Jesus. Fighting for the airplane. I'm not sure who was in charge. Apparently they couldnt figure it out either.
- NTSB issues the final report into the fatal accident involving a Bombardier CL-600-2B16 Challenger 605, N605TR, that occurred on July 26, 2021, near Truckee Airport (TKF/KTRK), Truckee, California:
On July 26, 2021, about 1318 Pacific daylight time, a Bombardier Inc. Challenger 605, N605TR, was destroyed when it was involved in an accident near Truckee-Tahoe Airport (TRK), Truckee, California. The captain, FO, and four passengers were fatally injured. The airplane was operated as a Part 91 personal flight.
The captain and first officer (FO) departed on a non-revenue flight operating under instrument flight rules with four passengers bound for Truckee, California. Most of the flight was uneventful. During the descent, air traffic control (ATC) told the flight crew to expect the area navigation (RNAV [GPS]) approach for runway 20. The captain (pilot flying [PF]) stated and the FO (pilot monitoring [PM]) calculated and confirmed that runway 20 was too short for the landing distance required by the airplane at its expected landing weight. Instead of making a request to ATC for the straight-in approach to runway 11 (the longer runway), the captain told the FO they could take the runway 20 approach and circle to land on runway 11, and the FO relayed this information to ATC. ATC approved, and the flight crew accepted the circle-to-land approach. Although the descent checklist required that the flight crew brief the new circle-to-land approach, and the flight crew’s acceptance of the new approach invalidated the previous straight-in approach brief, they failed to brief the new approach.
ATC instructed the flight crew to hold, but the captain was slow in complying with this instruction, so the FO started the turn to enter the holding pattern and then informed ATC once they were established in the hold. About 20 seconds later, ATC cleared them for the approach. Before the FO confirmed the clearance, he asked the captain if he was ready for the approach, and the captain stated that he was. The FO subsequently commented that they had too much airspeed at the beginning of the approach and then suggested a 360° turn to the captain, but the captain never acknowledged the excessive airspeed and refused the 360° turn.
After the FO visually identified the airport, he told the captain to make a 90° right turn to put the airplane on an approximate heading of 290°, which was parallel to runway 11 and consistent with the manufacturer’s operating manual procedures for the downwind leg of the circling approach. However, the FO instructed the captain to roll out of the turn prematurely, and the captain stopped the turn on a heading of about 233° magnetic, which placed the airplane at an angle 57° left of the downwind course parallel with runway 11. As a result of the early roll-out, the flight crew established a course that required an unnecessarily tight turning radius. When they started the turn to final, the airplane was still about 1.3 nautical miles (nm) from the maximum circling radius that was established for the airplane’s approach category. The FO also deployed flaps 45° after confirming with the captain (the manufacturer’s operating manual procedures for the downwind leg called for a flaps setting of 30°, but the manufacturer stated that a flight crew is not prohibited from a flaps 45° configuration if the approach remains within the limitations of the airplane’s flight manual).
The airplane’s airspeed was 44 kts above the landing reference speed (Vref) of 118 kts that the flight crew had calculated earlier in the flight; the FO told the captain, “I’m gonna get your speed under control for you.” The FO likely reduced the throttles after he made this statement, as the engine fan speeds (N1) began to decrease from about 88% to about 28%, and the airplane began to slow from 162 kts. After the FO repeatedly attempted to point out the airport to the captain, the captain identified the runway; the captain's difficulty in finding the runway might have been the result of reduced visibility in the area due to smoke. The FO continuously reassured and instructed the captain throughout the circle-to-land portion of the approach. On the base leg to the runway and about 25 seconds before impact with the ground, the FO started to repeatedly ask for control of the airplane, but neither flight crewmember verbalized a positive transfer of control as required by the operator’s general operating manual (GOM); we could not determine who had control of the airplane following these requests.
As the airplane crossed the runway extended centerline while maneuvering toward the runway, the FO noted that the airplane was too high. One of the pilots (recorded flight data did not indicate which) fully deployed the flight spoilers, likely to increase the airplane's sink rate. (The flight spoilers are deployed using a single control lever accessible to both pilots.) The airspeed at the time was 135 kts, 17 kts above the Vref based on the erroneous basic operating weight (BOW) programmed into the airplane’s flight management system (FMS). About 7 seconds later, the left bank became steeper, and the stall protection system (SPS) stick shaker and stick pusher engaged. The captain asked the FO, “What are you doing,” and the FO again asked the captain multiple times to “let [him] have the airplane.” The stick shaker and stick pusher then briefly disengaged before engaging again. The airplane then entered a rapid left roll, consistent with a left-wing stall, and impacted terrain. A postcrash fire consumed most of the wreckage.
