RECENT CITATION ACCIDENTS

What do these airplanes have in common?

N839QS N54PV

N697MC N492AT N486SB

N86CE N814ER OY-JET N50CV

N792MA

About Ben •  Co-founder of

jetAVIVA •  Flight Test •  NTSB •  ATP/CFI-AIM •  Type ratings in

CE-500, CE-510, Eclipse, Phenom

Unstabilized Approach Accidents N839QS September 1, 2008 Telluride, CO CE-560 N54PV April 19, 2008 Carlsbad, CA CE-510 / Mustang

N697MC October 27, 2007 Atlantic City, NJ CE-650 / III N492AT January 24, 2007 Butler, PA CE-550 / II N50CV July 10, 2006 Hamilton, MT CE-560 N486SB June 24, 2006 Upland, CA CE-560 / Encore N814ER February 1, 2006 Greensboro, NC CE-500 / I N86CE January 24, 2006 Carlsbad, CA CE-560 / Ultra OY-JET May 15, 2005 Atlantic City, NJ CE-525A / CJ2 N792MA August 25, 2004 Venice, FL CE-550 / Bravo

Why are we talking about this?

43%

Ground Handling

Mechanical Failure

Unsolved

Landing

Loss of Control / Other

54 Accidents

43% Landing

Landing Accident Breakdown

43%

13%

Unstabilized Approach

Landing (Maybe SA)

Other Landing

23 Landing Accidents

Up to 56% Unstabilized Approaches

Preventable •  This session focuses on accidents that are

preventable •  We will analyze four of these accidents •  What could have been done to prevent

them? •  Discuss simple lessons learned •  Questions and Round Table

Disclaimer

•  Stepping into pilot’s shoes is impossible •  It’s easy to Monday morning quarterback •  I wasn’t there •  All information is from NTSB website

N792MA •  Cessna CE-550 •  August 25, 2004 in Venice, Florida •  Low, slow, short approach •  Undershot runway •  Main landing gear punched through the

top of the wings •  No injuries

Flight History •  Aircraft departed Fort Pierce, Florida with

one passenger •  Approximately 45 minute flight •  Normal flight •  Some thunderstorms in the vicinity of

Venice, Florida

Accident Sequence •  Visual approach to

runway 13 •  DFDR data showed:

– Turn from base to final completed at 225 feet

– Speed varied from 90 to 95 for 15 seconds

– Speed was 83 for last five seconds of flight

Witnesses reported the approach was low and slow, very flat, with little or no flare

NTSB Probable Cause

The pilot’s failure to maintain adequate airspeed which resulted in a stall and

undershoot of the runway

N86CE •  Cessna CE-560 Ultra •  January 24, 2006 in Carlsbad, CA •  High, fast approach •  Aircraft overshot runway, hit localizer •  Four fatalities •  Aircraft destroyed by post-impact fire

Flight History •  Departed Sun Valley, Idaho early in the

morning with two passengers •  Slated to arrive in Carlsbad before the

tower opened •  Clear skies, winds 040 at six knots •  Landing on runway 24

Accident Sequence •  On descent at 6,700 feet, 8.5

miles from the threshold, ground speed was 300 knots

•  Four-tenths of a mile from the threshold, the rate of descent decreased from 3,000 feet per minute to 1,000 feet per minute

•  Calibrated airspeed was 124 knots, 23 knots faster than Vref

Accident Sequence cont’d •  Witness statements indicated that the

aircraft was “very fast” and touched down approximately 1,500 feet down the runway

•  Thrust reversers were deployed •  The first officer commanded twice for the

Captain to execute a go-around after the thrust reversers were deployed

•  A go-around was then attempted

Pilot Profile •  Captain:

– Earned ATP in 1972 – 17,000 hours and current

•  First Officer: – Also very experienced – 7,500 hours – Also type rated in the aircraft

NTSB Probable Cause •  The Captain’s delayed decision to execute

a go-around during the landing roll. •  Contributing factors:

– Decision to land with a tailwind – Excessive airspeed on approach – Failure to attain proper touchdown point

N697MC •  Cessna CE-650 Citation III •  October 27, 2007 in Atlantic City, NJ •  Substantial Damage, No Injuries •  Windshear, airspeed control, high sink rate •  Hard landing (and then go around) caused

loss of hydraulics and fuel leak •  No brakes or thrust reversers on landing •  Overran 10,000 foot runway

Flight History •  Departed Farmingdale, NY for 30 minute

flight to Atlantic City, NJ •  800 foot broken layer •  Flight on GPS approach •  Winds 11 gusting to 24 knots •  Broken ceiling at 800 feet, light rain, seven

miles visibility

Accident Sequence •  First officer was the pilot

flying •  First officer’s airspeed

indicator was fluctuating around Vref +20 (150 knots) at 300 feet AGL

•  When the aircraft began descending from the MDA, it was high and fast

Accident Sequence cont’d •  First officer momentarily deployed the

speed brakes to help slow and descend •  Speed brakes were stowed and thrust

levers remained idle from 200 feet AGL •  The airplane impacted the runway at an

excessive rate, bounced, drifted to the right, and the first officer initiated a go around

Pilot Profile •  Captain:

– ATP, 62 years old, 9,472 hours – 193 hours in type, 21 in previous 30 days

•  First Officer: – ATP, 26 years old, 2,535 hours – 120 hours in type, 38 in previous 30 days

NTSB Probable Cause •  The First Officer’s failure to maintain

airspeed during approach and the Captain’s inadequate remedial action.

•  Contributing factors: – First Officer’s failure to comply with

procedures – Windshear – Lack of windshear warning from ATC

N54PV •  Cessna CE-510 Citation Mustang •  April 19, 2008 in Carlsbad, CA •  Substantial Damage, No Injuries •  Autopilot anomaly during descent •  ILS approach with 2,700 foot ceiling •  High and fast approach •  Intentional ground loop

Flight History •  Single pilot operation •  Pilot flew from Stockton, CA to Lincoln, CA

to pick up passengers •  Was on second leg of the day from

Stockton, CA to Carlsbad, CA •  Copilot PFD data flickered followed by

autopilot disconnect and elec. trim fail •  Pilot continued by hand to destination

Accident Sequence •  Broke out and continued visually from 2,700 feet •  Pilot thought he was 15 knots fast on approach and

runway sufficient •  ATC said the aircraft was high and asked the pilot if he

could make it –  Pilot said “Yes”

•  ATC reports aircraft touched down well past halfway point on runway

•  With runway end approaching, pilot intentionally ground looped the aircraft

•  Gear and flaps collapsed

Pilot Profile •  Commercial, Instrument, Multi, CE-510S •  1,398 hours total time, 140 in type •  Current with 38 hours in past 30 days •  Received type rating seven months earlier

with 25 hours SOE limitation •  Transitioned from Piper Seneca •  57 years old, agriculture company exec

NTSB Probable Cause •  Pilot’s misjudgment of speed and

distance, resulting in runway overshoot •  Contributing factors:

– Pilot’s failure to follow the Autopilot Preflight Test Fail checklist

– Distraction with PFD with flickering data

Why Stabilized Approaches Work

•  Takes the guesswork out •  Easy •  Procedural •  No need to make a judgment call •  No need to second-guess a decision

What is a Stabilized Approach? •  At 500 Feet (VMC) or 1,000 Feet (IMC)

and below •  On glidepath •  In landing configuration •  On target speed (Vref to Vref +10 or gust) •  Power spooled up and stabilized •  Before Landing Checklist complete •  Cleared to land

What to do if not stabilized

AUTOMATIC GO AROUND Do Not Hesitate

Strategies for Success •  Brief the stabilized approach criteria / go-

around procedure prior to each approach, not just the missed approach procedure

•  Each time you hear the TAWS “Five Hundred” callout – verify that the approach meets the criteria and verbally say “Stable” or “Going Around”

Wrap up •  43% of Citation accidents were on landing •  56% of those could be attributed to

unstabilized approaches •  Strictly following stabilized approach

procedures could prevent one-quarter of all Citation accidents

•  These accidents are preventable

Q&A / Roundtable

RECENT CITATION ACCIDENTS