Confidence is that feeling you have before you really understand the problem.
30 January 1984
Catalina Airport, Santa Catalina Island (KAVX)
Avalon, California
Gates Learjet 24, N44GA
6 Fatal
As a pilot begins his flying career, he finds himself in a position where the cards are stacked against him in terms of his experience level (low) versus situations he can come across which he hasn't seen before or are new (high probability). As that pilot gains experience, certificates and hours, he also begins tipping the scales of the aforementioned balance more and more towards the experience side of the equation being a higher percentage than the amount of situations unseen or not experienced. Not by much, mind you, as there is no pilot who has seen it all or done it all; there's always a time a pilot can find himself confronted with a situation that can range across the spectrum from a simple out of the ordinary, all the way to a full-blown emergency. The challenge for pilots is to never be too comfortable in any given situation inflight, in terms of being ready for the unexpected. Relaxed? Sure, no problem. But with that relaxed stance, should be a "ready vigilence" of sorts, in terms of being ready to tackle the out of the ordinary, should it occur. In human factors studies of many accidents I've investigated and/or researched, experience levels have often been found to be directly proportional to the confidence level, which is expected. But high confidence levels have also been found to be directly proportional to complacency levels, whether intended or not or consciously realized or not. Oddly enough, this has been a factor in some crew-aircraft accidents where the lower experienced guy actually realized they were in a square corner before the higher experienced guy did, simply because his comfort level was reached lower than the experienced guy's was. Of course it doesn't always happen this way and there are accidents that follow the opposite model, but it is indeed interesting to see the varying combinations of experienced people flying together (or even solo). Though one might find two low-time pilots flying together in 14 CFR 91 ops in a Cessna/Piper or other light civil aircraft; it's obviously something that wouldn't be found in a 14 CFR 91 professional flying operation such as a charter or corporate department. Here you oftentimes have the opposite: two very high time, high experience, highly certificated pilots flying. And even with that, both sets of pilots can be affected by the varying combinations/percentages of experience level versus confidence, which has the potential to lead to overconfidence and/or pressure to perform the task/flight/mission at hand. The pilots of N44GA fit this category, as many pilots of this kind of experience level do, on the morning of 30 January 1984 while demonstrating their Learjet 24 for potential buyers .
On the morning of 30 January 1984, the crew of N44GA were preparing their Learjet 24 for a sales demonstration flight scheduled for midday. The aircraft, owned by Gee Bee Aero Inc, and operated by Aviation Business Flights of San Jose, California, had been recently put on the market for sale. This day, the aircraft was going to be taken on a demo flight for two business couples from northern California, each of whom were interested and potential buyers. The route of flight planned for the demo was to be from Santa Rosa, Ca (KSTS- Sonoma County Airport) south down the coast to Monterey, Ca (KMRY - Monterey Peninsula Airport), and return. The crew filed their VFR flight plan and loaded the passengers onboard, the weather forecast to be VMC/CAVU for the whole route. Takeoff from KSTS and the initial enroute portions of the flight were uneventful, however about halfway through the flight, one of the passengers inquired on whether the enroute stop could be changed to Catalina Island instead of Monterey, as he desired to take care of some personal business there and wanted to treat the crew to lunch. The crew agreed to the change, and coordinated the change with ATC, whom they were receiving VFR flight following with. The destination changes were made and the flight continued southeastbound down the coast past Monterey and to Catalina Island, the new enroute portion of the flight also proceeding uneventfully.
