NASA WANTS STUDENT INNOVATORS FOR 2011 GREAT MOONBUGGY RACE

FOR IMMEDIATE RELEASE
April 6, 2010
SB-10-10

POOR MAINTENANCE STARTED ACCIDENT CHAIN THAT RESULTED IN HIGH-SPEED RUNWAY EXCURSION THAT KILLED FOUR IN 2008, NTSB DETERMINES

Washington, DC – A chartered business jet crashed at a South Carolina airport 18 months ago because of the operator’s inadequate maintenance of the airplane’s tires and the decision by the captain to attempt a high-speed rejected takeoff, which went against standard operating procedures and training, the NTSB determined today.

On September 19, 2008, at 11:53 p.m. EDT, a Bombardier Learjet Model 60 (N999LJ) operated by Global Exec Aviation and destined for Van Nuys, California, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport. After the airplane left the departure end of runway 11, it struck airport lights, crashed through a perimeter fence, crossed a roadway and came to rest on a berm. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured.

The investigation revealed that prior to the accident the aircraft was operated while the main landing gear tires were severely underinflated because of Global Exec Aviation’s inadequate maintenance. The underinflation compromised the integrity of the tires, which led to the failure of all four of the airplane’s main landing gear tires during the takeoff roll.

Shortly after the first tire failed, which occurred about 1.5 seconds after the airplane passed the maximum speed at which the takeoff attempt could be safely aborted, the first officer indicated that the takeoff should be continued but the captain decided to reject the takeoff and deployed the airplane’s thrust reversers. Pilots are trained to avoid attempting to reject a takeoff at high-speed unless the pilot concludes that the airplane is unable to fly; the investigation found no evidence that the accident airplane was uncontrollable or unable to become airborne.

The tire failure during the takeoff roll damaged a sensor, which caused the airplane’s thrust reversers to return to the stowed position. While the captain was trying to stop the airplane by commanding reverse thrust, forward thrust was being provided at near-takeoff power because the thrust reversers were stowed. The Safety Board determined that the inadvertent forward thrust contributed to the severity of the accident.

The Safety Board also found that neither the Federal Aviation Administration nor Learjet adequately reviewed the Airplane’s design after a similar uncommanded forward thrust accident that occurred during landing in Alabama in 2001. While the modifications put into place after the Alabama accident provided additional protection against uncommanded forward thrust upon landing, no such protection was provided for a rejected takeoff.

“This accident chain started with something as basic as inadequate tire inflation and ended in tragedy,” said NTSB Chairman Deborah A.P. Hersman. “This entirely avoidable crash should reinforce to everyone in the aviation community that there are no small maintenance items because every time a plane takes off, lives are on the line.”

The safety recommendations that the NTSB made to the Federal Aviation Administration as a result of this investigation are: provide pilots and maintenance personnel with information on the hazards associated with tire underinflation, including the required intervals for tire pressure checks, and allow pilots to perform pressure checks in air taxi operations to ensure that tires remain safely inflated at all times; require tire pressure monitoring systems for all transport category airplanes; identify and correct deficiencies in both Learjet’s thrust reverser system safety analysis and the FAA’s design certification process to ensure that hazards encountered in all phases of flight are mitigated; require that simulator training for pilots who conduct turbojet operations include opportunities to practice responding to events other than engine failures near takeoff speeds; require that pilots who fly air taxi turbojet operations have a minimum level of pilot operating experience in an airplane type before acting as pilot-in- command in that type; and require that airplane tire testing criteria reflect the loads that may be imposed on tires both during normal operating conditions and after the loss of one tire.

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: November 24, 2010
SB-10-45

The National Transportation Safety Board today released a
final report on a fatal crash involving a transport-category
helicopter caused by a bird strike. The Board said the lack
of requirements for bird strike-resistant windshields
contributed to the crash, and called on the FAA to develop
such requirements.

On January 4, 2009, a dual-engine Sikorsky S-76C++
helicopter (N748P), registered to and operated by PHI, Inc.,
crashed into marshy terrain near Morgan City, Louisiana
approximately 7 minutes after takeoff from Amelie,
Louisiana, on a charter flight to an oil rig in the Gulf of
Mexico. Both pilots and 6 of the 7 passengers were killed
in the crash.

The aircraft had reached level cruise flight at 850 feet
mean sea level and 135 knots when the cockpit voice recorder
recorded a loud bang, followed by sounds consistent with
rushing wind and a power reduction on both engines. The
aircraft crashed several seconds later. Feathers and other
bird debris were collected from the canopy and windshield of
the aircraft. Laboratory analysis identified the remains as
coming from a female red-tailed hawk; the average weight of
such a bird is 2.4 pounds.

The investigation revealed that the impact of the bird on
the canopy just above the windshield near the engine control
quadrant likely jarred the fire extinguisher T-handles out
of their detents and moved them aft, pushing both engine
control levers into or near the flight idle position,
reducing fuel to both engines. The pilots were probably
disoriented from the broken windshield and rushing air and
were unable to react in time to maintain control of the
helicopter.

The helicopter was originally equipped with laminated glass
windshields that complied with European bird-strike
resistance standards. PHI replaced the windshields with
lighter-weight, aftermarket cast acrylic windshields that
did not have any bird-strike resistance standards.

The NTSB determined that the helicopter crashed because of
the sudden loss of power to both engines following the bird
strike and the subsequent disorientation of the crewmembers.
Contributing to the accident, the Board said, were the lack
of FAA regulations and guidance requiring helicopter
windshields to be resistant to bird strikes, the lack of
protections that would prevent the T-handles from
inadvertently dislodging out of their detents, and the lack
of a master warning light and audible system to alert the
flight crew of a low-rotor speed condition.

Recommendations were issued to the FAA dealing with, among
other things, the design of S-76C++ fire extinguisher T-
handles and engine control quadrants, and similar designs of
other helicopters, and of audible low-rotor alarm systems;
certification standards for helicopter windshields; and
simultaneous dual-engine power loss training for helicopter
pilots.