NTSB Airplane Accident Reports: Crash During Approach to Landing - History of Flight
Accident - Aviation NTSB Report
1.1 History of Flight
On February 16, 2005, about 0913 mountain standard time,1 a Cessna Citation 560, N500AT, operated by Martinair, Inc., for Circuit City Stores, Inc.,2 crashed
about 4 nautical miles (nm) east of Pueblo Memorial Airport (PUB), Pueblo, Colorado, while on an instrument landing system (ILS) approach to runway 26R. The two pilots and six passengers on board were killed, and the airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Instrument meteorological conditions (IMC) prevailed at the time of the accident.
The accident flight and another Circuit City Stores Cessna 560 (N500FK, referred to in this report as the "sister ship") were scheduled to transport Circuit City Stores employees from Richmond International Airport, Richmond, Virginia, to John Wayne Airport, Santa Ana, California, with scheduled fuel stops at Columbia Regional Airport (COU), Columbia, Missouri, and PUB. The accident flight departed Richmond about 0600 eastern standard time. The flight arrived at COU about 0736 central standard time and departed for PUB about 30 minutes later.
At 0847:48, while descending through about flight level 370,3 the cockpit voice recorder (CVR)4 recorded the Denver Air Route Traffic Control Center (ARTCC)
instructing the flight crew to descend to and maintain 13,000 feet. About 0851, the CVR recorded the flight crew start discussing the icing conditions. Specifically, at 0850:40, the captain stated, "I’m gonna heat ‘em up."5 About 4 minutes later, the captain stated that he turned the windshield heat on, and he then asked the first officer to let him know if he saw any ice on the wing. The first officer replied that he saw ice "building a little bit right on
1 Unless otherwise indicated, all times in this report are mountain standard time based on a 24-hour clock.
2 Circuit City Stores owned the airplane. Martinair, an aircraft management and charter company, operated and managed the accident airplane for Circuit City Stores. See section 1.17 for more information.
3 Flight level 370 is an altitude of 37,000 feet mean sea level (msl) based on an altimeter setting of 29.92 inches of mercury (Hg). Unless otherwise indicated, all altitudes referenced in this report are reported as height above msl.
4 Correlation of the CVR recording to mountain standard time was established using times from the air traffic control (ATC) transcript prepared by the Federal Aviation Administration and PUB airport surveillance radar-7 radar. The time alignment of the CVR recording and radar revealed that the CVR clock was about 10 seconds ahead of the radar clock. As a result, the CVR times are presented with a 10-second offset to provide a consistent time base between the CVR and ATC sources. The airplane was not equipped with a flight data recorder.
5 The captain’s comment most likely refers to the activation of the engine anti-ice system, which heats the engine inlets and the inboard wing leading edges. For more information about the airplane’s anti-ice and deice systems and guidance on the usage of these systems, see sections 1.6.3 and 1.17.1.3, respectively.
At 0858:20, as the airplane was descending through about 18,000 feet, the first officer suggested that the captain cycle the deice boots. After cycling the deice boots, the captain stated, "might’ve gotten rid of a little but not much." At 0859:29, the first officer stated that the Vref was 96 knots .6 About 3 1/2 minutes later, the captain told the first officer to "leave the heats on," and the first officer replied, "okay. Got everything nice and
warmed up."
At 0905:50, the first officer contacted PUB approach control and stated, "Pueblo approach…thirteen thousand with [automatic terminal information service] Juliet."7 The PUB local controller instructed the flight crew to fly heading 240° for the ILS runway 26R final approach course and to descend to and maintain 7,000 feet. The first officer asked, "did you say two six right now?" The controller confirmed that runway 26R was in use. The controller also reported that a regional jet was in a holding pattern over PUB at 9,000 feet and asked the pilots to report when they had the airplane in sight.8 The first officer then told the captain that the controller had changed the landing runway from 8L to 26R.
