Crash of Pinnacle Airlines Flight 3701 Bombardier CL-600 ..., Study notes of Aviation

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Crash of Pinnacle Airlines Flight 3701

Bombardier CL-600-2B19, N8396A

Jefferson City, Missouri

October 14, 2004

ACCIDENT REPORT

NTSB/AAR-07/ PB2007-

National Transportation Safety Board. 2007. Crash of Pinnacle Airlines Flight 3701, Bombardier CL-600-2B19, N8396A, Jefferson City, Missouri, October 14, 2004. Aircraft Accident Report NTSB/AAR-07/01. Washington, DC.

Abstract: This report explains the accident involving a Bombardier CL-600-2B19, N8396A, which crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, Jefferson City, Missouri. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. Safety issues discussed in this report focus on flight crew training in the areas of high altitude climbs, stall recognition and recovery, and double engine failures; flight crew professionalism; and the quality of some parameters recorded by flight data recorders on regional jet airplanes.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.

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The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report

Contents

Figures............................................................... vi

Abbreviations......................................................... vii

• 1. Factual Information Executive Summary x
  • 1.1 History of Flight
  • 1.2 Injuries to Persons
  • 1.3 Damage to Airplane
  • 1.4 Other Damage
  • 1.5 Personnel Information
    • 1.5.1 The Captain
      • 1.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain
    • 1.5.2 The First Officer
      • 1.5.2.1 Pilot and Simulator Instructor Interviews Regarding the First Officer
  • 1.6 Airplane Information
    • 1.6.1 Powerplants
    • 1.6.2 Systems
    • 1.6.3 Maintenance Records
  • 1.7 Meteorological Information
  • 1.8 Aids to Navigation
  • 1.9 Communications
  • 1.10 Airport Information
    • 1.10.1 Air Traffic Control
  • 1.11 Flight Recorders
    • 1.11.1 Cockpit Voice Recorder
    • 1.11.2 Flight Data Recorder
  • 1.12 Wreckage and Impact Information
    • 1.12.1 Powerplants
    • 1.12.2 Systems
  • 1.13 Medical and Pathological Information
  • 1.14 Fire
  • 1.15 Survival Aspects
  • 1.16 Tests and Research
    • 1.16.1 Aircraft Performance Study
      • 1.16.1.1 Climb to 41,000 Feet
      • 1.16.1.2 Aerodynamic Stall and Upset Event
      • 1.16.1.3 Descent and Glide Performance
    • 1.16.2 Cockpit Voice Recorder Studies
    • 1.16.3 Engine Tests
    • 1.16.4 Load Control Valve Simulation Study
  • 1.17 Organizational and Management Information
    • 1.17.1 Ground School and Simulator Training
      • 1.17.1.1 Upset Training iv Aircraft Accident Report
      • 1.17.1.2 High Altitude Climbs
      • 1.17.1.3 Double Engine Failure
      • 1.17.1.4 Stall Recognition and Recovery Training
      • 1.17.1.5 Crew Resource Management Training
      • 1.17.1.6 Leadership Training
    • 1.17.2 Flight Manuals
      • 1.17.2.1 High Altitude Climbs
      • 1.17.2.2 Double Engine Failure
      • 1.17.2.3 Stall Protection System
      • 1.17.2.4 Flight Operations
    • 1.17.3 Federal Aviation Administration Oversight
  • 1.18 Additional Information
    • 1.18.1 Oxygen Mask Use During the Accident Flight
    • 1.18.2 Core Lock
    • 1.18.3 Previous Related Safety Recommendations
      • 1.18.3.1 Core Lock
      • 1.18.3.2 Crew Professionalism
      • 1.18.3.3 Flight Data Recorder Data
    • 1.18.4 Federal Aviation Administration Notice
    • 1.18.5 Bombardier All Operator Message
• 2. Analysis
  • 2.1 General
  • 2.2 Accident Sequence
    • 2.2.1 Climb to 41,000 Feet
    • 2.2.2 Aerodynamic Stall and Upset Event
    • 2.2.3 Double Engine Failure
      • 2.2.3.1 Performance of the Double Engine Failure Checklist
        • and Management of Forced Landing 2.2.4 Communications With Air Traffic Controllers
    • 2.2.5 Accident Sequence Summary
  • 2.3 Flight Crew Training
    • 2.3.1 High Altitude Training
    • 2.3.2 Stall Recognition and Recovery Training
    • 2.3.3 Double Engine Failure Training
  • 2.4 Flight Crew Professionalism
    • 2.4.1 Part 91 Operations
    • 2.4.2 Industrywide Issues
      • 2.4.2.1 Pilot Responsibilities
      • 2.4.2.2 Operator Responsibilities
  • 2.5 Quality of Flight Data Recorder Data for Regional Jet Airplanes
• 3. Conclusions
  • 3.1 Findings
  • 3.2 Probable Cause
• 4. Safety Recommendations v Aircraft Accident Report
  • 4.1 New Recommendations
  • 4.2 Previously Issued Recommendation Reiterated and Classified in This Report
  • 4.3 Previously Issued Recommendations Resulting From This Accident Investigation
• 5. Appendixes
     • A: Investigation and Hearing.
     • B: Cockpit Voice Recorder
       • at the Time of the Accident. C: Pinnacle Airlines’ Double Engine Failure Checklist
     • D : Pinnacle Airlines’ Revised Double Engine Failure Checklist
     • E: Core Lock Safety Recommendation Letter.

