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Cases › DCA08MA098 · Major investigation · Class 1

Learjet LR60Global Exec Avaition

Columbia, SC, USA · 2008-09-20·N999LJ

4
fatal
2
serious
Fatal
highest injury
Destroyed
damage

What happened

NTSB summary, verbatim

The NTSB’s full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-10/02. On September 19, 2008, about 2353 eastern daylight time, a Bombardier Learjet Model 60, N999LJ, owned by Inter Travel and Services, Inc., and operated by Global Exec Aviation, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport, Columbia, South Carolina. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured. The nonscheduled domestic passenger flight to Van Nuys, California, was operated under 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed.

Probable cause

the Board's determination
The operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures. Contributing to the accident were (1) deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of critical systems in the wheel well area to result in uncommanded forward thrust that increased the severity of the accident; (2) the inadequacy of Learjet’s safety analysis and the FAA’s review of it, which failed to detect and correct the thrust reverser and wheel well design deficiencies after a 2001 uncommanded forward thrust accident; (3) inadequate industry training standards for flight crews in tire failure scenarios; and (4) the flight crew’s poor crew resource management (CRM).

Occurrence sequence

4 stepsNTSB coding · CICTT taxonomy
  1. 1 · Prior to flight
    Aircraft maintenance event
  2. 2 · Takeoff
    Sys/Comp malf/fail (non-power)
  3. 3 · Takeoff-rejected takeoff
    Runway excursion
    defining event
  4. 4 · Post-impact
    Fire/smoke (post-impact)

Findings

14 causal · 0 contributing
  • CAUSE
    Aircraft › Aircraft systems › Landing gear system › Tire casing — Incorrect service/maintenance
  • CAUSE
    Aircraft › Aircraft systems › Landing gear system › Tire casing — Failure
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Oversight › Oversight of maintenance — Operator
  • CAUSE
    Personnel issues › Action/decision › Action › Incorrect action selection — Pilot
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Use of policy/procedure — Pilot
  • CAUSE
    Organizational issues › Development › Design › Equipment design — Manufacturer
  • CAUSE
    Organizational issues › Development › Selection/certification/testing › Equip certification/testing — FAA/Regulator
  • CAUSE
    Organizational issues › Development › Selection/certification/testing › Equip certification/testing — Operator
  • CAUSE
    Organizational issues › Development › Selection/certification/testing › Personnel selection/training — Not specified
  • CAUSE
    Personnel issues › Task performance › Communication (personnel) › CRM/MRM techniques — Flight crew
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Oversight › Equipment monitoring — Manufacturer
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Oversight › Equipment monitoring — FAA/Regulator
  • CAUSE
    Aircraft › Aircraft power plant › Engine exhaust › Thrust reverser — Design
  • CAUSE
    Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Powerplant parameters — Attain/maintain not possible

Safety recommendations

20 issuedwhat changed because of this accident
  • A-09-055Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require Learjet to change the design of the Learjet 60 thrust lever system in future-manufactured airplanes so that the reverse lever positions in the cockpit match the positions of the thrust reverser mechanisms at the engines when the thrust reversers stow.

  • A-09-056Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Once design changes are developed per Safety Recommendation A-09-55, require Learjet 60 operators to retrofit existing airplanes so that the reverse lever positions in the cockpit match the positions of the thrust reverser mechanisms at the engines when the thrust reversers stow.

  • A-09-057Closed--No Longer ApplicableCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require Learjet to develop and install improved aural or visual cues on future-manufactured Learjet 60 airplanes that would allow pilots to recognize an inadvertent thrust reverser stowage in a timely manner.

  • A-09-058Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Once improved aural or visual cues are developed per Safety Recommendation A-09-57, require Learjet 60 operators to install those cues on existing Learjet 60 airplanes.

  • A-09-059Closed - Acceptable Alternate ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require that all Learjet 60 pilots receive training, for takeoff as well as landing phases of flight, on recognizing an inadvertent thrust reverser stowage, including the possibility that the stowage can occur when the requirements for deploying thrust reversers are not fully met, such as when the air/ground sensor squat switch circuits are damaged.

  • A-09-060Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the design of the thrust reverser controls and indications in Raytheon Hawker 1000 business jets for potential thrust reverser failure modes that are similar to those identified in Learjet 60 airplanes and implement necessary changes.