Approximately 10 miles northwest of KAVX, the crew made an advisory call on UNICOM and were given the following airfield advisories: winds 100/4, temp 72F, altimeter 29.97. The crew of 44GA elected to make right traffic to RW 22. RW 4/22 at KAVX is 3240' x 100' (back in 1984, now 75' width); with 120' displaced thresholds at both ends, giving a 3000' effective available landing distance. Additionally, the airport has NOTAMs for a runway upslope to midfield, and level-off thereafter for RW22, and that aircraft can't be seen on the departure ends of the runways due to this sloping, implying that the runway itself also can't be seen due to this also. The airport itself sits atop a 1602' MSL mesa, with 1600+' cliff dropoffs at both ends, also NOTAMd. Four witnesses on the ground, airport workers, reported that 44GAs downwind and base legs appeared normal, but that the final approach appeared somewhat steep at first, but was corrected by the crew. These four witnesses were paying particular attention to the Learjet's arrival, as turbojet aircraft were not normal users of KAVX, though nothing in 14 CFR 91 prevented these aircraft from doing so. The Learjet's initial touchdown occurred 527' down the 3000' runway. Witnesses said they saw the thrust reverser cans deploying and heard an increase in engine sound just prior to the first taxiway intersection, located just prior to midfield, about 1000' down the runway from the threshold (2000' remaining). They reported that the thrust sound diminished about the point of the second taxiway, located just past midfield at about the 2000' from threshold point (1000' remaining). At this point witnesses reported the engine sound increase as the aircraft reached the end of the runway and went past the displaced threshold and into the dirt, creating a dust cloud. The aircraft continued through the dirt and off the end of the sheer cliff in a slight nose high, wings level attitude. Too slow to fly, the aircraft dropped vertically out of sight of the witnesses and down the cliff area, impacting downsloping terrain in a wings-level attitude vertically 90' below the mesa. Initially, there was a small post-crash fire in the aft 1/3 of the fuselage, and the four witnesses/airport workers reached the scene within 3 minutes via a road surrounding the southwest side of the airport in a pickup truck equipped with a small amount of dry chemical firefighting agent, but they weren't trained firefighters and didn't attack the fire, fearing the aircraft would explode. They reported hearing screams from the pax within the aircraft, and within approximately 5-8 minutes, the fire spread rapidly and fully consumed the aircraft, fatally injuring the 2 crew and 4 pax onboard.
Probable Cause:
*Reason for Occurrance- Undetermined
Secondary Factors:
*Flight to Alternate Destination, Improper Planning- Pilot In Command
*Airport Facilities, Runway Landing Area/Condition- Uphill
*Airport Facilities, Runway Landing Area/Condition- Rough/Uneven
*Terrain Condition- Mountainous/Hills
*Terrain Condition- Downhill
Tertiary Factors:
*Improper Decision, Self Induced Pressure- Pilot In Command
*Improper Decision, Pressure Induced by Others- Pilot In Command
*Airport Fire/Rescue Service (CFR/ARFF)- Inadequate
MikeD says:
There was no Probable Cause determined for the accident of N44GA, as the severe postcrash fire consumed most all of the aircraft from nose to tail, leaving no evidence for confirming or denying the possibility of a mechanical malfunction of either the engines/thrust reversers or the braking system. Areas of detailed investigation that were focused on were:
1. Analysis of the Remaining Aircraft Wreckage
2. Learjet 24 Series TOLD Data and Performance
3. The Flightcrew's Experience
4. Catalina Airport geography and operations
Analysis of the Remaining Aircraft Wreckage: Although the severe postcrash fire consumed most of the fuselage from nose to tail, the remaining airframe components of N44GA that survived, the wing outer halves/tanks and the horizontal stab ends, showed no evidence of a flight control malfunction pre-impact. An additional item that survived was the left main gear assembly and tires, which showed no evidence of any flat spots or scrubbed areas consistent with heavy braking. The brake assemblies of 44GA had been overhauled 5 months prior, with no reports of any problems during the time leading up to the accident. The right main and nose tires were consumed in the fire. The aircraft's two General Electric CJ-610-4 turbojet engines, though heavily fire damaged, showed no evidence of a pre-impact malfunction, and it was determined that the thrust reversers were deployed during the accident. The engines had been inspected during the same inspection where the brakes were replaced, also with no problems found or experienced since then. The emergency braking system air bottle had been replaced at this time also, but its unknown whether this system was activated by the flight crew due to the severe fire damage. 44GA was not equipped with the optional drag chute system. At the time of the accident, 44GAs total aircraft time was 3,306 hours.
