Challenger 300 Turbulence Death - Prelim Released

[schloopy]

Preliminary report for the initially reported “turbulence fatality” from earlier this month just released. Turns out, nothing to do with turbulence and a lot more going on than was initially believed (shocker).

https://s3.documentcloud.org/documents/23722207/report_era23la135_106816_3_24_2023-10_09_31-am.pdf

“The flight crew reported that around 6,000 ft, they observed multiple EICAS caution messages. The crew recalled EICAS messages of ‘AP STAB TRIM FAIL’ [autopilot stabilizer trim failure] ‘MACH TRIM FAIL’ and ‘AP HOLDING NOSE DOWN’. Neither crewmember could recall exactly what order the EICAS messages were presented. They also reported that additional EICAS messages may have been annunciated.

The PIC asked the SIC to refer to the quick reference handbook. The SIC, via an electronic flight bag (iPad), located the quick reference card and the ‘PRI STAB TRIM FAIL’ [Primary Stabilizer Trim Failure] checklist. The SIC visually showed the PIC the checklist, and they both agreed to execute the checklist. The first action on the checklist was to move the stabilizer trim switch (‘STAB TRIM’), located on the center console, from ‘PRI’ (Primary) to ‘OFF.’ The SIC read the checklist item aloud and he subsequently moved the switch to off.

As soon as the switch position was moved, the airplane abruptly pitched up. The PIC reported that his left hand was on the flight controls and his right hand was guarding the right side of the flight controls. He immediately with both hands regained control of the airplane in what he estimated to be a few seconds after the airplane’s pitch oscillated up and down. During the oscillations, the PIC instructed the SIC to move the stabilizer trim switch back to the primary position, which the SIC accomplished.

…

The airplane immediately pitched up to about 11° and reached a vertical acceleration of about +3.8g. The airplane subsequently entered a negative vertical acceleration to about -2.3g. The airplane pitched up again to about 20° and a vertical acceleration of +4.2g was recorded. The stall protection stick pusher activated during this pitch up; subsequently, vertical acceleration lowered to about +2.2g which was followed by a cutout of FDR data.”


All of this occurring after an initial aborted takeoff due to a pitot cover-induced airspeed disagree, followed by a takeoff with unpopulated v-speeds. Plenty more happening on the ground as well. Certainly a lot going on here…

 

[MikeOH58]

CL30 has a “go / no go” guide which is a quick reference for any CAS (on ground) and offers a fast resource for determining if there is a path to MEL relief or if airplane is hard down based on CAS displayed. “Rudder limiter fault” is a no go item. It is not up for interpretation and it doesn’t require any special understanding.
Rudder limiter fault : No Go

They dispatched a broke jet and furthermore ran the wrong checklist in-flight. If I were the family of the deceased I would be pushing for criminal charges if they are possible. This shouldn’t have happened and that woman didn’t deserve to die that way.

 

[killbilly]

CL30 has a “go / no go” guide which is a quick reference for any CAS (on ground) and offers a fast resource for determining if there is a path to MEL relief or if airplane is hard down based on CAS displayed. “Rudder limiter fault” is a no go item. It is not up for interpretation and it doesn’t require any special understanding.
Rudder limiter fault : No Go

They dispatched a broke jet and furthermore ran the wrong checklist in-flight. If I were the family of the deceased I would be pushing for criminal charges if they are possible. This shouldn’t have happened and that woman didn’t deserve to die that way.

I've often wondered about advisory messages that are no-go - I know they exist, but it doesn't really make sense to me as to why that is. My very limited 121 experience on one very obsolete jet is the scope of my understanding here.

Why would a basic advisory message like that - one that is a no-go item - just be advisory? Why isn't it a hard, abort-worthy caution situation?

 

[MikeOH58]

I've often wondered about advisory messages that are no-go - I know they exist, but it doesn't really make sense to me as to why that is. My very limited 121 experience on one very obsolete jet is the scope of my understanding here.

Why would a basic advisory message like that - one that is a no-go item - just be advisory? Why isn't it a hard, abort-worthy caution situation?

The coding/coloring of warning, caution, status and advisory messages is done for in flight conditions. Hence, an on-ground go-no go guide.

Any type rated CL30 pilot should instinctually know that if there is a non normal CAS on ground, consulting the go no go guide is required before considering dispatch. If that’s not their instinctual reaction they aren’t fit to hold the type rating. Plain and simple and there is nothing else to say about it.

The Go/No Go guide which is the last section of QRH 2 is an awesome system, but it’s only as good as the monkeys willingness to use or ignore it.

 

[Minuteman]

Any type rated CL30 pilot should instinctually know that if there is a non normal CAS on ground, consulting the go no go guide is required before considering dispatch. If that’s not their instinctual reaction they aren’t fit to hold the type rating. Plain and simple and there is nothing else to say about it.

Yeah but it they were apparently getting that message a lot recently and it went away with a computer reset so...

 

[JordanD]

I've often wondered about advisory messages that are no-go - I know they exist, but it doesn't really make sense to me as to why that is. My very limited 121 experience on one very obsolete jet is the scope of my understanding here.

Why would a basic advisory message like that - one that is a no-go item - just be advisory? Why isn't it a hard, abort-worthy caution situation?

My best guess is someone thought “well you can’t do anything about it, so it’s advisory.” Which is dumb because that kind of thinking can lead to people writing it off. I’ve had a fire extinguisher bottle fail (or something to that effect) come up in the embraer. Advisory, but it ended up being a gate return and a lengthy delay while they swapped it out.

 

[Roger Roger]

Bombardier likes the non-dispatchable status messages. LR45 a couple we’ve run into: NWS FAULT. Directs you to the MEL, but the deferral for NWS has been removed from the MEL so now it’s a no-go. TR FAULT: now you’ve gotta have mx pin the TRs and collar some breakers.

 

[MikeOH58]

My best guess is someone thought “well you can’t do anything about it, so it’s advisory.” Which is dumb because that kind of thinking can lead to people writing it off. I’ve had a fire extinguisher bottle fail (or something to that effect) come up in the embraer. Advisory, but it ended up being a gate return and a lengthy delay while they swapped it out.

What does it matter how the CAS is categorized and whether or not you can do anything about it?

You can either dispatch or you can’t and in the Bombardier world thankfully we have a quick reference guide that takes 30 seconds to make a determination. The system works and nothing needs to be changed. At some point we have to pretend to be professionals and not have our hand held 24/7

 

[KLB]

CL30 has a “go / no go” guide which is a quick reference for any CAS (on ground) and offers a fast resource for determining if there is a path to MEL relief or if airplane is hard down based on CAS displayed. “Rudder limiter fault” is a no go item. It is not up for interpretation and it doesn’t require any special understanding.
Rudder limiter fault : No Go

They dispatched a broke jet and furthermore ran the wrong checklist in-flight. If I were the family of the deceased I would be pushing for criminal charges if they are possible. This shouldn’t have happened and that woman didn’t deserve to die that way.

Folks on social media are trying to blame it on their "inexperience" on the type. But a 5000hr and 8000hr should have the experience to go to the QRH and see that it's clearly a No-Go item. Also...attempting a takeoff with the pitot static covers on (having those covers on will give you a pitot static fault at the power up 99% of the time), aborting, and taking off again is rookie student pilot stuff. The only way to get rid of a rudder limiter fault is a hard reset.

 

[KLB]

My best guess is someone thought “well you can’t do anything about it, so it’s advisory.” Which is dumb because that kind of thinking can lead to people writing it off. I’ve had a fire extinguisher bottle fail (or something to that effect) come up in the embraer. Advisory, but it ended up being a gate return and a lengthy delay while they swapped it out.

All of the Bombardier supported big box programs teach it the same. The QRH is gone to for all non normal CAS messages. We have a GO-NO GO list that clearly shows that we can't go with this CAS....even when it being an advisory CAS. The screwed this one up all the way around. From the poor preflight to the continuation after the rejected takeoff with a rudder limiter fault. They didn't even reset their V-speeds. They didn't reconfigure for takeoff and just spit balled the V1, VR, and V2 speeds. This means that they were using the checklist.

 

[MikeOH58]

Folks on social media are trying to blame it on their "inexperience" on the type. But a 5000hr and 8000hr should have the experience to go to the QRH and see that it's clearly a No-Go item. Also...attempting a takeoff with the pitot static covers on (having those covers on will give you a pitot static fault at the power up 99% of the time), aborting, and taking off again is rookie student pilot stuff. The only way to get rid of a rudder limiter fault is a hard reset.

Time in type isn’t even a contributing factor in my mind. They hold a fresh type rating. Not knowing about the go/no go guide is as unbelievable as saying they didn’t know QRH2 exists. They ignored it to get the job done and ended up killing a person. I’m pissed off over this.

 

[CoffeeIcePapers]

The light jet candidate market is getting scary.

 

[KLB]

Time in type isn’t even a contributing factor in my mind. They hold a fresh type rating. Not knowing about the go/no go guide is as unbelievable as saying they didn’t know QRH2 exists. They ignored it to get the job done and ended up killing a person. I’m pissed off over this.

I agree! I only bring it up because the 300/350/3500 group insinuate "diversity hire" without knowing the race, gender, or age of the pilots.

 

[Brian29]

Time in type isn’t even a contributing factor in my mind. They hold a fresh type rating. Not knowing about the go/no go guide is as unbelievable as saying they didn’t know QRH2 exists. They ignored it to get the job done and ended up killing a person. I’m pissed off over this.

This happens hundreds of times a day in part 135 and it’s a miracle there isn’t this kind of incident weekly if not daily. It’s disgusting
I won’t discuss on a public forum the conversations I’ve had with DO’s and CP’s but let’s just say the way these operations are run is damn near criminal.

 

[Roger Roger]

Also doesn’t like….every bizjet use the secondary trim for autopilot trim? Going after the wrong QRH procedure on that one is kinda a big oops.

 

[SteveC]

This happens hundreds of times a day in part 135 and it’s a miracle there isn’t this kind of incident weekly if not daily. It’s disgusting
I won’t discuss on a public forum the conversations I’ve had with DO’s and CP’s but let’s just say the way these operations are run is damn near criminal.

Counter point; there are a lot of good operators out there that would never tolerate that stuff.

 

[turbojet28]

Holy S

 

[JordanD]

What does it matter how the CAS is categorized and whether or not you can do anything about it?

You can either dispatch or you can’t and in the Bombardier world thankfully we have a quick reference guide that takes 30 seconds to make a determination. The system works and nothing needs to be changed. At some point we have to pretend to be professionals and not have our hand held 24/7

Never flown the Bombardier, just saying it can be misleading or have a false sense of security in some types.

 

[Brian29]

Counter point; there are a lot of good operators out there that would never tolerate that stuff.

Mean anything is possible but in the decade I spent in that part of the industry I never met or heard of one. A bit tongue in cheek of course, broad brushes and all that but…
With the garbage planes flown by most/some of these operators and the ever increasing concentration of bad/lesser experienced pilots driven by 121 gobbling anyone with the bare requirements and ability to put an app together I’m afraid this little incident is just the tip of the iceberg.

 

[KLB]

Never flown the Bombardier, just saying it can be misleading or have a false sense of security in some types.

They were new to the type. It should have warranted even more caution honestly. The CL30 is a very honest and forgiving airplane. It's very modern and not very difficult to fly. This crew just screwed it all up. I can't find any excuses to show why they allowed things to go the way that they did.