Pennsylvania

The commercial pilot stated that, during the takeoff roll, the airplane swerved to the right, and he corrected to the left and aborted the takeoff; however, the airplane departed the left side of the runway and collided with an embankment. At the time of the accident, a quartering tailwind was present. The pilot had no previous experience in the accident airplane make and model or in any other multiengine airplane equipped with engines capable of producing 300 horsepower. During a postaccident conversation with a mechanic, the pilot stated that the airplane "got away from him" during the attempted takeoff. Because a postaccident examination of the airplane did not reveal any evidence of a preimpact mechanical malfunction or failure of the airplane's flight controls or nosewheel steering system that would have precluded normal operation and the pilot did not have any previous experience operating this make and model of airplane, it is likely that the pilot lost directional control during takeoff with a quartering tailwind.

The commercial pilot was completing an instrument flight rules air taxi flight on a route that he had flown numerous times for the customer on board. Radar and voice communication data revealed that the airplane was vectored to the final approach course for the precision approach and was given a radio frequency change to the destination airport control tower frequency. The tower controller issued a landing clearance, which the pilot acknowledged; there were no further communications with the pilot. Weather conditions at the airport at the time of the accident included an overcast ceiling at 300 ft with 1 mile visibility in mist. The wreckage was located in densely-wooded terrain. Postaccident examination revealed no evidence of any mechanical malfunctions or anomalies that would have precluded normal operation. The wreckage path and evidence of engine power displayed by numerous cut tree branches was consistent with a controlled, wings-level descent with power. A radar performance study revealed that, as the airplane crossed the precision final approach fix 6.7 nautical miles (nm) from the runway threshold, the airplane was 800 ft above the glideslope. At the outer marker, 5.5 nm from the runway threshold, the airplane was 500 ft above the glideslope. When radar contact was lost 3.2 nm from the threshold, the airplane was about 250 ft above the glideslope. Although the airplane remained within the lateral limits of the approach localizer, its last two recorded radar returns would have correlated with a full downward deflection of the glideslope indicator in the cockpit, and therefore, an unstabilized approach. Further interpolation of radar data revealed that, during the last 2 minutes of the accident flight, the airplane's rate of descent increased from 400 ft per minute (fpm) to greater than 1,700 fpm, likely as a result of pilot inputs. During the final minute of the flight, the rate decreased briefly to 1,000 fpm before radar contact was lost. The company's standard operating procedures stated that, if a rate of descent greater than 1,000 fpm was encountered during an instrument approach, a missed approach should be performed. The airplane's relative position to the glideslope and its rapid changes in descent rate after crossing the outer marker suggest that the airplane never met the operator's stabilized approach criteria. Rather than executing a missed approach procedure as outlined in the company's operating procedures, the pilot chose to continue the unstabilized approach, which resulted in a descent into trees and terrain. It is unlikely that the pilot's well-controlled diabetes and effectively treated sleep apnea contributed to the circumstances of this accident. However, whether or not the pilot's multiple sclerosis contributed to this accident could not be determined.

Before pushback from the gate, the first officer, who was the pilot monitoring, initialized the flight management computer (FMC) and mistakenly entered the incorrect departure runway (27R instead of the assigned 27L). As the captain taxied onto runway 27L for departure, he noticed that the wrong runway was entered in the FMC. The captain asked the first officer to correct the runway entry in the FMC, which she completed about 27 seconds before the beginning of the takeoff roll; however, she did not enter the FLEX temperature (a reduced takeoff thrust setting) for the newly entered runway or upload the related V-speeds. As a result, the FMC's ability to execute a FLEX power takeoff was invalidated, and V-speeds did not appear on the primary flight display (PFD) or the multipurpose control display unit during the takeoff roll. According to the captain, once the airplane was cleared for takeoff on runway 27L, he set FLEX thrust with the thrust levers, and he felt that the performance and acceleration of the airplane on the takeoff roll was normal. About 2 seconds later, as the airplane reached about 56 knots indicated airspeed (KIAS), cockpit voice recorder (CVR) data indicate that the flight crew received a single level two caution chime and an electronic centralized aircraft monitoring (ECAM) message indicating that the thrust was not set correctly. The first officer called "engine thrust levers not set." According to the operator's pilot handbook, in response to an "engine thrust levers not set" ECAM message, the thrust levers should be moved to the takeoff/go-around (TO/GA) detent. However, the captain responded by saying "they're set" and moving the thrust levers from the FLEX position to the CL (climb) detent then back to the FLEX position. As the airplane continued to accelerate, the first officer did not make a callout at 80 KIAS, as required by the operator's standard operating procedures (SOPs). As the airplane reached 86 KIAS, the automated RETARD aural alert sounded and continued until the end of the CVR recording. According to Airbus, the RETARD alert is designed to occur at 20 ft radio altitude on landing and advise the pilot to reduce the thrust levers to idle. The captain later reported that he had never heard an aural RETARD alert on takeoff, only knew of it on landing, and did not know what it was telling him. He further said that when the RETARD aural alert sounded, he did not plan to reject the takeoff because they were in a high-speed regime, they had no red warning lights, and there was nothing to suggest that the takeoff should be rejected. The first officer later reported that there were no V-speeds depicted on the PFD and, thus, she could not call V1 or VR during the takeoff. She was not aware of any guidance or procedure that recommended rejecting or continuing a takeoff when there were no V-speeds displayed. She further said she "assumed [the captain] wouldn't continue to takeoff if he did not know the V-speeds." The captain stated that he had recalled the V-speeds as previously briefed from the Taxi checklist, which happened to be the same V-speeds for runway 27L. The captain continued the takeoff roll despite the lack of displayed V-speeds, no callouts from the first officer, and the continued and repeated RETARD aural alert. FDR data show that the airplane rotated at 164 KIAS. However, in a postaccident interview, the captain stated that he "had the perception the aircraft was unsafe to fly" and that he decided "the safest action was not to continue," so he commenced a rejected takeoff. FDR data indicate that the captain reduced the engines to idle and made an airplane-nose-down input as the airplane reached 167 KIAS (well above the V1 speed of 157 KIAS) and achieved a 6.7 degree nose-high attitude. The airplane's pitch decreased until the nose gear contacted the runway. However, the airplane then bounced back into the air and achieved a radio altitude of about 15 ft. Video from airport security cameras show the airplane fully above the runway surface after the bounce. The tail of the airplane then struck the runway surface, followed by the main landing gear then the nose landing gear, resulting in its fracture. The airplane slid to its final resting position on the left side of runway 27L. The operator's SOPs address the conditions under which a rejected takeoff should be performed within both low-speed (below 80 KIAS) and high-speed (between 80 KIAS and V1) regimes but provide no guidance for rejecting a takeoff after V1 and rotation. Simulator testing performed after the accident demonstrated that increasing the thrust levers to the TO/GA detent, as required by SOPs upon the activation of the "thrust not set" ECAM message, would have silenced the RETARD aural alert. At the time of the accident, neither the operator's training program nor manuals provided to flight crews specifically addressed what to do in the event the RETARD alert occurred during takeoff; although, 9 months before the accident, US Airways published a safety article regarding the conditions under which the alert would activate during takeoff. The operator's postaccident actions include a policy change (published via bulletin) to its pilot handbook specifying that moving the thrust levers to the TO/GA detent will cancel the RETARD aural alert. Although simulator testing indicated that the airplane was capable of sustaining flight after liftoff, it is likely that the cascading alerts (the ECAM message and the RETARD alert) and the lack of V-speed callouts eventually led the captain to have a heightened concern for the airplane's state as rotation occurred. FDR data indicate that the captain made erratic pitch inputs after the initial rotation, leading to the nose impacting the runway and the airplane bouncing into the air after the throttle levers had been returned to idle. Airbus simulation of the accident airplane's acceleration, rotation, and pitch response to the cyclic longitudinal inputs demonstrated that the airplane was responding as expected to the control inputs. Collectively, the events before rotation (the incorrect runway programmed in the FMC, the "thrust not set" ECAM message during the takeoff roll, the RETARD alert, and the lack of required V-speeds callouts) should have prompted the flight crew not to proceed with the takeoff roll. The flight crewmembers exhibited a self-induced pressure to continue the takeoff rather than taking the time to ensure the airplane was properly configured. Further, the captain initiated a rejected takeoff after the airplane's speed was beyond V1 and the nosewheel was off the runway when he should have been committed to the takeoff. The flight crewmembers' performance was indicative of poor crew resource management in that they failed to assess their situation when an error was discovered, to request a delayed takeoff, to communicate effectively, and to follow SOPs. Specifically, the captain's decision to abort the takeoff after rotation, the flight crew's failure to verify the correct departure runway before gate departure, and the captain's failure to move the thrust levers to the TO/GA detent in response to the ECAM message were all contrary to the operator's SOPs. Member Weener filed a statement, concurring in part and dissenting in part, that can be found in the public docket for this accident. Chairman Hart, Vice Chairman Dinh-Zarr, and Member Sumwalt joined the statement.

Following a normal landing, the pilot felt no wheel braking action on the left wheel, and the brake pedal went to the floor. The pilot attempted to maintain directional control; however, the airplane departed the right side of the runway and traveled into the grass. The landing gear collapsed, and the airplane came to a stop, sustaining structural damage to the left wing spar. Postaccident examination confirmed that the left brake was inoperative and revealed a small hydraulic fluid leak at the shaft of the parking brake valve in the pressurized section of the cabin. Air likely entered the brake line at the area of the leak while the cabin was pressurized, rendering the left brake inoperative.

Toward the end of a 6 hour, 20 minute flight, during a night visual approach, the pilot flew the airplane to a left traffic pattern downwind leg. At some point, he lowered the landing gear and set the flaps to 30 degrees. He turned the airplane to a left base leg, and after doing so, was heard on the common traffic frequency stating that he had an "engine out." The airplane then passed through the final leg course, the pilot called "base to final," and the airplane commenced a right turn while maintaining altitude. The angle of bank was then observed to increase to where the airplane's wings became vertical, then inverted, and the airplane rolled into a near-vertical descent, hitting the ground upright in a right spin. Subsequent examination of the airplane and engines revealed that the right engine was not powered at impact, and the propeller from that engine was not in feather. No mechanical anomalies could be found with the engine that could have resulted in its failure. The right fuel tank was breeched; however, fuel calculations, confirmed by some fuel found in the right fuel tank as well as fuel found in the engine fuel filter housing, indicated that fuel exhaustion did not occur. Unknown is why the pilot did not continue through a left turn descent onto the final approach leg toward airport, which would also have been a turn toward the operating engine. The pilot had a communication device capable of voice calls, texting, e-mail and alarms, among other functions. E-mails were sent by the device until 0323, and an alarm sounded at 0920. It is unknown if or how much pilot fatigue might have influenced the outcome.

After landing at Harrisburg Airport, the undercarriage collapsed and the aircraft came to rest on its belly. Both occupants escaped uninjured while the aircraft was damaged beyond repair.

The air traffic controller, with both ground and local (tower) responsibilities, cleared the accident airplane to land when it was about 8 miles from the runway. Another airplane landed in front of the accident flight, and the controller cleared that pilot to taxi to the hangar. The controller subsequently cleared a tractor with retractable (bat wing) mowers, one on each side, and both in the “up” position, to proceed from the terminal ramp and across the 6,350-foot active runway at an intersection about 2,600 feet from the threshold. The controller then shifted his attention back to the airplane taxiing to its hangar, and did not see the accident airplane land. During the landing rollout, the airplane’s left wing collided with the right side of the tractor when the tractor was “slightly” left of runway centerline. Calculations estimated that the airplane was about 1,000 feet from the collision point when the tractor emerged from the taxiway, and skid marks confirmed that the airplane had been steered to the right to avoid impact. Prior to the crossing attempt, the tractor operator did not scan the runway, and was concentrating on the left side bat wing. Federal Aviation Administration publications do not adequately address the need for ground vehicle operators to visually confirm that active runways/approaches are clear, prior to crossing with air traffic control authorization, thus overlooking an additional means to avoid a collision.

During landing at its home airport, the airplane overran the runway and traveled down a 40-foot embankment before coming to rest against trees and sustaining substantial damage. According to the pilot, his speed on approach was a little fast but he thought it was manageable. Recorded data from the accident airplane revealed that 20 seconds before touchdown, when the pilot selected flaps 30 (landing flaps) the airspeed was approximately 27 knots above the maximum flap extension speed, and as the airplane touched down its airspeed was approximately 14 knots higher than specified for landing. The runway had a displaced threshold with 3,097 feet of runway length available. Skid marks from the accident airplane began approximately 868 feet beyond the displaced threshold, and continued for about 2,229 feet until they left the paved portion of the runway.

The Citation 550 was being repositioned for an air ambulance transportation flight, and was on approach to land on a 4,801-foot-long, grooved, asphalt runway. The airplane was being flown manually by the copilot, who reported that the landing approach speed (Vref) was 106 knots. The pilot-in-command (PIC) estimated that the airplane "broke out" of the clouds about two miles from the runway. Both pilots stated that the airplane continued to descend toward the runway, while on the glide slope and localizer. Neither pilot could recall the airplane's touchdown point on the runway, or the speed at touchdown. Witnesses observed the airplane, "high and fast" as it crossed over the runway threshold. The airplane touched down about halfway down the runway, and continued off the departure end. It then struck a wooden localizer antenna platform, and the airport perimeter fence, before crossing a road, and coming to rest about 400 feet from the end of the runway. Data downloaded from the airplane's Enhanced Ground Proximity Warning System (EGPWS) revealed that the airplane's groundspeed at touchdown was about 140 knots. Review of the cockpit voice recorder suggested that the PIC failed to activate the airplane's speed brake upon touchdown. Braking action was estimated to be "fair" at the time of the accident, with about 1/4 to 1/2 inches of loose, "fluffy" snow on the runway. The PIC reported that he thought the runway might be covered with an inch or two of snow, which did not concern him. The copilot reported encountering light snow during the approach. Both pilots stated that they were not aware of any mechanical failures, or system malfunctions during the accident; nor were any discovered during post accident examinations. According to the airplane flight manual, the conditions applicable to the accident flight prescribed a Vref of 110 knots, with a required landing distance on an uncontaminated runway of approximately 2,740 feet. The prescribed landing distance on a runway contaminated with 1-inch of snow, at a Vref of 110 knots was approximately 5,800 feet. At Vref + 10 knots, the required landing distance increased to about 7,750 feet.

The airplane encountered in-flight icing, and the pilot diverted to an airport to attempt to knock the ice off at a lower altitude. During the instrument approach, the pilot advised the tower controller of the ice, and that it depended on whether or not the ice came off the airplane if she would land. As the airplane broke out of the clouds, it appeared to tower personnel to be executing a missed approach; however, it suddenly "dove" for the runway. The tower supervisor noticed that the landing gear were not down, and at 75 to 100 feet above the runway, advised the pilot to go around. The airplane continued to descend, and by the time it impacted the runway, the landing gear were only partially extended, and the propellers and airframe impacted the pavement. The pilot then attempted to abort the landing. The damaged airplane became airborne, climbed to the right, stalled, and nosed straight down into the ground.