Learjet 24 Series TOLD Data and Performance: As stated previously by the witnesses, turbojet operations into and out of KAVX were an extremely rare occurance, due to the short runway length/width as well as the lack of fuel (no fuel sales at all at KAVX) or other ramp services that many jets require. On the issue of TakeOff and Landing Data (TOLD), the investigation ran the TOLD numbers for a Lear 24 for the runway length/ gradient/elevation RW22, and the meterological conditions of that day. Based on dispatch data and computed fuel burn for the route flown, it was determined that 44GA was at an approximate landing weight of 11,500lbs, well within weight and CG limitations for landing. The landing distance for the conditions on 30 January showed that 44GA required a landing roll of 3,100' with a 118 KIAS Vref. This landing roll takes into account use of flaps, spoilers and anti-skid braking. With the thrust reversers figured into the equation, the Lear 24 AFM showed a 26% decrease in the landing roll with max braking used, resulting in an approximately 2,300' distance. With 3000' of effective runway available (3120', if one includes the departure-end threshold), 44GA had 20' of error with the threshold included, and was 100' short of the necessary runway; both being worst case numbers for no-thrust reversers being available. With the thrust reversers available, 44GA had a 700' margin available (820' to the end of the asphalt, if including the departure threshold). Having landed 527' down the runway from the approach end, there was very little margin for error even with thrust reversers available, leaving approximately 150' for the normal runway, and 270' to the end of the asphalt at the departure end. For contingency planning, for use of the emergency braking system, the Lear 24 AFM calls for a 60% increase in landing roll to the computed data, resulting in 44GA needing a 4,900' landing roll had its use become necessary.
But landing wasn't 44GAs only problem that day, takeoff was also. At the same 11,500 lbs (as there was no opportunity to upload fuel, and assuming all other factors of pax/crew/bags to be the same as during arrival), 44GA required a takeoff distance of 3,740', the greater of the accelerate-stop and accelerate-go distances per the AFM. As part of the diversion to the alternate, had the crew of 44GA ran TOLD while still enroute, they would've known of the extremely tight landing distance requirements, as well as the unworkable takeoff distance requirements, and could've come up with an alternate plan then and there. By operating under 14 CFR 91, as opposed to 14 CFR 135, there were no regulatory requirements for an added safety margin of available runway, to the landing distance computed.
The Flightcrew's Experience: The flightcrew of 44GA were both highly experienced, both in total time as well as time in type. Each possessed ATPs with type ratings in LR23/24 as well as other LR models. The Capt had 8000TT with approximately 1100 in type, while the co-pilot had 4400TT with approximately 1300 in type. Both had completed Learjet recurrent at FlightSafety within the last year, and both were well qualifed for the flight. According to a former co-pilot, the captain had previously landed at KAVX, but in a Beech Baron, and had demonstrated short-field landing techniques to the co-pilot during that flight. As such, the captain should've been familiar enough with Catalina to know about the runway visual illusions present. It's thought that the crew, not being able to see the opposite end of the runway, may have though they were running out of runway when they really weren't, and the varying engine noises reported by the witnesses suggest a possible decision to go around, then a quick change of mind to stop. However that theory cannot be substantiated with the available evidence, as by all normal accounts, 44GA should've been able to stop with the landing distance computed for thrust reverser usage, and it is known the thrust reversers were operating at the time. The spoilers were found to be retracted in the wreckage, but it is thought that this was a post-impact condition. In any event, no conclusion can be drawn from whether they were deployed or not, just as there is no conclusive evidence of any crew indecisiveness. The possibility of a mechanical malfunction of some type cannot be ruled out, even though there was evidence of braking action on the runway surface even into the departure end threshold.
Catalina Airport Geography and Operations: KAVX is a privately-owned airport operated by the Catalina Island conservancy and is open for public use. As stated previously, the airport sits atop a Mesa surrounded by dropoffs past each end of the runways, with RW 22 having an upslope gradient of 1.7% for the first 2000', with the remainder being level; creating a situation of pilots not being able to see the opposite ends of the runways. RW 22 has a two-box VASI system that provides a 3 degree glidepath that brings aircraft across the runway end at 30' AGL with touchdown approximately 200'-600' down the runway. By all witness accounts, the crew of 44GA were predominately on a normal approach path during the final approach phase, and touched down within the confines of the VASI glidepath. However, with the tight TOLD data, there was still extremely little room for error, as previously noted.
With the Catalina Airport being privately owned, and with no scheduled airline service, there were no FAA requirements to have any Crash/Fire/Rescue (CFR) capability on field. The four airport employees who arrived on-scene did have approximately 700lbs of dry chemical firefighting agent mounted to a "skid unit" in the bed of the pickup truck they arrived on. They also had firefighting turnout gear on the truck. However none of the four employees were trained firefighters at all, and with 44GA partially on fire at this time and located somewhat uphill from their road position on El Rancho Escondido Road (which runs downhill past the extended centerline of RW 22s departure end), the four employees chose not to attack the fire for fear of an imminent explosion. The impact itself was deemed survivable insofar as impact forces to the crew/passengers, and screams heard from persons onboard show that those onboard did survive the impact to the final rest point and at least some were conscious. Post-mortem analysis showed death was from smoke inhalation and thermal burns, and the locking pins of both halves of the main cabin door on the left side of the fuselage were retracted; further evidence that all occupants were alive and attempting escape just prior to their deaths. There was no evidence that an attempt to open the emergency exit on the right side of the fuselage was made.
As Catalina Airport has no CFR/ARFF vehicles or firefighters, fire protection is provided by the Los Angeles County Fire Department. LACFD's Station 55 is located 10 miles away in the town of Avalon, and access to the airport is via the winding and narrow Airport Road, an approximately 20 minute drive. Additionally, this station only has one medium-size wildland/structural engine, and two light wildland engines. The location and vehicles, combined with the non-CFR/ARFF trained firefighters, make fire/rescue protection of aircraft operations at Catalina airport wholly inadequate. As such, when the fire department was called immediately after the accident occurred, their response time of 20 minutes, a roughly 10 minute time to knockdown the fire, and a further 20 minutes to completely extinguish it, was well beyond the average 2 minute survival time of persons trapped in an aircraft on fire.
NTSB Recommendations: In light of both the TOLD data problems, as well as the extreme CFR/ARFF limitations that were demonstrated as a result of this accident, the NTSB made the following recommendations to the Federal Aviation Administration (FAA) and the County of Los Angeles Fire Department and Santa Catalina Island conversancy:
Federal Aviation Administration:
"Issue an operations bulletin directing general aviation inspectors and accident prevention specialists to urge operators of transport category airplanes in general aviation operations to use minimum landing runway lengths which provide the safety margin required by 14 CFR 135 or at the least a safety margin consistent with the performance of the emergency brake system of the airplane. Tke operations bulletin should highlight the use of the emergency brake system or alternate emergency procedures (ie, aborted landings) not only for preplanned failed brake landings, but for use in the event the brakes fail after touchdown. Copies of the operations bulletin should be provided to the National Business Aircraft Association for Dissemination (Class II. Priority Action) (A-85-115)"
County of Los Angeles Fire Department; Santa Catalina Island conservency:
"Improve the current crash/fire/rescue (CFR) capability at the Catalina Airport by: (1) stationing a fully trained CFR unit at the airport during its operating hours; or (2) training airport personnel in CFR techniques under the guidelines provided by Federal Aviation Administration Advisory Circular 139-49; or (3) stationing one or more trained CFR personnel at the airport during operating hours to direct airport personnel who have some training in CFR procedures. (Class E, Priority Action) (A-85-116)"
MikeDs Final Thoughts: This accident is one of those ones where a relatively minor oversight, the TOLD data for the new destination, had major consequences in terms of the accident itself. And the additional bad luck of surviving this accident, only to perish due to non-existant CFR/ARFF service at the airport, only adds to this needless tragedy. Whether the pilots were rushed trying to change destinations midflight, whether they had a "hack the mission" mentality with this being a sales demonstration flight and the resultant pressure and desire to "make the sale", or whether they got complacent with a "simple" VFR out and back flight; we will never know. What is known from this accident, is that two highly experienced pilots overlooked a crucial item of information....whether due to overconfidence in personal or the aircraft's ability, or the need for that information simply having just dropped out of their crosscheck in a distraction type of way; the end result was a chain of events where 6 lives were taken away, and their last chance for survival in the wreckage being only further suffering. For the crew and passengers of N44GA, the End of the Runway should've resulted in the sale of a 1978 Learjet 24 after a fine day of flying. Instead, the End of the Runway became their End of the Road, in more ways than one.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