vi Aircraft Accident Report

Figures

1. Components in the CRJ Pneumatic Supply and Start Systems...................... 12 2. Glide Distances for the Accident Airplane...................................... 24

Abbreviations viii Aircraft Accident Report

FDR flight data recorder

FMS flight management system

FOQA flight operational quality assurance

fpm feet per minute

FSDO flight standards district office

GAO Government Accountability Office

GE General Electric

GPWS ground proximity warning system

Hg mercury

ICAO International Civil Aviation Organization

ILS instrument landing system

ISA International Standard Atmosphere

JEF Jefferson City Memorial Airport, Jefferson City, Missouri

KIAS knots indicated airspeed

LBO Floyd W. Jones Lebanon Airport, Lebanon, Missouri

LCV load control valve

LIT Little Rock National Airport, Little Rock, Arkansas

LOSA Line Operations Safety Audit

METAR meteorological aerodrome report

msl mean sea level

MSP Minneapolis-St. Paul International Airport, Minneapolis, Minnesota

N1 engine fan speed

N2 engine core speed

NWS National Weather Service

POI principal operations inspector

SB service bulletin

SGF Springfield-Branson Regional Airport, Springfield, Missouri

SMS safety management system

S/N serial number

Abbreviations ix Aircraft Accident Report

SPS stall protection system

TBN Waynesville Regional Airport, Fort Leonard Wood, Missouri

VIH Rolla National Airport, Rolla/Vichy, Missouri

1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

On October 14, 2004, about 2215:06 central daylight time,^1 Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19,^2 N8396A, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport (JEF), Jefferson City, Missouri. The airplane was on a repositioning flight^3 from Little Rock National Airport (LIT), Little Rock, Arkansas, to Minneapolis-St. Paul International Airport (MSP), Minneapolis, Minnesota. During the flight, both engines flamed out^4 after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

Flight 3701 departed LIT about 2121. The flight plan indicated that the company-planned cruise altitude was 33,000 feet. About 5 seconds after takeoff, when the airplane was at an altitude of about 450 feet mean sea level (msl) 5 (about 190 feet above ground level), the first of three separate pitch-up maneuvers during the ascent occurred when the flight crew moved the control column to 8º airplane nose up (ANU), causing the airplane’s pitch angle to increase to 22º and resulting in a vertical load of 1.8 Gs. 6 The rate of climb during this pitch-up maneuver was 3,000 feet per minute (fpm). Immediately afterward, the flight data recorder (FDR) recorded stickshaker and stickpusher activations,^7 a full airplane-nose-down (AND) control column deflection, a decrease in pitch angle, and a drop in vertical load to 0.6 G.

About 2125:55, when the airplane was at an altitude of about 14,000 feet, the flight crew engaged the autopilot. The air traffic control (ATC) transcript and FDR data showed

(^1) All times in this report are central daylight time based on a 24-hour clock. (^2) The accident airplane was a Canadair regional jet (CRJ) -200 model, which is one of three models in the CL-600-2B19 series. (The other two models are the CRJ-100 and CRJ-440.) Bombardier acquired Canadair in December 1986. (^3) A repositioning flight relocates an airplane to the airport where the airplane’s next flight is scheduled. Repositioning flights do not carry revenue passengers or cargo but can carry nonrevenue passengers. (^4) A flameout is an interruption of a turbine engine’s combustion process that results in an uncommanded engine shutdown. (^5) All altitudes and elevations in this report are msl unless otherwise noted. (^6) G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity (32.174 feet/second 2 ). (^7) The stickshaker produces vibrations in the control columns to warn pilots of an impending stall. If the angle of attack (AOA) continues to increase, the stickpusher moves the control columns forward (nose down) automatically to prevent an aerodynamic stall, which can occur afterward.

Factual Information 2 Aircraft Accident Report

that the flight crewmembers changed seats in the cockpit during this time,^8 but the ATC transcript did not indicate the reason for the seat change. About 2127:15, when the airplane was at an altitude of about 15,000 feet, the flight crew disengaged the autopilot.

About 2127:17, when the airplane was in level flight at an altitude of 15,000 feet, the second pitch-up maneuver began when the flight crew moved the control column to 3.8º ANU, causing the airplane’s pitch angle to increase to 17º and resulting in a vertical load of 2.3 Gs. The rate of climb during this pitch-up maneuver reached 10,000 fpm briefly. Between about 2128:40 and about 2128:43, the flight crew made a left rudder input of 4.2º, a right rudder input of 6.0º, and a left rudder input of 0.4º, resulting in lateral loads of -0.16 G, 0.34 G, and -0.18 G, respectively. About 17 seconds later, the flight crew made a right rudder input of 7.7º. About 2132:40, when the airplane was in level flight at an altitude of 24,600 feet, the third pitch-up maneuver began when the flight crew moved the control column to 4º ANU, which increased the airplane’s pitch angle to more than 10º and resulted in a vertical load of 1.87 Gs.^9 The rate of climb during this pitch-up maneuver reached 9,000 fpm briefly.

The ATC transcript showed that the captain requested a climb to 41,000 feet, which is the Canadair regional jet (CRJ) maximum operating altitude, 10 about 2135:36^11 and received clearance to climb to that altitude about 2136:13.^12 The cockpit voice recorder (CVR) recording began about 2144:44 with the captain and the first officer discussing the climb to 41,000 feet. About 2148:44, the first officer stated, “man we can do it. Forty one it.” About 2151:51, the first officer stated, “there’s four one oh my man.” About 2152:04, the CVR recorded the first officer laughing as he stated, “this is … great.” FDR data showed that, about 2152:08, the airplane was in level flight at 41,000 feet. FDR data also showed that the airplane climbed from 37,000 to 41,000 feet at an airspeed that decreased from 203 knots/0.63 Mach^13 at the start of the climb to 163 knots/0.57 Mach as the airplane leveled off.^14 The FDR data further showed that the autopilot vertical speed

(^8) The cockpit voice recorder (CVR) did not preserve any information or sounds associated with the seat change because the CVR had the capability to record only the final 30 minutes of the flight. For information about the seat change, see section 1.16.2. (^9) According to the ATC transcript, the controllers made no transmissions to the pilots that required them to perform the three pitch-up maneuvers during the ascent. For more information about the three pitch-up maneuvers, see section 1.16.1.1. (^10) The maximum operating altitude of the CRJ-200 is the maximum density altitude at which the airplane is certified to operate. For the CRJ-200, the maximum operating altitude of 41,000 feet represents the maximum capability of the airplane; the actual altitude capability will primarily depend on airspeed, weight, and ambient temperature. (^11) The airplane was at an altitude of about 32,000 feet at the time. (^12) During postaccident interviews, Pinnacle Airlines pilots stated that some pilots had expressed curiosity about operating the airplane at 41,000 feet and that an informal “[flight level] 410 club” existed at the airline. Managers at Pinnacle Airlines, including the chief pilot, the CRJ program manager, and the vice president of safety and regulatory compliance, were not aware of the club’s existence. (^13) Mach is a number that expresses the ratio of the speed of an object to the speed of sound in the surrounding medium. The Safety Board calculated Mach number using the computed airspeed and total air temperature recorded on the FDR. (^14) All airspeeds cited in this report are knots indicated airspeed unless noted otherwise.

Factual Information 4 Aircraft Accident Report

About 2154:57, the FDR recorded the fifth activation of the stickshaker and the fourth activation of the stickpusher. Even with the stickpusher’s activation, the motion of the airplane continued to increase its AOA to the maximum measurable value of 27º.^20 The pitch angle increased to 29º, and the airplane entered an aerodynamic stall. Afterward, a left rolling motion began, which eventually reached 82º left wing down, the airplane’s pitch angle decreased to -32º, and both engines flamed out. About 2155:06, the captain stated to the controller, “declaring emergency. Stand by.” FDR data showed that, during the next 14 seconds, the flight crew made several control column, control wheel, and rudder inputs and recovered the airplane from the upset at an altitude of 34,000 feet. During the recovery, the CVR recorded a sound similar to decreasing engine rpm, and FDR data showed that the No. 1 and No. 2 engines’ N 1 indications continued to decrease and that the engines’ fuel flow indications were at zero. 21

About 2155:14, the controller told the pilots to descend and maintain an altitude of 24,000 feet; about 5 seconds later, the captain acknowledged the assigned altitude. About 2155:20, the FDR stopped recording because normal a.c. power to the airplane was lost. (The CVR had a different source of power and continued to record.) The last reliable N 2 (core speed) recorded by the FDR before it stopped operating was 46 percent for the No. 1 engine and 51 percent for the No. 2 engine.

About 2155:23, one pilot stated to the other, “we don’t have any engines,” and, about 10 seconds later, the captain stated, “double engine failure.” About 2156:42, the flight crew began performing the double engine failure checklist,^22 which required pilots to maintain 240 knots until they were ready to initiate the double engine failure procedure.^23 The checklist indicated that, if the airplane were at or below 21,000 feet and above 13,000 feet, pilots should relight the engines using the windmill restart procedure,^24 which required an airspeed of at least 300 knots. The procedure indicated that an altitude loss of 5,000 feet could be expected when accelerating from 240 to 300 knots.

The FDR resumed operation about 2159:16.^25 FDR data showed that the auxiliary power unit (APU) was supplying electrical power to the airplane, both engines’ N 1 indications continued to decrease, and both engines’ N 2 indications were at zero. FDR data also showed that the airplane’s altitude was 29,200 feet and that its airspeed was 178 knots.

(^20) The 27º AOA value is the physical limit of the sensor that measures this parameter. AOAs that are physically higher were recorded as this limit. (^21) FDR data and the CVR recording indicated that the engines were operating normally before the upset. (^22) For information about this checklist, see section 1.17.2.2. (^23) This requirement was a checklist memory item. (^24) A windmill restart is an emergency in-flight procedure in which the effect of ram airflow passing through the engine provides rotational energy to turn the engine’s core. (^25) At that time, the cabin altitude warning signal was being recorded by the FDR. The FDR did not record the cabin altitude warning signal any time before the loss of engine power or the beginning of the gap in FDR data. The CVR recorded the first activation of the cabin pressure warning about 2157:04. For information about the cabin pressurization system and oxygen mask use during the flight, see sections 1.6. and 1.18.1, respectively.

Factual Information 5 Aircraft Accident Report

About 2200:38, the captain told the first officer to increase the airspeed to above 300 knots, and the first officer acknowledged this instruction. FDR data showed that the airplane pitched down to -4.4º and accelerated to an airspeed of 200 knots but that, during the next 25 seconds, the airplane pitched up to 0º while its airspeed remained at 200 knots. About 1 minute later, the captain again told the first officer to increase the airspeed to 300 knots. FDR data showed that the airplane pitched down to -7.5º and accelerated to an airspeed of 236 knots (the maximum airspeed achieved during the windmill restart attempt) but that, during the next 22 seconds, the airspeed decreased to 200 knots.^26

About 2201:51, the captain stated, “we’re not getting any N two at all. So we’re gonna have … to go to … thirteen thousand feet. We’re going to use the APU bleed air [restart] procedure.” 27 Shortly afterward, the captain resumed the double engine failure checklist, which indicated that pilots were to maintain between 170 and 190 knots until they were ready to initiate the APU bleed air restart procedure.

About 2203:09, the controller asked the flight crew about the nature of the emergency. The captain responded, “we had an engine failure up there … so we’re gonna descend down now to start our other engine.” About 2203:30, the captain stated, “we’re descending down to thirteen thousand to start this other engine,” and the controller replied, “understand controlled flight on a single engine right now.” FDR data showed that, during the next several minutes, four APU-assisted engine restarts were attempted, but the N 2 speed for both engines remained at zero throughout the restarts. About 2206:40, the controller asked the flight crewmembers whether they wanted to land; the captain replied, “just stand by right now we’re gonna start this other engine and see … if everything’s okay.” About 2206:54, the controller informed the flight crew that JEF was up ahead, and the captain acknowledged this information.

About 2208:17, the CVR recorded the captain stating, “switch.” About 2209:02, the captain instructed the first officer to tell the controller that they needed “to get direct to [an] airport neither engine’s started right now.” The first officer informed the controller for the first time of the double engine failure,^28 and the controller then asked the pilots if they wanted to go direct to JEF. The captain stated, “any airport and closest airport,” and the first officer told the controller, “closest … airport. We’re descending fifteen hundred feet per minute we have … nine thousand five hundred feet left.”

Between about 2210:21 and about 2211:20, the controller provided information about the winds, the approach frequency, and the localizer frequency for an instrument landing system (ILS) landing to runway 30 at JEF. About 2212:24, the first officer asked the controller where to look for the airport,^29 and the controller provided position, distance, and heading information. About 1 minute later, the controller provided additional location information for JEF. About 2213:37, the captain asked the first officer whether

(^26) For more information about these and other events during the airplane’s descent, see section 1.16.1.3. (^27) Bleed air refers to pressurized air that is provided by the engines or the APU. (^28) At this time, the first officer was recorded transmitting from the right seat, which was his proper position in the cockpit. (^29) The airplane had descended out of clouds at an altitude of about 5,000 feet.

Factual Information 7 Aircraft Accident Report

1.4 Other Damage

Trees were damaged during the accident sequence. Also, a garage and items in the backyards of six houses were damaged by the impact of the airplane, a property line fence was damaged when the No. 1 engine separated from the airframe after impact, and nearby houses received heat damage from the postcrash fire.

1.5 Personnel Information

1.5.1 The Captain

The captain, age 31, held an airline transport pilot certificate and a Federal Aviation Administration (FAA) first-class medical certificate dated July 22, 2004, with a limitation that required him to wear corrective lenses while exercising the privileges of this certificate. The captain received a type rating on the CL-65 in August 2004. (The CL-600-2B19 airplane is included in the CL-65 type rating.)

The captain was hired by Pinnacle Airlines in February 2003. According to the captain’s application for employment, he graduated in May 1995 from Embry-Riddle Aeronautical University in Florida with a bachelor of science degree in aeronautical science. The application indicated that the captain worked as a flight instructor for Embry-Riddle Aeronautical University from August 1996 to October 1999, a first officer on the British Aerospace Jetstream at Trans States Airlines from January 1999 to May 2000, and a captain on the Beech 1900 at Gulfstream International Airlines from June 2000 to September 2002.^30 The captain’s résumé indicated that he had received FAA high altitude physiological training.

Pinnacle Airlines employment and flight records indicated that the captain had accumulated 6,900 hours of total flying time, including 5,055 hours as a pilot-in-command, 973 hours on the CL-65, and 150 hours as a CL-65 pilot-in-command. He had flown 667, 154, and 75 hours in the 12 months, 90 days, and 30 days, respectively, before the accident. The captain’s last recurrent ground training occurred on December 8, 2003; his last recurrent proficiency check was on August 10, 2004; and his last pilot-in-command line check occurred on August 26, 2004. FAA records indicated no accident or incident history or enforcement action, and a search of records at the National Driver Register found no history of driver’s license revocation or suspension.

According to his wife, the captain was in good health and exercised regularly. He did not smoke and used alcohol only occasionally. He did not take prescription or nonprescription medicine (other than daily vitamins and ibuprofen when needed). He had not been sick in the days before the accident. He would generally wake at 0745 and go to sleep no later than 2300 when on reserve and not flying. A company first officer (who knew the captain since they were at Gulfstream International Airlines) stated that no

(^30) In August 2000, the captain received a type rating on the Beech 1900.

Factual Information 8 Aircraft Accident Report

significant changes had occurred in the captain’s life during the year preceding the accident.

The captain went to a movie with his wife on the evening before the accident. On the day of the accident, he went to a park with his family, went shopping, and went out for lunch. The captain was on standby status at Detroit Metropolitan Wayne County Airport (DTW), Detroit, Michigan, on the day of the accident. Crew scheduling notified him about 1700 that he was to “deadhead” (that is, travel on a company flight as a nonrevenue passenger) on flight 5809 from DTW to LIT, reposition the accident airplane from LIT to MSP, and remain in Minneapolis overnight. Flight 5809 departed DTW about 1919 and arrived at LIT about 2036. Two Northwest Airlines^31 customer service agents, who spoke briefly with the captain after he deplaned, reported that he “looked fine,” “did not appear tired,” and “appeared to be in a good mood.” The captain’s wife did not think that he had flown with the accident first officer before the accident flight.

The captain’s wife stated that he had experienced only one previous emergency during his flying career, which occurred while he was with Gulfstream International Airlines. She stated that the landing gear did not extend and that the flight crew had to use the emergency extension procedures. She also stated that the captain had received a letter of commendation from the president of Gulfstream International Airlines, which recognized the captain’s actions during a landing in challenging crosswind conditions.

1.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain

Most pilots who had flown with the captain had favorable comments about his flying abilities. These pilots stated that the captain operated the airplane in a standard manner, demonstrated good crew resource management (CRM) skills, and was “easy to get along with.” Also, a first officer (who had known the captain since they were at Gulfstream International Airlines) stated that the captain was “the best stick and rudder pilot he had ever flown with.” Another first officer stated that the captain set a tone in the cockpit that made the first officer feel comfortable bringing concerns to the captain’s attention.

A first officer who flew with the captain from October 7 to 8, 2004, stated that the flights were conducted in a standard manner with no deviations from the flight crew operating manual (FCOM). Another first officer (who had also known the captain since they were at Gulfstream International Airlines) stated that the captain did not seem to be a risk taker. All of the pilots who were interviewed after the accident stated that the captain had never discussed flying at 41,000 feet.

The simulator instructor who conducted part of the captain’s upgrade training stated that, during training, the captain did not always perform checklists according to company procedures and did not always use the correct checklists.^32 For example, the instructor stated that the captain would, at times, misstate the status of a checklist item,

(^31) At LIT, Northwest Airlines provided ground support for Pinnacle Airlines. (^32) The simulator instructor stated that he debriefed the captain about these deficiencies.