At 0907:36, the PUB local controller asked the pilots if they had the airplane in sight, and the first officer stated that he did not. The controller replied, "give me a best rate of descent through niner thousand or maintain one zero thousand. I’ll just turn you." The first officer stated that they would descend to 7,000 feet. At 0908:25, the first officer reported to the controller that the flight was in IMC at an altitude of about 9,400 feet. The controller then instructed the flight to turn left to a heading of 170°. At 0908:55, the controller instructed the flight crew to turn right to a heading of 290° to intercept the localizer inbound. He then instructed the flight crew to maintain 7,000 feet and cleared the flight for the approach.
6 Vref is the landing reference airspeed with full flaps and landing gear down. In accordance with company guidance, if any amount of residual ice (that is, ice that remains on the deice surface after the deice boots have been cycled) is present, the Vref should be increased by 8 knots, which would have resulted in a Vref of 104 knots instead of the 96 knots reported by the first officer. For more information about guidance on operations in icing conditions, see section 1.17.1.2.
7 Automatic terminal information service (ATIS) information "Juliet," which broadcast the 0753 weather, reported the following: wind 060° at 6 knots, visibility 10 statute miles, measured ceiling 1,400 feet overcast, temperature -3° Celsius (C), dew point -5° C, altimeter 30.16 inches of Hg. ATIS information "Juliet" also indicated that the landing runway in use was 8L. Altitudes referenced in this report from surface weather observations and terminal aerodrome forecasts are reported as height above ground level (agl). See section 1.7 for more meteorological information.
8 During postaccident interviews, the captain of the holding airplane stated that he had initially requested and received a holding pattern altitude of 8,000 feet. He stated that, although he was informed by ATC that icing conditions existed at that altitude, he decided to descend to 8,000 feet. As the airplane descended toward 8,000 feet into IMC, it began accumulating ice. He stated that he turned on the airplane’s wing anti-ice and immediately requested a climb to 9,000 feet to exit the icing conditions. He stated that, at 9,000 feet, the airplane was above the cloud layer and mostly in the clear. He characterized the icing as rime ice but did not know its accumulation rate or severity.
9 The first officer replied, "all right, will do." At 0909:41, the PUB local controller provided the flight crew with the current weather, which indicated the following: cloud ceilings broken at 900 feet and overcast at 1,400 feet, visibility 6 statute miles (sm) in mist, temperature -3° Celsius (C), dew point -4° C, wind 070° at 7 knots, and altimeter 30.16 inches of mercury (Hg).
At 0910:22, the first officer stated, "ignition is on with the anti-ice, now it’s on for sure. Glideslope is alive." At 0911:10, the captain stated, "[landing] gear’s down." The PUB local controller cleared the flight to land on runway 26R and instructed the flight crew to maintain its present heading and altitude until established on the ILS localizer. At 0911:45, the CVR recorded the captain stating, "speed brakes coming back out." The first officer replied, "okay…there’s your glideslope intercept." The captain then called for full flaps. The first officer responded, "full flaps, here we go…full selected and indicated." At 0912:00, the first officer briefed the missed approach. Four seconds later, he stated, "you are plus twenty five,"10 and the captain replied, "slowing." At 0912:37, the first officer stated, "I don’t know if you want to run your ice a little bit. You got the Vref there."
Airplane performance calculations show that, about 0912:40, immediately after passing through about 6,100 feet,11 the airplane experienced an upset and the onset of a large roll to the left concurrent with a rapid decrease in pitch. The CVR recorded a short tone concurrent with the beginning of the upset. The frequency and the duration of the tone were consistent with the autopilot disconnect horn.12 At 0912:46, the CVR recorded the enhanced ground proximity warning system (EGPWS) "bank angle" aural warning alert.13 The last radar return was received at 0912:54 while the airplane was at an altitude of about 4,922 feet. One second later, the CVR stopped recording. According to the Federal Aviation Administration (FAA) air traffic control (ATC) transcript, at 0912:57, the PUB local controller issued an altitude alert to the accident flight, stating, "zero alpha tango altitude alert altitude indicates four thousand niner hundred over."
1.1.1 The Sister Ship History of Flight
During postaccident interviews, the sister ship captain indicated that, according to the airplane’s traffic alert and collision avoidance system (TCAS), the accident airplane was about 19 nm ahead of the sister ship en route to PUB. The flight crewmembers reported that, during the descent to PUB, the airplane was accreting rime ice;14 however, 9 The captain was most likely referring to the windshield anti-ice bleed air valves, which control the volume of engine bleed air to the windshield. The three-position (LOW, OFF, and HIGH) windshield bleed air switch controls the temperature of the air to the windshield.