30 January 1984
Catalina Airport, Santa Catalina Island (KAVX)
Avalon, California
Gates Learjet 24, N44GA
6 Fatal
As a pilot begins his flying career, he finds himself in a position where the cards are stacked against him in terms of his experience level (low) versus situations he can come across which he hasn't seen before or are new (high probability). As that pilot gains experience, certificates and hours, he also begins tipping the scales of the aforementioned balance more and more towards the experience side of the equation being a higher percentage than the amount of situations unseen or not experienced. Not by much, mind you, as there is no pilot who has seen it all or done it all; there's always a time a pilot can find himself confronted with a situation that can range across the spectrum from a simple out of the ordinary, all the way to a full-blown emergency. The challenge for pilots is to never be too comfortable in any given situation inflight, in terms of being ready for the unexpected. Relaxed? Sure, no problem. But with that relaxed stance, should be a "ready vigilence" of sorts, in terms of being ready to tackle the out of the ordinary, should it occur. In human factors studies of many accidents I've investigated and/or researched, experience levels have often been found to be directly proportional to the confidence level, which is expected. But high confidence levels have also been found to be directly proportional to complacency levels, whether intended or not or consciously realized or not. Oddly enough, this has been a factor in some crew-aircraft accidents where the lower experienced guy actually realized they were in a square corner before the higher experienced guy did, simply because his comfort level was reached lower than the experienced guy's was. Of course it doesn't always happen this way and there are accidents that follow the opposite model, but it is indeed interesting to see the varying combinations of experienced people flying together (or even solo). Though one might find two low-time pilots flying together in 14 CFR 91 ops in a Cessna/Piper or other light civil aircraft; it's obviously something that wouldn't be found in a 14 CFR 91 professional flying operation such as a charter or corporate department. Here you oftentimes have the opposite: two very high time, high experience, highly certificated pilots flying. And even with that, both sets of pilots can be affected by the varying combinations/percentages of experience level versus confidence, which has the potential to lead to overconfidence and/or pressure to perform the task/flight/mission at hand. The pilots of N44GA fit this category, as many pilots of this kind of experience level do, on the morning of 30 January 1984 while demonstrating their Learjet 24 for potential buyers .
On the morning of 30 January 1984, the crew of N44GA were preparing their Learjet 24 for a sales demonstration flight scheduled for midday. The aircraft, owned by Gee Bee Aero Inc, and operated by Aviation Business Flights of San Jose, California, had been recently put on the market for sale. This day, the aircraft was going to be taken on a demo flight for two business couples from northern California, each of whom were interested and potential buyers. The route of flight planned for the demo was to be from Santa Rosa, Ca (KSTS- Sonoma County Airport) south down the coast to Monterey, Ca (KMRY - Monterey Peninsula Airport), and return. The crew filed their VFR flight plan and loaded the passengers onboard, the weather forecast to be VMC/CAVU for the whole route. Takeoff from KSTS and the initial enroute portions of the flight were uneventful, however about halfway through the flight, one of the passengers inquired on whether the enroute stop could be changed to Catalina Island instead of Monterey, as he desired to take care of some personal business there and wanted to treat the crew to lunch. The crew agreed to the change, and coordinated the change with ATC, whom they were receiving VFR flight following with. The destination changes were made and the flight continued southeastbound down the coast past Monterey and to Catalina Island, the new enroute portion of the flight also proceeding uneventfully.
Approximately 10 miles northwest of KAVX, the crew made an advisory call on UNICOM and were given the following airfield advisories: winds 100/4, temp 72F, altimeter 29.97. The crew of 44GA elected to make right traffic to RW 22. RW 4/22 at KAVX is 3240' x 100' (back in 1984, now 75' width); with 120' displaced thresholds at both ends, giving a 3000' effective available landing distance. Additionally, the airport has NOTAMs for a runway upslope to midfield, and level-off thereafter for RW22, and that aircraft can't be seen on the departure ends of the runways due to this sloping, implying that the runway itself also can't be seen due to this also. The airport itself sits atop a 1602' MSL mesa, with 1600+' cliff dropoffs at both ends, also NOTAMd. Four witnesses on the ground, airport workers, reported that 44GAs downwind and base legs appeared normal, but that the final approach appeared somewhat steep at first, but was corrected by the crew. These four witnesses were paying particular attention to the Learjet's arrival, as turbojet aircraft were not normal users of KAVX, though nothing in 14 CFR 91 prevented these aircraft from doing so. The Learjet's initial touchdown occurred 527' down the 3000' runway. Witnesses said they saw the thrust reverser cans deploying and heard an increase in engine sound just prior to the first taxiway intersection, located just prior to midfield, about 1000' down the runway from the threshold (2000' remaining). They reported that the thrust sound diminished about the point of the second taxiway, located just past midfield at about the 2000' from threshold point (1000' remaining). At this point witnesses reported the engine sound increase as the aircraft reached the end of the runway and went past the displaced threshold and into the dirt, creating a dust cloud. The aircraft continued through the dirt and off the end of the sheer cliff in a slight nose high, wings level attitude. Too slow to fly, the aircraft dropped vertically out of sight of the witnesses and down the cliff area, impacting downsloping terrain in a wings-level attitude vertically 90' below the mesa. Initially, there was a small post-crash fire in the aft 1/3 of the fuselage, and the four witnesses/airport workers reached the scene within 3 minutes via a road surrounding the southwest side of the airport in a pickup truck equipped with a small amount of dry chemical firefighting agent, but they weren't trained firefighters and didn't attack the fire, fearing the aircraft would explode. They reported hearing screams from the pax within the aircraft, and within approximately 5-8 minutes, the fire spread rapidly and fully consumed the aircraft, fatally injuring the 2 crew and 4 pax onboard.
Probable Cause:
*Reason for Occurrance- Undetermined
Secondary Factors:
*Flight to Alternate Destination, Improper Planning- Pilot In Command
*Airport Facilities, Runway Landing Area/Condition- Uphill
*Airport Facilities, Runway Landing Area/Condition- Rough/Uneven
*Terrain Condition- Mountainous/Hills
*Terrain Condition- Downhill
Tertiary Factors:
*Improper Decision, Self Induced Pressure- Pilot In Command
*Improper Decision, Pressure Induced by Others- Pilot In Command
*Airport Fire/Rescue Service (CFR/ARFF)- Inadequate
MikeD says:
There was no Probable Cause determined for the accident of N44GA, as the severe postcrash fire consumed most all of the aircraft from nose to tail, leaving no evidence for confirming or denying the possibility of a mechanical malfunction of either the engines/thrust reversers or the braking system. Areas of detailed investigation that were focused on were:
1. Analysis of the Remaining Aircraft Wreckage
2. Learjet 24 Series TOLD Data and Performance
3. The Flightcrew's Experience
4. Catalina Airport geography and operations
Analysis of the Remaining Aircraft Wreckage: Although the severe postcrash fire consumed most of the fuselage from nose to tail, the remaining airframe components of N44GA that survived, the wing outer halves/tanks and the horizontal stab ends, showed no evidence of a flight control malfunction pre-impact. An additional item that survived was the left main gear assembly and tires, which showed no evidence of any flat spots or scrubbed areas consistent with heavy braking. The brake assemblies of 44GA had been overhauled 5 months prior, with no reports of any problems during the time leading up to the accident. The right main and nose tires were consumed in the fire. The aircraft's two General Electric CJ-610-4 turbojet engines, though heavily fire damaged, showed no evidence of a pre-impact malfunction, and it was determined that the thrust reversers were deployed during the accident. The engines had been inspected during the same inspection where the brakes were replaced, also with no problems found or experienced since then. The emergency braking system air bottle had been replaced at this time also, but its unknown whether this system was activated by the flight crew due to the severe fire damage. 44GA was not equipped with the optional drag chute system. At the time of the accident, 44GAs total aircraft time was 3,306 hours.
Learjet 24 Series TOLD Data and Performance: As stated previously by the witnesses, turbojet operations into and out of KAVX were an extremely rare occurance, due to the short runway length/width as well as the lack of fuel (no fuel sales at all at KAVX) or other ramp services that many jets require. On the issue of TakeOff and Landing Data (TOLD), the investigation ran the TOLD numbers for a Lear 24 for the runway length/ gradient/elevation RW22, and the meterological conditions of that day. Based on dispatch data and computed fuel burn for the route flown, it was determined that 44GA was at an approximate landing weight of 11,500lbs, well within weight and CG limitations for landing. The landing distance for the conditions on 30 January showed that 44GA required a landing roll of 3,100' with a 118 KIAS Vref. This landing roll takes into account use of flaps, spoilers and anti-skid braking. With the thrust reversers figured into the equation, the Lear 24 AFM showed a 26% decrease in the landing roll with max braking used, resulting in an approximately 2,300' distance. With 3000' of effective runway available (3120', if one includes the departure-end threshold), 44GA had 20' of error with the threshold included, and was 100' short of the necessary runway; both being worst case numbers for no-thrust reversers being available. With the thrust reversers available, 44GA had a 700' margin available (820' to the end of the asphalt, if including the departure threshold). Having landed 527' down the runway from the approach end, there was very little margin for error even with thrust reversers available, leaving approximately 150' for the normal runway, and 270' to the end of the asphalt at the departure end. For contingency planning, for use of the emergency braking system, the Lear 24 AFM calls for a 60% increase in landing roll to the computed data, resulting in 44GA needing a 4,900' landing roll had its use become necessary.
But landing wasn't 44GAs only problem that day, takeoff was also. At the same 11,500 lbs (as there was no opportunity to upload fuel, and assuming all other factors of pax/crew/bags to be the same as during arrival), 44GA required a takeoff distance of 3,740', the greater of the accelerate-stop and accelerate-go distances per the AFM. As part of the diversion to the alternate, had the crew of 44GA ran TOLD while still enroute, they would've known of the extremely tight landing distance requirements, as well as the unworkable takeoff distance requirements, and could've come up with an alternate plan then and there. By operating under 14 CFR 91, as opposed to 14 CFR 135, there were no regulatory requirements for an added safety margin of available runway, to the landing distance computed.
The Flightcrew's Experience: The flightcrew of 44GA were both highly experienced, both in total time as well as time in type. Each possessed ATPs with type ratings in LR23/24 as well as other LR models. The Capt had 8000TT with approximately 1100 in type, while the co-pilot had 4400TT with approximately 1300 in type. Both had completed Learjet recurrent at FlightSafety within the last year, and both were well qualifed for the flight. According to a former co-pilot, the captain had previously landed at KAVX, but in a Beech Baron, and had demonstrated short-field landing techniques to the co-pilot during that flight. As such, the captain should've been familiar enough with Catalina to know about the runway visual illusions present. It's thought that the crew, not being able to see the opposite end of the runway, may have though they were running out of runway when they really weren't, and the varying engine noises reported by the witnesses suggest a possible decision to go around, then a quick change of mind to stop. However that theory cannot be substantiated with the available evidence, as by all normal accounts, 44GA should've been able to stop with the landing distance computed for thrust reverser usage, and it is known the thrust reversers were operating at the time. The spoilers were found to be retracted in the wreckage, but it is thought that this was a post-impact condition. In any event, no conclusion can be drawn from whether they were deployed or not, just as there is no conclusive evidence of any crew indecisiveness. The possibility of a mechanical malfunction of some type cannot be ruled out, even though there was evidence of braking action on the runway surface even into the departure end threshold.
Catalina Airport Geography and Operations: KAVX is a privately-owned airport operated by the Catalina Island conservancy and is open for public use. As stated previously, the airport sits atop a Mesa surrounded by dropoffs past each end of the runways, with RW 22 having an upslope gradient of 1.7% for the first 2000', with the remainder being level; creating a situation of pilots not being able to see the opposite ends of the runways. RW 22 has a two-box VASI system that provides a 3 degree glidepath that brings aircraft across the runway end at 30' AGL with touchdown approximately 200'-600' down the runway. By all witness accounts, the crew of 44GA were predominately on a normal approach path during the final approach phase, and touched down within the confines of the VASI glidepath. However, with the tight TOLD data, there was still extremely little room for error, as previously noted.