  • A-10-046Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Provide pilots and maintenance personnel with information that (1) transport-category aircraft tires can lose up to 5 percent pressure per day, (2) it may take only a few days for such tires to reach an underinflation level below what the aircraft maintenance manual specifies for tire replacement, and (3) the underinflation level that would require tire replacement is not visually detectable.

  • A-10-047Closed - ReconsideredCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators perform tire pressure checks at a frequency that will ensure that the tires remain inflated to within aircraft maintenance manual-specified inflation pressures.

  • A-10-048Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require that aircraft maintenance manuals specify, in a readily identifiable and standardized location, required maintenance intervals for tire pressure checks as applicable to each aircraft.

  • A-10-049Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Allow pilots to perform tire pressure checks on aircraft, regardless of whether the aircraft is operating under 14 Code of Federal Regulations Part 91, Part 91 subpart K, or Part 135.

  • A-10-050Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require tire pressure monitoring systems for all transport-category airplanes.

  • A-10-051Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Identify the deficiencies in Learjet’s system safety analyses, both for the original Learjet 60 design and for the modifications after the 2001 accident, that failed to properly address the thrust reverser system design flaws related to this accident, and require Learjet to perform a system safety assessment in accordance with 14 Code of Federal Regulations 25.1309 for all other systems that also rely on air-ground signal integrity and ensure that hazards resulting from a loss of signal integrity are appropriately mitigated to fully comply with this regulation.

  • A-10-052Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Revise available safety assessment guidance (such as Advisory Circular 25.1309-1A) for manufacturers to adequately address the deficiencies identified in Safety Recommendation A-10-51, require that designated engineering representatives and their Federal Aviation Administration (FAA) mentors are trained on this methodology, and modify FAA design oversight procedures to ensure that manufacturers are performing system safety analyses for all new or modified designs that effectively identify and properly mitigate hazards for all phases of flight, including foreseeable events during those phases (such as a rejected takeoff).

  • A-10-053Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Revise Federal Aviation Administration Order 8110.48 to require that the most current airworthiness regulations related to equipment, systems, and installations (14 Code of Federal Regulations 25.1309) are applied to all derivative design aircraft certificated as changed aeronautical products.

  • A-10-054Closed - ReconsideredCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Review the designs of existing derivative design aircraft that were certificated as changed aeronautical products against the requirements of the current revision of 14 Code of Federal Regulations 25.1309 and require modification of the equipment, systems, and installations to fully comply with this regulation.

  • A-10-055Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Define and codify minimum simulator model fidelity requirements for tire failure scenarios. These requirements should include tire failure scenarios during takeoff that present the need for rapid evaluation and execution of procedures and provide realistic sound and motion cueing.

  • A-10-056Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Once the simulator model fidelity requirements requested in Safety Recommendation A-10-55 are implemented, require that simulator training for pilots who conduct turbojet operations include opportunities to practice responding to events other than engine failures occurring both near V1 and after V1, including, but not limited to, tire failures.

  • A-10-057Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require that pilots who fly in 14 Code of Federal Regulations (CFR) Part 135 operations in aircraft that require a type rating gain a minimum level of initial operating experience, similar to that specified in 14 CFR 121.434, taking into consideration the unique characteristics of Part 135 operations.

  • A-10-058Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require that pilots who fly in 14 Code of Federal Regulations (CFR) Part 135 operations in an aircraft that requires a type rating gain a minimum level of flight time in that aircraft type, similar to that described in 14 CFR 121.434, taking into consideration the unique characteristics of Part 135 operations, to obtain consolidation of knowledge and skills.

  • A-10-059Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require that tire testing criteria reflect the actual static and dynamic loads that may be imposed on tires both during normal operating conditions and after the loss of one tire and consider less-than-optimal allowable tire conditions, including, but not limited to, the full range of allowable operating pressures and acceptable tread wear.

NTSB analysis

from the final report

The NTSB’s full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-10/02. On September 19, 2008, about 2353 eastern daylight time, a Bombardier Learjet Model 60, N999LJ, owned by Inter Travel and Services, Inc., and operated by Global Exec Aviation, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport, Columbia, South Carolina. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured. The nonscheduled domestic passenger flight to Van Nuys, California, was operated under 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed.