Lear down TEB

[Ted]

Ok people, put yourself in the captain's seat, what's done is done, you are there, so answers like "I would never get myself in this situation" won't fly. Let's say from 1 minute up to 5 minutes before the stall, what would you do differently?

Without rereading the CVR, the following come to mind:

- Say we need to go to sterile cockpit as it's a busy airspace.
- Take over pilot flying roles given how much the SIC was screwing up with, well, everything. Put the SIC back to pilot monitoring.
- When that close in to the airport and not lined up with the runway, execute a missed/go-around and try again.

The lack of the sterile cockpit is a significant issue that was causing distractions. Neither the PIC nor the SIC was paying full attention to what was going on.

The SIC clearly wasn't able to operate the plane, and being that close in the PIC should've realized it and asserted captain's authority.

Rather than trying to salvage the circle, he should've just accepted the problem and gone missed.

 

[denverpilot]

Ok people, put yourself in the captain's seat, what's done is done, you are there, so answers like "I would never get myself in this situation" won't fly. Let's say from 1 minute up to 5 minutes before the stall, what would you do differently?

Less reacting, more planning. Nobody seems to have a picture of where they want this airplane to be in the next minute, or the minute after that...

They both got pretty fixated on the crossing altitude for the fix and weren’t thinking about what was beyond that point in terms of aircraft performance and what needed to happen to circle to land.

They let complacency get them low and slow in a Lear with no plan, and that’s been known for a long time to be something that the airplane will make you pay for dearly.

It did.

It’s the old, “Where will this airplane be in five minutes” constant mental question that has to be asked.

 

[Getonit]

Yeah, I could see them filing for 15k maybe. In a Lear 35, that wouldn't take long to get up to and get back down from. But FL270?

Regardless, 4k is what you're gonna get on that route. Just the way it is. Anyone who's flown there knows that.

And if going into TEB from the south you are at 8,000 100 miles out.....just the way it is.

 

[Let'sgoflying!]

I feel like instead of looking at the runway (as I suspect he was) thinking "I can make this happen" - he might have done better to be looking at the bank angle on the eadi and saying "I will not exceed 30° degrees" and the asi; "I will not let it degrade below vref+10"....with glances at his aoa and at the outside environment.
And, he should be comfortable with, and thinking about executing his backup plan at any moment "this is not working out - and I am ok with it! I am going to level the wings, power up, have sic announce to twr."

 

[PaulS]

I think it's important to remember we know the outcome when we read these transcripts, these guys didn't when they were living it. They absolutely didn't expect what ended up happening. That's the insidious part of these events, it seems what works ok many times before, finally doesn't work. I suspect that these guys knew each other pretty well and they both knew the co-pilot's limitations. I think the banter had worked well for them in previous flights and the Captain was probably used to those types of interactions, although probably not with all pilots with which he flew. In reading the transcript my impression is that when you start falling behind the airplane it should be a time to knock any BS off and get yourself back ahead of the AC. What stood out to me early on were the large thrust variations and speed variations where to me things should have been under close control. That probably should have caused big warning bells to go off in these guy's heads, but it didn't. My experience level is pretty low with no experience in an aircraft like a Lear jet. But I'm hoping, were it me, that as things kept being unstable, like chasing airspeeds and uncertainties about altitude and other situational things that I would have bailed the approach, let ATC know I needed a place to go and regroup.

 

[mscard88]

Well, I've done my time as a Capt and this episode was a cluster, almost from the beginning. I may have missed it but never heard any checklists being called for, or very few maybe, Capt appeared to be in a hurry to get there which is fine but not with a SIC who is basically new to the jet and the procedures. Numerous commands to fly to faster to the SIC, even cheating with the +- 10 knots on airspeed. I flew 135 back in the late 70s-early 80s and it was loose then, no one even had CRM or heard of it then either. Yes sterile cockpit is a biggie, at least in the 121 world especially with voice recorders. I don't think they're required under 135, maybe a jet under 135 I don't know. SIC tried to give the jet back to the PIC like 2-3 times and the Capt should have taken the controls. Basically the Capt should have taken control of not just of the jet, but recognize the situation was headed for the shetter and bail out of it.

 

[Kritchlow]

Well, I've done my time as a Capt and this episode was a cluster, almost from the beginning. I may have missed it but never heard any checklists being called for, or very few maybe, Capt appeared to be in a hurry to get there which is fine but not with a SIC who is basically new to the jet and the procedures. Numerous commands to fly to faster to the SIC, even cheating with the +- 10 knots on airspeed. I flew 135 back in the late 70s-early 80s and it was loose then, no one even had CRM or heard of it then either. Yes sterile cockpit is a biggie, at least in the 121 world especially with voice recorders. I don't think they're required under 135, maybe a jet under 135 I don't know. SIC tried to give the jet back to the PIC like 2-3 times and the Capt should have taken the controls. Basically the Capt should have taken control of not just of the jet, but recognize the situation was headed for the shetter and bail out of it.

I agree with everything you say, and that certainly set up the whole mess, but...

Am I wrong that the captain had the controls long enough before the stall to avoid it?
I mean, yes I totally agree with th sh.. sh.. prior, but in a way that was only a symptom of the accident (showing lack of quality), not the cause. What happened 10 minutes prior, or even 3 minutes prior really had no bearing on the stall. But the whole mess IS a symptom of WHY it happened. Poor traning, poor procedures, poor SOP’s.

 

[mscard88]

I agree with everything you say, and that certainly set up the whole mess, but...

Am I wrong that the captain had the controls long enough before the stall to avoid it?
I mean, yes I totally agree with th sh.. sh.. prior, but in a way that was only a symptom of the accident (showing lack of quality), not the cause. What happened 10 minutes prior, or even 3 minutes prior really had no bearing on the stall. But the whole mess IS a symptom of WHY it happened. Poor traning, poor procedures, poor SOP’s.

I didn't think the Capt took the controls, but he may have. I missed it if he did.

 

[Kritchlow]

I didn't think the Capt took the controls, but he may have. I missed it if he did.

I may be wrong on that. I thought he did at the end... third request from FO.

 

[mscard88]

I may be wrong on that. I thought he did at the end... third request from FO.

Yeah I heard the SIC trying to relinquish the controls like you said, 2-3 times, just not sure the Capt took the controls. I could have easily missed it though.

 

[denverpilot]

Poor traning, poor procedures, poor SOP’s.

The “poor training” part is a hard one. They seem to do like a lot of smaller operators do, and send folks to known sim companies. Those places aren’t awful.

The sim company employees seem to have communicated back to the employer that neither was going to pass rides and requested more time with them, which was approved (and in that world that means more $$$, many operators won’t pay it, they’ll just wash out and the company hires someone else) which indicates at least a better willingness to invest in their pilots than a great many operators.

You can train someone all week in a sim to do it a certain way and then they go do it differently in the airplane when they leave. The real ugliness seems to be in the monitoring of performance later on in these places. No way to tell if standards were taught and then just ignored.

The SOPs in that second document are weak for circle to land, but definitely were published for other types of approaches, as well as call and response checklists and mandatory phraseology. They have them. They just had no idea if anyone was actually doing them.

It’s the old engineering problem. You can build something to spec but if you never measure the performance after it’s built...

 

[Fearless Tower]

Am I wrong that the captain had the controls long enough before the stall to avoid it?

The impression I got was that when the captain did finally take the aircraft, the aircraft might not have been stalled yet, but the loss of control was imminent.

Very much like the Execujet Akron crash, a weak captain let the sic get in way too deep until it was too late to recover.

Frank Borman once said “a superior pilot uses his superior judgment to avoid situations which require the use of his superior skill.”

Problem is this PIC has neither superior judgement nor skill.

 

[Fearless Tower]

The “poor training” part is a hard one. They seem to do like a lot of smaller operators do, and send folks to known sim companies. Those places aren’t awful.

There is a lot of discussion about this general issue on the professional boards. Unfortunately, it isn’t positive.

The issue/chief complaint is that while the the sim schools try to provide good training, in the end, their goal is to qualify the student. That is what the 135 company is paying them for. So whereas with standard pilot certificate check rides, if you don’t meet the PTS, you get a notice of failure, with the sim schools, for the most part, they just give you extra training/sessions until you pass.

 

[Ted]

It’s hard to correlate how bad things were when the pilot took the controls, but I’m thinkig he attempted to do the circle too close in and then knife edged it. In 2004 basically the same thing happened at a 135 one of my friends used to work at. Also a Lear 35.

 

[Radar Contact]

I think the biggest take away for us here is not that they were behind the plane (which they were) or that they didn't have a sterile cockpit (obvious from the transcribed CVR) but is the accelerated stall risk. If you are using a Vref speed similar to 1.3 Vso and you decide to do an almost 2g turn, you will get into an accelerated stall. Never put yourself in a position maneuvering to land that will exceed an appropriate bank angle. If you find yourself starting to think you need to exceed it, start rolling out, fly the plane and when you get a chance, let ATC know.

 

[Bill Watson]

Question; were they intending to fly a a full 360deg circling approach to 1 or was it a sidestep?


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[Bill]

I’ll never be a captain, and unless I hit the lotto, I’m likely to never be more than a Mooney driver, but IMHO the mistake was made before takeoff. Short low flight in congested airspace in IMC? The captain should have been the pilot flying.

 

[Radar Contact]

Question; were they intending to fly a a full 360deg circling approach to 1 or was it a sidestep?


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Semantics aside (side-step vs circle), in this case it's the ILS to 6 and about 4 miles out you turn right and "circle" south of the field for a couple Mississippi's and turn final to runway 01.

 

[Fearless Tower]

Question; were they intending to fly a a full 360deg circling approach to 1 or was it a sidestep?


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What SHOULD have happened is that at TORBY, they would have turned right and made a base leg to 1. That is what everyone else does.

Who in the heck knows what they intended. I have a funny feeling they didn’t really have a plan.

One (of the many) things that bothers me is even at the end, I’m not sure they really realized what the winds were. They never listened to that part of the ATIS. Never commented on the winds aside from it being bumpy. And yet all the info was there if they just paid attention.

 

[denverpilot]

There is a lot of discussion about this general issue on the professional boards. Unfortunately, it isn’t positive.

The issue/chief complaint is that while the the sim schools try to provide good training, in the end, their goal is to qualify the student. That is what the 135 company is paying them for. So whereas with standard pilot certificate check rides, if you don’t meet the PTS, you get a notice of failure, with the sim schools, for the most part, they just give you extra training/sessions until you pass.

Understand. Just not sure how you stop that. It’s not the military and folks get to try again.

In an environment where lower end companies are having a hard time hiring, they’re left with the choice of letting someone keep training until they barely make minimum standard, or starting over on someone new.

I don’t see this getting better in the current hiring climate. But I’m always looking at ideas on how to make sure the attitudes seen in the transcript don’t start at the initial training level, long before they’re in the sim for a jet.

 

[Tarheelpilot]

There is a lot of discussion about this general issue on the professional boards. Unfortunately, it isn’t positive.

The issue/chief complaint is that while the the sim schools try to provide good training, in the end, their goal is to qualify the student. That is what the 135 company is paying them for. So whereas with standard pilot certificate check rides, if you don’t meet the PTS, you get a notice of failure, with the sim schools, for the most part, they just give you extra training/sessions until you pass.

Airlines are the same. That’s not a 135/91 thing

 

[Fearless Tower]

Airlines are the same. That’s not a 135/91 thing

I believe you, but there is a growing concern that it is going to get worse in the 135 world as more and more pilots go 121.

 

[weilke]

The pilot shortage must be real.

 

[Tarheelpilot]

I believe you, but there is a growing concern that it is going to get worse in the 135 world as more and more pilots go 121.

Used to be the airlines had no problem washing a guy out. Its all driven by market forces. The majors can still be selective. Everyone else down stream are struggling to crew airplanes. I have a friend that is in the process of the rotor to wings transition at a regional airline. He needed a few extra sims. Last I talked to him he had received over 60 hours of IOE and had been sent back to the sim for some practice and was back on the line getting more IOE. He seemed to think that as long as he was willing to keep working at getting qualified on the line he would have a job. I'm telling you the two airlines I worked for would never have allowed that much training and frankly just a few years ago the one he works for would not have either.

Edit:

My point is this is a problem at more than just 135/91 companies.

 

[GRG55]

I may be wrong on that. I thought he did at the end... third request from FO.

Thats the way I read it too.
The captain confirmed he would accept control at 15:29:28.5
15:29:43.9 was the last transmission from the plane. Barely 15 seconds.

This just feels so much like the fatal Cirrus accident at Hobby in June 2016. Busy airspace, lose situational awareness, get behind the plane, let the airspeed bleed off, stall it in a bank.

