NTSB: Pilot Error Caused Fatal Jet Crash

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Key Takeaways:

  • Pilot error, specifically failure to follow proper anti-skid system failure procedures, was the primary cause of a Beechcraft 390 Premier crash.
  • The pilot's inadequate knowledge of the aircraft's systems and procedures, compounded by fatigue, contributed significantly to the accident.
  • The pilot's incorrect flap settings and failure to retract the lift dump during a go-around compromised the aircraft's ability to stop safely, resulting in a fatal collision.
  • The NTSB emphasized the importance of pilot adherence to aircraft flight manuals and the necessity of sufficient rest to prevent accidents.
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image: 11alive.com

The captain of a Beechcraft 390 Premier failed to follow the correct procedures for an anti-skid failure, resulting in a fiery crash that killed five passengers, the NTSB said in its final report on Tuesday. The jet was returning to Thomson-McDuffie County Airport, in Thomson, Georgia, on February 20, 2013, when it failed to slow down after touchdown. The captain initiated a go-around. Nine seconds later, the jet collided with a utility pole about 1,835 feet from the end of the runway, 63 feet above the ground. The captain and first officer suffered serious injuries. NTSB Acting Chairman Christopher Hart said crew fatigue was a factor in the accident.

“This pilot’s inadequate knowledge of his aircraft was compounded by his fatigue,” said Hart. “As a result, five people died who did not have to. Just as pilots should not take off without enough fuel, they should not operate an aircraft without enough rest.” The captain failed to adhere to the airplane’s flight manual procedures for anti-skid failure in flight and did not retract the lift dump — a critical system to assist in stopping the aircraft — immediately after making the decision to perform a go-around, according to the NTSB. According to the checklist for an anti-skid system failure, the flap configurations available for the pilot were flaps up or flaps 10. Either of these configurations would have required a longer landing distance than the runway provided. As a result, the pilot should have sought landing at an alternate airport, the NTSB said.

Investigators found the aircraft had extended flaps 30 on the approach, which is prohibited by the anti-skid failure procedures. At the time of impact, the flaps were transitioning through flaps 15. Additionally, while both the airplane’s flight manual and a placard in the cockpit warned against extending the lift dump in flight, the go-around was attempted with the lift dump deployed, making a safe climb unlikely. The full report is posted online.

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