| Pilots transitioning from one type of aircraft
to another have a responsibility to themselves and to their passengers to
ensure that they are comfortable and safe in the new aircraft. Others,
from instructors to designated check airmen to company managers, have the
job of overseeing the process and ensuring that when a recently upgraded
pilot makes his first flights in a new type of aircraft, there is no
compromise in safety. Sometimes, a breakdown occurs in the upgrade process
that allows a pilot to "step up" before he or she is ready to do
so. Such a breakdown appears to have been involved in the 1994
crash of a Learjet
25D at Dulles airport.
The airplane, operated by TAESA, a Mexican airline and charter
operator, left Mexico City at 11 p.m. on June
18, 1994
with 10 passengers and two pilots. The destination was Washington, D.C.
with a fuel stop planned in New Orleans. After landing at Lakefront
Airport at 0125, there was a delay because the Customs agent was waiting
for the aircraft at New Orleans International, on the other side of the
city. The airplane didn't leave New Orleans until 0347.
Near the Dulles airport. the crew had to hold for four and a half
minutes while ATC helped a Mooney pilot who had declared an emergency. The
Learjet then was
cleared direct to the Armel VOR at 11,000 feet, and Dulles Approach
vectored the aircraft to Runway 1R for an ILS approach. The ATIS was
reporting the weather as ''indefinite ceiling 600, sky obscured,
visibility one-half fog, temperature 71, dew point 71, wind 140 at
four."
The Lear 25 received its approach clearance at 0608, and the crew
switched over to the tower frequency. Four minutes later, the crew
declared a missed approach and advised that they'd like to try it again.
United Flight 186 Heavy, a DC- 10, reported a missed approach shortly
after the Learjet
did. The captain of the United flight briefly discussed trying the ILS to
l9L, because the runway visual range (RVR) on that side of the airport was
higher, but he decided, instead, to proceed to his alternate airport. He
may have felt that by the time he got around to the other approach, the
visibility would be just as bad as the south side of the airport. The Learjet
captain made no mention of trying the other approach.
As the controller vectored the Learjet
back to the final approach course, the touchdown RVR for Runway 1R was
only 600 feet and the rollout RVR was 4,000 feet. The airplane crashed
about three-quarters of a mile from the runway, killing all aboard.
Below Standards
The 27-year-old captain had upgraded from copilot only two months
before the accident
and had flown about 87 hours as PIC in Learjets. His total flying time was
only 1,706 hours, including 1,314 as copilot. His upgrade training had
been performed at FlightSafety International. It included 14 hours of
ground training and 12 hours of simulator time. His instructor had noted a
defective instrument scan and poor use of the flight director. Notes
written on the last day of training stated, "Pilot needs more CRM
[cockpit resource management] training to be competent as PIC. Below
standards for PIC. Additional training offered and declined."
The instructor told investigators that the pilot allowed the airplane
to become airborne on every rejected takeoff on the last day of training
and that his instrument approaches did not meet ATP standards. He said the
pilot was interested in additional training but believed his company
needed him to fly the line. Back home, the pilot was required to fly 10
hours as PIC with an instructor pilot aboard and to take a written test
and a flight check before receiving his Learjet
type rating.
Before sending the pilot for his check ride, TAESA's operations
director requested a confidential evaluation from FlightSafety but
received only a copy of the training record carried back by the pilot. He
again requested a confidential evaluation, including instructor's notes,
but was advised that the notes were only for internal use. He did,
however, receive a letter stating, "During his simulator training, he
demonstrated satisfactory flying skills when flying the aircraft under
normal conditions. He requires emphasis in crew management and decision
making skills during his training to upgrade to captain. [He] needs to
improve his airmanship and command skills, especially when operating under
the stress of abnormal and emergency situations. His most notable strength
is his ability to smoothly fly the aircraft under normal operations. He
displayed excellent qualities when acting in the capacity of first
officer. [He] can be considered for upgrade to pilot-in-command. During
upgrade training, situational awareness under high workload conditions
should be emphasized. He should fly with a strong training captain or
first officer during his upgrade."
Hidden Weaknesses
It's obvious that the training facility thought the pilot would receive
more training from his company before being upgraded to captain -- and he
did. He flew 10 hours with an instructor to demonstrate that he could act
as PIC. But the pilot's weaknesses may not have been apparent if the 10
hours were spent flying in relatively good weather and low-workload
situations. It's doubtful that the instructor would have simulated
emergency situations during revenue flights.
The fact that the captain had so little overall experience should have
caused the training facility and the company to increase their awareness
of his progress. The company's operations director, who twice had
requested complete information on the pilot, may have been satisfied by
the statement that the "pilot can be considered for upgrade to
pilot-in-command.' Had the instructor's notes been furnished, instead of
the letter of evaluation, the company might have been more concerned about
the ability of the pilot to upgrade so quickly to captain. NTSB recognized
that the language the training facility used in its letter was
"permissive in nature" and probably was taken as an approval of
the applicant for upgrade to captain.
Several recent airline accidents have been attributed, in part, to the
pairing of crew members who were relatively inexperienced in the aircraft
they were flying. The copilot of the Learjet
had a total of 852 flying hours, 426 in Learjets. TAESA is sure that the
captain was flying the aircraft due to the weather conditions and the fact
that the copilot was handling the radios.
On the first approach, the aircraft intercepted the localizer about 14
miles from the runway threshold, but the approach was never stabilized.
The airplane wandered back and forth between the limits of the localizer
course. The vertical path was erratic and finally wound up well above the
full flydown limit of the glide slope. The airplane then descended at more
than 2,000 fpm until it was back on the glide slope, but it was also at
the full right limit of the localizer. The aircraft leveled at 600 feet
MSL and maintained that altitude until it was about a mile north of the
departure end of the runway. We can only wonder if the crew intentionally
flew well past the missed approach point while trying to find the airport
visually, despite the poor weather. It was only when the controller asked
if they were going around that the copilot replied in the affirmative.
Below Minimums
On the second approach, the localizer tracking was better, but the
airplane descended at an average rate of 1,300 fpm between 1,300 feet and
about 500 feet MSL. The decision height was 513 feet. NTSB noted that due
to the resolution of the radar data, the aircraft could have descended as
low as 350 feet. It then climbed at 1,300 fpm to 600 feet and, five
seconds later, began a 3,000-fpm descent that lasted until it hit the
ground.
It's obvious that the captain lacked situational awareness on both
approaches. On the first approach, he flew to the right of the runway at
600 feet with no apparent consideration of a missed approach until queried
by the tower. TAESA's operations manual states that a descent to the
runway will not be attempted if the ceiling and visibility are below the
approved minimums. Minimums for a Category 1 ILS are given as 200 feet and
a half mile visibility (RVR 2,400), or RVR 1,800 if centerline and
touchdown lights are in use. The touchdown RVR was 1,000 feet when the
first approach was initiated and 600 when the second was begun.
Why did the captain initiate two approaches when the weather was below
landing minimums? We can only speculate that he felt his alternate,
Baltimore, had similar weather. But there is no record that he checked
Baltimore's weather during the approach sequence. (NTSB did not include
the actual BWI weather in its report, so we don't know if the alternate
was open.
Fatigue may have played a part in this accident.
The captain had been awake for 11.5 hours following a three hour nap he
took in preparation for the flight. But what is more important is that
both pilots flew all night -- a disruption of their normal habits.
Chasing the Needles
Another thing to consider is the conduct of the approaches and how that
relates to the instructor's notes on the captain's performance in the
simulator. Instrument students attempting to perform a precision approach
with an instrument scan that is too slow for what's happening around them
often will "chase the needles," with large control deflections
that result in oscillations to both sides of the horizontal and vertical
centerlines. The student tends to concentrate on the needles instead of
the approach. That means a loss of situational awareness as the pilot
becomes so intent on getting the needles centered that the rest of the
instruments are forgotten.
The training facility instructor's notes show that he was not happy
with the Learjet
pilot's performance during the first simulator session. His instrument
scan was deficient, and he made poor use of the flight director. Although
the pilot did better during the second session, he ultimately was deemed
not up to ATP standards, which are used in assessing a pilot for a type
rating.
A flight director can be a great aid during an instrument approach, but
it is only an aid. The pilot must still scan the rest of his instruments
to be certain that the flight director is providing proper guidance and to
maintain an awareness of where the airplane is in relationship to the
airport and the decision height or minimum descent altitude for the
approach.
The training facility's instructor did not note what the pilot's
problem was with the flight director. With 1,300 hours in the right seat
of the Lear, he should have been thoroughly familiar with its operation,
even if the airplane had only one instrument on the captain's side. But I
have seen some pilots who simply don't understand the flight director and
don't use it. It is apparent from the localizer and glide slope deviations
that the captain was not using the flight director during the first
approach. Unless he was totally "stressed" because of the
weather, the earlier unexpected hold and the long night of flying, use of
the flight director should have kept him more aligned.
It's possible that he did use it on the second approach, because his
horizontal track was more in line with the extended runway centerline. His
vertical tracking, however, was still not up to speed. Perhaps, as he got
closer to the runway, he took his eyes off the instruments in an attempt
to locate the runway -- a job the copilot should have been doing. It's
possible that when the airplane dropped below the glide slope to a
dangerous elevation, the captain pulled the nose up to the command bars of
the flight director, then lost control because he was, once again, looking
for the runway. We can only speculate on what happened in the cockpit in
the moments before the impact because the aircraft was not equipped with a
cockpit voice recorder.
NTSB said that a ground proximity warning system (GPWS) might have
prevented this accident.
A warning would have been issued approximately 64 seconds before impact at
an altitude of 1,200 feet MSL. Although the board recommended that all
jets with six or more passenger seats be required to have GPWS, the FAA
does not agree that the requirement be extended beyond turbojet aircraft
with 10 or more passenger seats.
This Learjet
was fitted with eight passenger seats, but there were 10 passengers
aboard. Six of them were children, all five years of age or older, and it
is likely that they were illegally sharing seats or sitting on the floor.
Self-Evaluation
The sole responsibility for the
safety of flight rests with the pilot-in-command. The captain of the Learjet
knew from his encounter with the training agency's simulator that his
approaches were not as good as they should have been. Although he did fly
with an instructor and passed a check ride for his type rating, there is
no evidence that his performance had improved.
He attempted a second approach
after a sloppy first one. Even if the captain believed that by positioning
himself better he might see the runway environment, a United flight had
declared a missed approach after he did and proceeded to its alternate.
That, and the low RVR readings, should have been a tipoff that he wouldn't
get into Dulles until the weather improved. Perhaps, the pilot was
concerned about his fuel. The report makes no mention of the airplane's
fuel status. But if it was a factor, the pilot should have been keeping
tabs on fuel, time and the weather; if it looked tight, he should have
headed for a suitable alternate with plenty of time to spare.
Flight instructors should take
note of the discrepancy between the training facility instructor's notes
and the letter that was sent to TAESA saying the pilot could be considered
for upgrade. The wording of any verbal or written report is crucial in
similar circumstances. If you are not the person writing the reports on
your students, ask to see them before they are sent. Be certain there is
no room for misinterpretation of the facts by anyone who will review the
report.
Whether a pilot is upgrading from
the right to left seat of a Learjet
or from a Cessna 172 to a Cessna 182RG, there is a standard that must be
met before he or she is signed off. Pilots-in-training and flight
instructors must not compromise safety of flight by flying or allowing
others to fly new aircraft before they are competent. Just because you
feel good in the "new" light single or twin in VFR conditions
doesn't mean you can handle it when the weather is bad or workload is
high.
There are too many things that can happen when you're in the clouds
that will distract you and take your attention from the job at hand:
flying the airplane. The Lear captain may have been suffering from fatigue
and been distracted by the weather. He may have been searching for the
airport instead of flying the airplane. Ultimately, this may have been the
last link in the error chain that caused this crash.
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