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PSA Airlines 2495

Accident Case Study

 


 

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Photo: PSA Airlines N246PS, from Wikimedia Commons.

Accident Report

  • Date: 19 Jan 2010
  • Time: 1613 EST
  • Type: CL-600-2B19
  • Operator: PSA Airlines
  • Registration: N246PS
  • Fatalities: 0 of 3 crew, 0 of 31 passengers
  • Aircraft Fate: Minor damage
  • Phase: Takeoff
  • Departure Airport: Yeager Airport, Charleston, WV
  • Destination Airport: Charlotte/Douglas International Airport, Charlotte, NC

Narrative

[NTSB Factual Report DCA10IA022, ¶C.] On January 19, 2010, PSA Airlines (d.b.a. US Airways Express) flight 2495, a Bombardier CL600-2B19, registration N246PS, rejected the takeoff and ran off the end of the runway at Yeager Airport, Charleston, West Virginia. The airplane stopped in the Engineered Materials Arresting System (EMAS) installed in the safety area. There were no injuries to the 31 passengers or 3 crew members onboard and the airplane received minor damage. The flight was operating under the provisions of 14 CFR Part 121 and its intended destination was Charlotte/Douglas International Airport, Charlotte, North Carolina.

[NTSB Probable Cause DCA10IA022]

  • Cockpit voice recorder (CVR) information revealed that the flight crew began a personal conversation (that is, a conversation not pertinent to the operation of the airplane) during departure delay. The flight crewmembers continued the nonpertinent conversation throughout the entire taxi, which was not in accordance with company procedures and Federal regulations regarding sterile cockpit. CVR information also revealed that, although the flight crew completed all of the required checklist items during the taxi, each item was read and responded to in a very quick and routine manner.
  • About 1609, the captain called for flaps 20 and then for the Taxi checklist. Flight data recorder (FDR) data indicated that, 1 second later, the flaps moved from the flaps 0 to the flaps 8 position. Further, while conducting the checklist, the first officer stated, "flaps 8" and "eight degrees," indicating that he had selected the flap handle to the flaps 8 position, not to the flaps 20 position as called for by the captain. However, the captain responded, "set" and "eight," respectively, indicating that he did not notice the incorrect flap setting. The rapid and perfunctory manner in which the flight crew conducted the Taxi checklist resulted in the captain not visually comparing the airplane's flap position with the aircraft communications addressing and reporting system data, which was his normal practice.
  • The captain had nearly 10,000 hours total time, half of it in this particular type. He was very proficient. The first officer had nearly 2,000 hours in type. Judging by the banter in the cockpit, they were very comfortable flying with each other. They were prime candidates for complacency.

  • After rapidly completing the Taxi checklist, the flight crew continued the nonpertinent conversation until the captain called for the Before Takeoff checklist. After the flight crew rapidly conducted this checklist, without including a proper takeoff briefing, the flight was cleared for takeoff. The takeoff was normal until the airplane reached an airspeed of about 120 knots. At this time, FDR data showed the flaps beginning to move from the flaps 8 to the flaps 20 position. Shortly thereafter, the first officer stated, "V one [the takeoff decision speed]," which was 127 knots. The CVR then recorded the sound of the airplane master caution and flaps and spoilers configuration aural alerts. The captain initiated a rejected takeoff (RTO) about 5 seconds after he started moving the flaps and when the airplane was at an airspeed of about 140 knots, which was 13 knots above V1.
  • The CL-600 is certified for takeoff flap settings of 8 or 20. The accelerate stop distance, 5,730 feet, was fairly close to the runway length, 6,300 feet. It appears the takeoff warnings were generated by the movement of the flap handle from one valid setting to another.

  • Bombardier computed the total distance required for the incident airplane to accelerate stop using data from the FAA-approved Airplane Flight Manual and the planned takeoff performance data (including configuration, weight, altitude, and reduced thrust takeoff). The calculations indicated that the airplane would have stopped about 5,730 feet from the beginning of the takeoff roll if the deceleration had been initiated at the planned V1 (127 knots). Given that the runway was 6,300 feet long and that FDR data indicated a normal deceleration during the RTO, sufficient runway distance would have existed for the airplane to stop on the runway surface if the captain had initiated the RTO immediately after he identified the misconfigured flap setting instead of reconfiguring the flaps. The captain should have called for an RTO as soon as he recognized the flaps were in the wrong position. As a result of the captain's decision to attempt to reconfigure the flaps and delay the RTO, the airplane overran the runway end and entered the engineered materials arresting system (EMAS) at an airspeed of about 50 knots. The airplane stopped 128 feet into the EMAS arrestor bed with about 277 feet of arrestor bed remaining. Before the installation of the EMAS in September 2007, the runway end safety area for runway 23 was only 120 feet long. If this incident had occurred before the installation of the EMAS, the airplane most likely would have traveled beyond the length of the original safety area and off the steep slope immediately beyond its end.

Probable Cause

[NTSB Probable Cause DCA10IA022]

  1. The flight crewmembers' unprofessional behavior, including their nonadherence to sterile cockpit procedures by engaging in nonpertinent conversation, which distracted them from their primary flight-related duties and led to their failure to correctly set and verify the flaps;
  2. The captain's decision to reconfigure the flaps during the takeoff roll instead of rejecting the takeoff when he first identified the misconfiguration, which resulted in the rejected takeoff beginning when the airplane was about 13 knots above the takeoff decision speed and the subsequent runway overrun; and
  3. The flight crewmembers' lack of checklist discipline, which contributed to their failure to detect the incorrect flap setting before initiating the takeoff roll. Contributing to the survivability of this incident was the presence of an engineered materials arresting system beyond the runway end.

See Also:

References

NTSB Group Chairman's Factual Report of Investigation, DCA10IA022, CL-600-2B19, N246PS, January 19, 2010

NTSB Probable Cause, DCA10IA022, Bombardier CL600, N246PS, 10/29/2010

Wikimedia Commons, Public Domain Artwork

Revision: 20140618
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