Analysis of data retrieved from the flight data recorder (FDR) indicated that the engines were functioning normally at the time of impact and there were no indications of a flight control or system malfunction. Most of the wreckage was consumed by postcrash fire, and the flight control linkages were destroyed either by high energy impact forces or the postcrash fire, which precluded a complete examination of the wreckage. Examination of the primary flight control surfaces did not reveal any preimpact mechanical anomalies. Engine data from the accident flight did not show any interruptions in power or suggest any mechanical anomalies with the power production capabilities of either engine.
- Flight Crew Performance:
The captain and FO were appropriately qualified to perform their respective duties as pilot-in-command (PIC) and second-in-command of the accident flight, which was the first pairing of this crew for the operator. A review of operator documentation revealed that the flight complied with the requirements of Title 14 Code of Federal Regulations (CFR) Part 91, General Operating and Flight Rules, and was not conducted under the operator’s 14 CFR Part 135 certificate. Although toxicology testing detected ethanol in the FO’s tissue, given the different concentrations of ethanol, the presence of n-propanol, and the state in which the body was found, it is likely that the identified ethanol was from sources other than ingestion.
The flight crew elected to conduct a circling approach to runway 11 and never asked ATC for the straight-in RNAV (GPS) approach to the desired runway. The crew also failed to brief the new circling approach after previously briefing the anticipated straight-in approach. The flight crew’s failure to brief the circling approach prevented them from sharing a mental model for how the approach should have been conducted and points to poor crew resource management (CRM) because they failed to prepare for adverse situations and contingencies, such as a missed approach. Because of their lack of preparation, they made critical errors on the approach that reduced the safety margin, which included:
1) flying the circling approach at a higher airspeed than the upper limit specified for the airplane’s category C approach category.
2) failing to establish the airplane on the downwind leg of the circle-to-land approach, and
3) failing to visually identify the runway early in the approach, likely due to obscuration by smoke.
The airplane’s higher airspeed reduced the flight crew’s time to configure the airplane, assess their position relative to the runway, and make corrections to their trajectory, which further reduced the safety margin. During the approach, the FO made several announcements to the captain that the airplane was fast. The captain rejected the FO’s suggestion to take a 360° turn early in the approach, which would have provided additional time and distance for speed control. The circling approach maneuver began at 160 kts, which was 20 kts higher than the upper limit of the circle-to-land approach speed established for this airplane’s approach category (category C) and did not drop below the category C maximum speed until the flight crew was preparing to start their base leg turn.
The captain’s failure to establish the airplane on the downwind leg and the airplane’s proximity to the airport during the approach also reduced the safety margin by limiting the space available to align the airplane with the runway centerline. The captain did not establish the airplane on a downwind leg parallel to the destination runway, as depicted in the manufacturer’s operating manual, but instead flew a downwind leg that converged on the runway centerline. This tightened the pattern and resulted in an overshoot of the runway centerline only 0.8 nm from the runway threshold during the base-to-final turn, limiting the flight crew’s ability to properly align the airplane with the runway centerline for final approach.
The FO received updated weather information from an automated weather observation system (AWOS) early in the approach, which included an advisory of reduced visibility due to heavy smoke in the area, but he did not relay this visibility advisory to the captain, further reducing the safety margin. The smoke likely made it more difficult for the captain to visually identify the airport.
The FO reassured the captain throughout the approach about needing to be patient and having plenty of time (despite the time constraints resulting from the fast and tight circling maneuver). These reassurances demonstrated that the FO was aware of the adverse effects of self-induced pressure to perform; however, he exhibited self-induced pressure to salvage a deteriorating approach. In addition, despite the captain not properly setting up the approach, he failed to ask for more time in the holding pattern and rejected the FO’s suggestion to use a 360° turn to slow the airplane. Without any external pressure to land immediately, the captain’s actions indicated a self-induced pressure to perform without being corrected.
Following the turn to the base leg, the airplane was not in a position from which it could align with the runway without overshooting the centerline, nor could the pilots execute a normal descent to the runway. Further, the airspeed was not on target or approaching the flight crew’s target Vref of 118 kts. The stabilized approach criteria in the operator’s GOM required that the airplane be in a position to execute a normal descent to the runway and that the airspeed be on target or approaching target no later than 500 ft above field elevation in visual meteorological conditions (VMC). The accident approach did not meet those criteria and was therefore unstabilized.
Once the approach became unstabilized, the crew should have abandoned the approach and gone around but did not. The operator’s GOM empowered both pilots to perform a go-around, and the circumstances of the approach did not preclude a go-around; there was no time- or fuel-related pressure to land. Even so, the flight crew never announced a go-around, and the FO did not make callouts for going around as required in his role as PM (as the PM, it would have been the FO’s duty to call for a go-around once the operator’s stabilized approach criteria were violated). The flight crew’s choice to continue the unstabilized approach rather than go around was consistent with self-induced pressure to perform and degraded decision-making.
About 8 seconds after the FO asked for control of the airplane the first time, he said, “We’re gonna go through it and come back okay?”, likely referring to the runway centerline, and indicating an intent to salvage the unstable approach. As the airplane crossed the centerline, the captain said, “It’s here” (also likely referring to the centerline), and the FO responded, “Yes yes it’s here we are very high,” indicating that he was aware that the airplane was not in a position to make a normal descent to the runway. At the same time, the spoilers were deployed. Given the FO’s stated intent to overshoot the runway centerline and then return to it and his recognition that they were high, it is likely that the FO deployed the spoilers in an attempt to descend quickly toward a nominal glidepath to the runway.
Once the airplane crossed the extended runway centerline, it approached a stall and the stick shaker engaged; the FO again requested control of the airplane multiple times, likely motivated by a desire to continue the approach. However, the cockpit voice recorder (CVR) did not record a positive transfer of control or any indication that the captain had relinquished control to the FO. The FO had acted as an instructor to the captain throughout the flight; seeing himself in this role might have driven his desire to take the controls in the final moments of the flight. Given the FO’s clear motivation to continue the approach and his multiple requests for control of the airplane, it is likely that he improperly attempted to take control of the aircraft without permission from the captain and increased the bank angle of the left turn, which contributed to the left wing’s stall. In his leadership position as PIC, the captain should have taken decisive action to exercise his authority to ensure airplane control when the FO likely improperly attempted to take control; however, he failed to do so.
In addition, both the FO’s decision to attempt to salvage the unstabilized approach and the captain’s failure to intervene demonstrated degraded performance and vigilance. Further, during the final 10 seconds of the flight, the CVR captured reactive statements from both crewmembers, including the FO’s multiple requests for control of the airplane, that suggest they were not working together. The captain's lack of assertiveness in exercising his authority, each flight crewmember’s failure to recognize their own psychological stresses, and the flight crew's disregard for safety while attempting to salvage the approach all point to improper CRM in the final moments of the accident flight. Failures in CRM generally describe a lack of clear communication and a failure to recognize degraded performance and vigilance in the cockpit. In this case, poor CRM contributed to the flight crew’s degraded performance and competition for control of the airplane, ultimately resulting in a stall.
- Airplane Performance:
Examination of paperwork for previous maintenance done on the airplane established that the weight and balance information was incorrect in the airplane’s FMS. About 10 months before the accident, a maintenance facility serviced the airplane’s FMS units to comply with a scheduled battery replacement. Although the maintenance facility reinstalled the required databases, which included the approach speeds and performance databases, it did not input a weight specific to the accident airplane. As a result, the airplane had likely been operating with an incorrect empty weight since the maintenance; the operator reported flying the airplane for four flights since the operator took possession of it in May 2021.
The default empty weight in the FMS was about 3,000 lbs lighter than the estimated actual airplane empty weight for the accident flight. Because of the inaccurate empty weight, the FMS had computed for the flight crew an erroneous Vref of 118 kts, which was 6 kts slower than the correct reference landing speed of 124 kts. Although this oversight showed a lack of attention to detail by the operator, an airplane performance study determined that the weight and balance discrepancy did not contribute to the stall because the airplane was flying several kts above the correct reference speed in its final moments.
The performance study and accident data revealed that the full deployment of the flight spoilers about 12 seconds before the accident had a significant effect on the stall margin of the airplane in the final moments before impact. Performance analysis showed that the airplane would have been at a bank angle of about 36° when the stick shaker engaged at a calibrated airspeed of 130 kts. Had the flight spoilers been stowed at this airspeed, the stick shaker would not have engaged until the airplane reached a calculated bank angle of about 50°. Therefore, the airplane’s stall margin was significantly reduced by the deployment of the flight spoilers.
As discussed above, the CVR evidence suggests that the FO most likely deployed the spoilers. We were unable to determine if any of the statements recorded by the CVR at the time of spoiler deployment were specifically related to that action. For example, the CVR captured the captain questioning an action taken by the FO just before the stall warning; it was unclear whether this statement might have been in response to a specific control input made by the FO or to the FO’s continued and repeated requests to take control of the airplane in general. Although the stall warning disengaged briefly, this was likely the result of the stick pusher providing angle of attack (AOA) recovery rather than a timely response of the flight crew to the stall warning; in any case, the stall warning subsequently re-engaged.
The combination of the FO’s improper deployment of the flight spoilers and the airplane’s bank angle and airspeed at the time resulted in the airplane exceeding the critical AOA, followed by an asymmetric stall (of the left wing), a rapid left roll, and impact with terrain.
- Probable Cause: The first officer’s (FO’s) improper decision to attempt to salvage an unstabilized approach by executing a steep left turn to realign the airplane with the runway centerline, and the captain’s failure to intervene after recognizing the FO’s erroneous action, while both ignored stall protection system warnings, which resulted in a left-wing stall and an impact with terrain. Contributing to the accident was the FO's improper deployment of the flight spoilers, which decreased the airplane's stall margin; the captain’s improper setup of the circling approach; and the flight crew’s self-induced pressure to perform and poor crew resource management, which degraded their decision-making
- Report:
- Docket:
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