10 The first officer’s comment "plus twenty five" refers to the Vref plus 25 knots.
11 The airplane was at an altitude of about 1,500 feet above ground level at the time of the upset.
12 The autopilot can be manually disconnected by the pilot or it can be automatically disconnected if certain conditions occur, such as a roll angle of more than 40° or a roll rate of more than 20° per second.
13 Analysis of the EGPWS data indicated that the bank angle at the time of the alert was about 50°.
Factual Information 4 Aircraft Accident Report
15 The captain stated that they broke out of the clouds about 1,200 to 1,400 feet and that the visibility was about 6 nm with no precipitation.
The captain stated that he heard the PUB controller clear the accident airplane to land and the flight crew acknowledge the clearance. He stated that, shortly afterward, he heard the controller issue a low-altitude warning of about 4,900 feet. He stated that the controller called for the accident flight three or four times but that the flight crew did not acknowledge. He stated that he then looked at the TCAS and saw that the accident airplane was no longer displayed. The sister ship landed on runway 8L about 0926 without incident. The flight crew and passengers reported that they observed some ice on the airplane after landing.
A review of the sister ship’s CVR revealed that the pilots conducted several procedures to minimize any icing problems, including cycling the wing deice boots five times, turning the windshield heat to the HIGH position, using only approach flaps until close to the ground, and keeping the engine power and speed as high as possible until clear of the clouds and landing was assured.
14 Rime ice is an opaque, granular, and rough deposit of ice that usually forms on the airplane’s surfaces, including, in part, the wing leading edges, the horizontal stabilizers, and the engine inlets.
15 Airplane performance calculations revealed that the sister ship’s airspeed was more than 160 knots as the airplane descended through about 6,200 feet and that the airplane maintained an airspeed of about 120 knots until it was about 200 feet above airport elevation. Calculations revealed that the accident airplane’s airspeed was about 98 knots as it descended through about 6,200 feet.
Damage to Aircraft
The airplane was destroyed by impact forces and a postcrash fire.
1.4 Other Damage
No other damage resulted from this accident.
1.5 Personnel Information
1.5.1 The Captain
The captain, age 53, was hired by Martinair on February 1, 2002. He held a multiengine airline transport pilot (ATP) certificate, issued October 11, 1996, with type ratings in Beechcraft 300 and 1900, Cessna 500, and Dassault Falcon DA-10 series airplanes. The captain held a first-class FAA airman medical certificate, dated February 7, 2005, with the limitations that he "must wear lenses for distance" and "possess glasses for near vision."
According to the captain’s employment application for Martinair, from July 1989 to January 2001, he worked as a pilot in Cessna 560 airplanes at Southern States. From January 2001 to February 2002, he worked as a pilot in Cessna Citation Ultra airplanes at Chesapeake Corporation. Martinair records indicated that the captain had accumulated 8,577 total flight hours, including 2,735 hours in Cessna Citation airplanes, 1,500 hours of which were as pilot-in-command. He had flown about 113, 39, 12, and 3 hours in the 90, 30, and 7 days and 24 hours, respectively, before the accident. The captain’s last Cessna 500 series proficiency check occurred on November 1, 2004; his last recurrent ground training occurred on November 30, 2004; and his last line check occurred on January 4, 2005. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificate or rating failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation.
According to the captain’s wife, he slept his normal sleep schedule16 at home in Richmond for several nights before February 15, 2005. On February 14, he flew a
roundtrip to South Bend, Indiana, during the day (with the accident first officer). She stated that, on February 15, he left home by early afternoon, returned about 1500, and was awake in bed when she returned about 2030 to 2100. She stated that, on the morning of the accident, he awoke early; however, she did not know what time he departed for the airport.
16 According to the captain’s wife, he normally went to sleep about 2200 to 2300 and awoke by 0700 when he did not have to work. She stated that the captain sometimes had difficulty sleeping.
The First Officer
The first officer, age 42, was hired by Martinair in November 2004. He held a multiengine ATP certificate, issued March 3, 2004, with a type rating in Cessna 500 series airplanes. The first officer held a first-class FAA airman medical certificate, dated August 2, 2004, with no limitations.
According to the first officer’s employment application for Martinair, from April 2002 to November 2004, he worked as a pilot in Cessna Citation airplanes for
Commonwealth Aviation Services, Inc. Martinair records indicated that the first officer had accumulated 2,614 total flight hours, including 1,397 hours in Cessna Citation series airplanes, 322 hours of which were as pilot-in-command. He had flown about 127, 37, 11, and 3 hours in the 90, 30, and 7 days and 24 hours, respectively, before the accident. The first officer’s last Cessna Citation 500 series proficiency check and line check occurred on February 10, 2005, and his last recurrent ground training occurred on December 30, 2004. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificate or rating failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation.
According to the first officer’s wife, he slept his normal sleep schedule17 at home in Richmond for several nights before February 15, 2005. She stated that, on February 14, he was still in bed when she left the house about 0730; he flew a roundtrip to South Bend that afternoon; and he went to bed about 2200 to 2300. On February 15, he flew another roundtrip to South Bend, and he went to bed about 2100 to 2130. On the morning of the accident, he awoke about 0300 and left the house about 0345 to 0400.
1.6 Aircraft Information
1.6.1 General Aircraft Information
The accident airplane, serial number 0146, was manufactured by Cessna Aircraft Company on October 22, 1991, and was certified to 14 CFR Part 25 standards. At the time of the accident, the airplane had accumulated about 3,658 total flight hours. The airplane was equipped with two Pratt & Whitney Canada (PWC) JT15D-5A turbofan engines. The time since new for both engines was about 3,585 hours, and the time since overhaul for both engines was about 114 hours.
Martinair provided National Transportation Safety Board investigators with estimated weight and balance information for the accident flight.18 According to these estimates, the accident airplane’s landing weight was about 13,040 pounds, including 17 According to the first officer’s wife, he normally went to sleep about 2200 and awoke by 0800 when he did not have to work.
18 The actual weight and balance information for the accident airplane was not found. Title 14 CFR Part 91 regulations do not require pilots to leave a manifest at the departure airport.
The airplane was equipped with speedbrakes, which are small panels that extend from the upper and lower surfaces of each wing to increase descent rates.19 After the accident, the left speedbrakes remained attached to the wing and were in the fully extended position. The right speedbrakes remained attached to the wing but were in an intermediate position. However, the speedbrake panels and hydraulic actuators on both wings were able to move freely.
1.6.2 Stall Warning System
The accident airplane was equipped with a stall warning and angle-of-attack (AOA) system, which consisted of an AOA vane, indicator, indexer, and computer, and a stickshaker mounted on the forward side of the pilot’s control column. The AOA vane, which is located on the forward right side of the fuselage, streamlines with the relative airflow and transmits the sensed angle to the AOA system. Inputs from the AOA system are transmitted to the stickshaker, which has an electric motor with rotating weights that induce vibration to the control columns, providing a tactile warning to pilots of an impending stall. The stickshaker is designed to alert pilots of an impending stall about 7 percent above the actual stall speed when the airplane’s surfaces are not contaminated by ice.20
According to the Cessna Model 560 Citation V Operating Manual, the airplane was equipped with an upgraded, dual-mode AOA computer, which incorporated normal and ice modes. The ice mode is activated when either engine anti-ice switch is selected ON. In normal mode, stickshaker activation is referenced to standard airplane stall speeds, and, in ice mode, stickshaker activation is referenced to standard airplane stall speeds plus 5 knots to account for the increase in stall speed caused by airframe ice accumulation.21
According to the Cessna Model 560 Citation V Airplane Flight Manual (AFM), the accident airplane’s stall speed, with no ice on the wings and assuming an airplane weight of about 13,300 pounds and full flaps selected, should have been about 76 knots. The AFM states that, with ice on the wings, the stall speed increases by 5 knots; therefore,
19 The speedbrakes are electrically controlled and hydraulically actuated by a switch located on the throttle quadrant in the cockpit and may be selected to the fully extended or fully retracted (stowed) position. The speedbrakes are held in the stowed position by mechanical catches. A light illuminates in the cockpit when the speedbrakes are in transition and when they are fully extended.
20 According to Advisory Circular 25-7, "Flight Test Guide for Certification for Transport Category Airplanes," "the stall warning should normally begin at a speed not less than 7 percent above the stall speed."
21 During flight tests of Cessna 560 series airplanes, which were conducted by the FAA in 1996, it was determined that the stall speed increased from 3 to 5 knots in icing conditions. In early 1999, Cessna began installing stall warning systems that incorporated the ice mode. For more information about these tests and subsequent FAA and Cessna actions, see section 1.18.1.
The Cessna Model 560 Citation V AFM states that the stall warning system must be operable and a preflight check must be performed before takeoff. The sister ship captain, who flew the accident airplane the day before the accident, reported no pre- or in-flight stall warning system problems. Further, no discrepancies were noted during the last scheduled maintenance inspection of the stall warning system, which was completed on December 1, 2003.
Post accident examinations of the stall warning system components revealed that the AOA computer and vane electrical heating element exhibited heat and fire damage, which precluded functional checks. The AOA vane was able to move freely. The stall warning stick shaker and the vane heating elements were found to be functional during post accident tests.
1.6.3 Anti-Ice and Deice Systems
The Cessna 560 is certified to operate in known icing conditions and is equipped with anti-ice and deice systems to prevent ice accumulation on various exterior areas of the airplane.22 The engine anti-ice system uses engine bleed air to heat the engine inlets and the inboard wing leading edges, and the windshield anti-ice system uses engine bleed air to heat the windshield. The pilot static anti-ice system uses electrical heating elements to prevent ice buildup on the pilot tubes, static ports, and AOA vane. The anti-ice systems are activated by switches in the cockpit. Activation of the engine and windshield anti-ice systems and failures of the engine and pilot static anti-ice systems are annunciated by lights in the cockpit.
The surface deice system consists of pneumatic boots on the outboard wing leading edges and the horizontal stabilizer. The deice system is typically activated by
selecting the surface deice switch to the AUTO position. During the 18-second automatic deice boot cycle,23 pneumatic pressure from engine bleed air inflates the lower boots on the wing leading edges and the boot on the left horizontal stabilizer, then these boots completely deflate. The upper boots on the wing leading edges and the boot on the right horizontal stabilizer then inflate and deflate. After deflation of the upper deice boots, the cycle is terminated. Deice boot system activation is annunciated by lights in the cockpit.
The deice boot system can also be operated manually by holding the deice surface control switch in the MANUAL position. As long as the control switch is held in the MANUAL position, all of the deice boots will inflate simultaneously and deflate when the
22 According to the Cessna Model 560 Citation V AFM, the airplane’s anti-ice and deice systems were not designed to protect against freezing rain or severe conditions of mixed or clear ice.
23 The AUTO mode automatically cycles the deice boots through one 18-second deice boot cycle. However, to activate another 18-second cycle, the pilot would have to move the surface deice switch to the AUTO position again.
CVR information indicated that the captain activated the deice boots and that the boots had removed some of the ice. Further, no discrepancies were noted during the last scheduled maintenance inspections of the anti-ice and deice systems, which were completed on December 1, 2003.
After the accident, the engine anti-ice switches were found fractured, and their positions could not be determined. The windshield bleed air switches were missing. The left and right windshield bleed air valve positions could not be determined because the cables had been pulled out of both control mechanisms. The pilot static heat switch was found in the ON position. The surface deice switch was found spring-loaded to the neutral position. The deice control valves were found separated from the wreckage and damaged. On-scene disassembly revealed that the deice control valves were free of obstruction, and a functional test showed that the valves functioned properly.
The left- and right-wing leading edge deice boots were severely damaged by impact and post crash fire. The left and right horizontal stabilizer deice boots were
damaged. The deice boot air supply lines from the tail section to the wings were damaged and/or consumed by fire.
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