With the Catalina Airport being privately owned, and with no scheduled airline service, there were no FAA requirements to have any Crash/Fire/Rescue (CFR) capability on field. The four airport employees who arrived on-scene did have approximately 700lbs of dry chemical firefighting agent mounted to a "skid unit" in the bed of the pickup truck they arrived on. They also had firefighting turnout gear on the truck. However none of the four employees were trained firefighters at all, and with 44GA partially on fire at this time and located somewhat uphill from their road position on El Rancho Escondido Road (which runs downhill past the extended centerline of RW 22s departure end), the four employees chose not to attack the fire for fear of an imminent explosion. The impact itself was deemed survivable insofar as impact forces to the crew/passengers, and screams heard from persons onboard show that those onboard did survive the impact to the final rest point and at least some were conscious. Post-mortem analysis showed death was from smoke inhalation and thermal burns, and the locking pins of both halves of the main cabin door on the left side of the fuselage were retracted; further evidence that all occupants were alive and attempting escape just prior to their deaths. There was no evidence that an attempt to open the emergency exit on the right side of the fuselage was made.
As Catalina Airport has no CFR/ARFF vehicles or firefighters, fire protection is provided by the Los Angeles County Fire Department. LACFD's Station 55 is located 10 miles away in the town of Avalon, and access to the airport is via the winding and narrow Airport Road, an approximately 20 minute drive. Additionally, this station only has one medium-size wildland/structural engine, and two light wildland engines. The location and vehicles, combined with the non-CFR/ARFF trained firefighters, make fire/rescue protection of aircraft operations at Catalina airport wholly inadequate. As such, when the fire department was called immediately after the accident occurred, their response time of 20 minutes, a roughly 10 minute time to knockdown the fire, and a further 20 minutes to completely extinguish it, was well beyond the average 2 minute survival time of persons trapped in an aircraft on fire.
NTSB Recommendations: In light of both the TOLD data problems, as well as the extreme CFR/ARFF limitations that were demonstrated as a result of this accident, the NTSB made the following recommendations to the Federal Aviation Administration (FAA) and the County of Los Angeles Fire Department and Santa Catalina Island conversancy:
Federal Aviation Administration:
"Issue an operations bulletin directing general aviation inspectors and accident prevention specialists to urge operators of transport category airplanes in general aviation operations to use minimum landing runway lengths which provide the safety margin required by 14 CFR 135 or at the least a safety margin consistent with the performance of the emergency brake system of the airplane. Tke operations bulletin should highlight the use of the emergency brake system or alternate emergency procedures (ie, aborted landings) not only for preplanned failed brake landings, but for use in the event the brakes fail after touchdown. Copies of the operations bulletin should be provided to the National Business Aircraft Association for Dissemination (Class II. Priority Action) (A-85-115)"
County of Los Angeles Fire Department; Santa Catalina Island conservency:
"Improve the current crash/fire/rescue (CFR) capability at the Catalina Airport by: (1) stationing a fully trained CFR unit at the airport during its operating hours; or (2) training airport personnel in CFR techniques under the guidelines provided by Federal Aviation Administration Advisory Circular 139-49; or (3) stationing one or more trained CFR personnel at the airport during operating hours to direct airport personnel who have some training in CFR procedures. (Class E, Priority Action) (A-85-116)"
MikeDs Final Thoughts: This accident is one of those ones where a relatively minor oversight, the TOLD data for the new destination, had major consequences in terms of the accident itself. And the additional bad luck of surviving this accident, only to perish due to non-existant CFR/ARFF service at the airport, only adds to this needless tragedy. Whether the pilots were rushed trying to change destinations midflight, whether they had a "hack the mission" mentality with this being a sales demonstration flight and the resultant pressure and desire to "make the sale", or whether they got complacent with a "simple" VFR out and back flight; we will never know. What is known from this accident, is that two highly experienced pilots overlooked a crucial item of information....whether due to overconfidence in personal or the aircraft's ability, or the need for that information simply having just dropped out of their crosscheck in a distraction type of way; the end result was a chain of events where 6 lives were taken away, and their last chance for survival in the wreckage being only further suffering. For the crew and passengers of N44GA, the End of the Runway should've resulted in the sale of a 1978 Learjet 24 after a fine day of flying. Instead, the End of the Runway became their End of the Road, in more ways than one.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
Last edited:
