaker Stops Gear Extension

Beech King Air 350. Substantial damage. No injuries.

The flight crew was returning to Taichung (Taiwan) Airport after completing an aerial photography flight the afternoon of Nov. 7, 2015. They attempted to extend the landing gear on approach but saw that only the nose gear down-and-locked indicator had illuminated.

The crew conducted a go-around and then attempted again to extend the landing gear after re-entering the landing pattern. This time, only the down-and-locked indicators for the nose gear and right main landing gear illuminated. “The flight crew judged that this condition [had] resulted from the failure of the landing gear indication lights,” said the report by the Aviation Safety Council of Taiwan.

The crew recycled the landing gear, but the left landing gear light again did not illuminate. However, the pilots saw through their windows that both main landing gear appeared to be extended; they also saw that the locking hook on the gear handle was in place. The airport traffic controller also confirmed that the landing gear appeared to be extended. These observations apparently supported the crew’s belief that the landing gear indication lights were malfunctioning.

However, when the crew extended full flaps, they heard the landing gear warning horn sound. They recycled the flaps, and the gear warning horn sounded again. “Instead of executing the manual extension procedure as required by the operating manual to lower and down-lock the landing gear, the flight crew decided to land anyway,” the report said. “Upon touching ground, the landing gear on both sides and the nose gear retracted, forcing the aircraft to slide on its belly until it came to a full stop.” The King Air was substantially damaged, but the two aerial photographers and the pilots were not hurt.

Examination of the airplane revealed that the 2-ampere landing gear circuit breaker was open. The report said the breaker likely had opened during the crew’s first attempt to extend the gear, isolating electrical power from the landing gear motor.

Forced Landing on Taxiway

Cessna 208B. No damage. No injuries.

A pilot receiving recurrent training in the Caravan the afternoon of Nov. 11, 2016, pitched the nose up on takeoff from Darwin Airport in Australia’s Northern Territory to achieve the best-angle-of-climb speed. The flight instructor noticed that airspeed was decreasing below the target speed as the aircraft climbed through 500 ft.

“At the same time, the instructor heard the engine lose power and [saw that] a thin film of fuel partially obscured the windscreen,” said the report by the Australian Transport Safety Bureau (ATSB). The instructor also noticed that engine torque, fuel flow and inter-turbine temperature indications were decreasing.

Airspeed was decreasing below 60 kt when the instructor took control of the Caravan. He “immediately felt a strong nose-down force through the control column,” the report said. “The aircraft pitched significantly nose-down.” The instructor recovered control and established a glide at 85 kt. After an unsuccessful attempt to restart the engine, the crew feathered the propeller.

One of the pilots declared an urgency and stated that they were returning to the airport. “After clearing the hangars and trees, the instructor observed [a] taxiway and elected to land on [the] taxiway,” the report said. “The instructor and trainee were not injured, and the aircraft was not damaged in the incident.”

After exiting the Caravan, the pilots saw fuel leaking from the engine cowling and a large pool of fuel below the fuselage. Examination of the engine revealed that the locking plate for the no. 8 fuel nozzle was not in place and that the fuel line had separated from the adaptor, causing a substantial leak and starving the engine of fuel.

“The lack of damage to the locking plate mounts, along with the locking plate being entirely missing and the fasteners being found installed, indicates the locking plate probably did not fail,” the report said. Investigators determined that the locking plate on the no. 8 nozzle likely had not been reinstalled when all the fuel nozzles were replaced 86 flight hours before the incident.

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Piston Airplanes

Magneto Fails on Takeoff

Cessna 401A. Substantial damage. Three serious injuries.

The right engine lost power shortly after the airplane lifted off the runway at Fulton, Missouri, U.S., for a business flight the evening of Nov. 17, 2014. The pilot flying rejected the takeoff and then shut down the left engine after determining that he would not be able to stop the 401 on the remaining runway.

The airplane overran the runway onto rough terrain. The two pilots and their passenger were seriously injured, and the 401 was substantially damaged.

Examination of the right engine, a Continental Motors TSIO-520E8, revealed that the nylon distributor drive gears in the magneto had failed, causing the power loss, the NTSB report said. The drive gears exhibited a brown discoloration indicative of exposure to extreme heat. The report noted that Continental requires replacement of magnetos when such discoloration is found.

The report said that the airplane operator’s “failure to inspect and maintain the magnetos in accordance with the engine manufacturer’s specifications” was a contributing factor in the accident. Continental’s maintenance instructions specify that magnetos should be inspected every 500 hours and either overhauled or replaced every five years. Maintenance records for the 401 showed that the magnetos had been overhauled eight years before the accident and that the airplane subsequently had been flown about 697 hours.

Simulation Goes Bad

Beech 76. Substantial damage. No injuries.

A flight instructor was administering a flight review at Davis, California, U.S., the morning of Nov. 5, 2016. He told investigators that he used the mixture control to simulate failure of the left engine after the pilot released the brakes and added full power for takeoff.

“The pilot ‘froze’ at the flight controls, and the airplane veered to the left,” the NTSB report said. “The flight instructor attempted to fail the right engine via the right mixture control in order to regain directional control, but his hand came off the mixture control and the airplane exited the runway.”

The Duchess was substantially damaged when the nose landing gear collapsed, but the pilot and flight instructor were not hurt. The NTSB concluded that the probable causes of the accident were “the pilot’s failure to maintain directional control” and “the flight instructor’s delayed remedial action.”

Long Touchdown On Wet Runway

Beech 58P Baron. Substantial damage. One minor injury.

The Baron was nearing San Antonio, Texas, U.S., from the south the afternoon of Nov. 20, 2014, when the pilot was instructed by the air traffic controller to circle and land on Runway 14. The airport had 2 mi (3,200 m) visibility in heavy rain, a 1,600-ft ceiling, and surface winds from 270 degrees at 3 kt. The controller advised the pilot that there was “rain on the airport.”

A witness said that the Baron was still airborne when it passed the midpoint of the 4,128-ft (1,258-m) runway. “The airplane subsequently touched down, ran off the end of the runway and went through a barrier fence before coming to a stop on a service road,” the NTSB report said.

The pilot believed that the airplane’s brakes had failed, but investigators found evidence that the wheels had locked and hydroplaned on the wet runway. “When informed by the local controller that it was raining at the airport, the pilot should have realized that hydroplaning was a possibility and ensured that the airplane touched down near the approach end of the runway to maximize the available landing distance,” the report said.

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Helicopters

Pressed On Into Marginal Weather

Airbus Helicopters EC135-T1. Substantial damage. Three fatalities.

The pilot landed the helicopter in a cleared area in a valley after encountering adverse weather conditions during a private flight from Breeza, New South Wales, Australia, to Terrey Hills, 270 km (146 nm) south, the afternoon of Nov. 7, 2015. The flight had been planned for the previous day but was postponed due to severe storms along the route. The ATSB report noted that the pilot was not instrument-rated and did not file any notifications for the flight.

“After 40 minutes on the ground, the pilot departed to the east towards rising terrain in marginal weather conditions,” the report said. “Approximately 9 km [5 nm] east of the interim landing site, the helicopter collided with terrain.” The pilot and his two passengers were killed.

Thirty-six hours later, relatives of the occupants notified search-and-rescue authorities that the helicopter was overdue. The wreckage was found a day later. Examination of the helicopter revealed that the emergency locator transmitter had been removed and that two personal locator beacons (PLBs) requiring manual activation were being carried aboard the helicopter.

“While in this accident it did not affect the outcome for the occupants, the lack of activation [of the PLBs], combined with the absence of flight notification information, delayed the search and rescue response,” the report said.

Rotor Drive Clutch Fails

Robinson R44. Destroyed. Three fatalities, one serious injury.

The pilot was scheduled to conduct six sightseeing flights near Mumbai, India, on Nov. 12, 2016. Two passengers boarded the R44 for the second flight, and a maintenance technician occupied a front seat so that the helicopter would meet weight-and-balance requirements, said the report by India’s Ministry of Civil Aviation.

About five minutes after takeoff, the pilot told air traffic control that he was conducting a forced landing due to “clutch failure.” The clutch failure caused disengagement of the engine from the rotor driveshaft. The R44 was being flown about 500 ft above the ground when the failure occurred.

The maintenance technician, who survived the accident with serious injuries, said that the pilot had selected a field on which to land the helicopter but rejected the approach after seeing children playing in the field. Rotor speed decreased as the pilot attempted to “stretch” the autorotative glide to another field, the report said. The maintenance technician said that the pilot then saw workers in the second field and applied right yaw to miss them. “This resulted in the helicopter side-slipping and a slight roll to the right into a grove of trees and bushes,” the report said. “The helicopter caught fire just after impact with the ground.”

Local residents pulled the four people out of the helicopter. The pilot was declared dead on arrival at a hospital, and the two passengers later succumbed to their injuries. Investigators were unable to determine the cause of the helicopter’s clutch failure.

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