 

[Ted]

I think the biggest take away for us here is not that they were behind the plane (which they were) or that they didn't have a sterile cockpit (obvious from the transcribed CVR) but is the accelerated stall risk. If you are using a Vref speed similar to 1.3 Vso and you decide to do an almost 2g turn, you will get into an accelerated stall. Never put yourself in a position maneuvering to land that will exceed an appropriate bank angle. If you find yourself starting to think you need to exceed it, start rolling out, fly the plane and when you get a chance, let ATC know.

Another thing to keep in mind is wing loading. Push the nose down and unload the wing and you won’t get into an accelerated stall.

 

[Matthew]

Another thing to keep in mind is wing loading. Push the nose down and unload the wing and you won’t get into an accelerated stall.

It's the simple things, things we learn in PP training, that seem to get either forgotten, overlooked, or for whatever reason just don't get applied. Sometimes you just have to say, "Something ain't right, so I'm going to fly the plane until I figure it out."

 

[kyleb]

Another thing to keep in mind is wing loading. Push the nose down and unload the wing and you won’t get into an accelerated stall.

You're low and slow and you just have to make the landing. So you just crank in a little more bank and then you're looking at the ground through the top of the cockpit widows... Seriously, I think they had target fixation.

 

[Ted]

You're low and slow and you just have to make the landing. So you just crank in a little more bank and then you're looking at the ground through the top of the cockpit widows... Seriously, I think they had target fixation.

I’d agree. My point was more as an educational reminder to those reading.

 

[Paulie]

The thing that bugs me is that those guys didn't take their job seriously. Someone is paying you do to a job, do it correctly. Unfortunately I've seen airline mechanics spend more effort not working than doing the job right would have taken. Aviation is a serious business, act a fool and you can end up dead or make someone else dead.
There were guys I flat out refused to work with, I imagine pilots have had similar encounters.

 

[DMBand]

This was from May of last year, why post it like it’s current? Am I missing something?

 

[SixPapaCharlie]

This was from May of last year, why post it like it’s current? Am I missing something?

The crash was last year but the CVR and data is more recent.

We on POA are great at noting crashes and Monday morning quarterbacking them
But it can take a year or more for the NTSB data to come out.

Probably a good idea to follow up on crash announcements with the NTSB findings when they come out.

I don't think anything was posted like it is current.
The original thread was started in May 2017. The NTSB findings are more recent.

 

[DMBand]

The crash was last year but the CVR and data is more recent.

We on POA are great at noting crashes and Monday morning quarterbacking them
But it can take a year or more for the NTSB data to come out.

Probably a good idea to follow up on crash announcements with the NTSB findings when they come out.

I don't think anything was posted like it is current.
The original thread was started in May 2017. The NTSB findings are more recent.

The crash was last year but the CVR and data is more recent.

We on POA are great at noting crashes and Monday morning quarterbacking them
But it can take a year or more for the NTSB data to come out.

Probably a good idea to follow up on crash announcements with the NTSB findings when they come out.

I don't think anything was posted like it is current.
The original thread was started in May 2017. The NTSB findings are more recent.

ohhhhhhhhh ok. I was thinking am I missing something??? And I was.

 

[denverpilot]

Another thing to keep in mind is wing loading. Push the nose down and unload the wing and you won’t get into an accelerated stall.

It was interesting to read the warning in the report from the Lear operations data that said if you deep stall it, you may not have enough elevator authority to recover without retracting the flaps... that’s a no win situation down low.

This was from May of last year, why post it like it’s current? Am I missing something?

NTSB report came out along with the pilot’s training report and other factual data. Linked above.

 

[Sluggo63]

The “poor training” part is a hard one. They seem to do like a lot of smaller operators do, and send folks to known sim companies. Those places aren’t awful.

The issue/chief complaint is that while the the sim schools try to provide good training, in the end, their goal is to qualify the student.

I disagree. In this case, as with a lot of times, these CAE instructors didn't know what they were teaching.

According to one CAE Lear 35A instructor, when asked if the AOA indicator was a useful tool, said he never used it and did not want to rely entirely on the AOA. He did not know the threshold for stick shaker or pusher activation, and assumed a stick nudger and pusher were the same things. Another CAE Lear 35A instructor said the stick pusher would lower the nose at the red/yellow AOA indicator, which was 1 knot above the stall. He also said CAE did not train for accelerated stalls. Another CAE Lear 35A instructor stated that the AOA indicator was actually a stall margin indicator, not an AOA indicator similar to what a fighter pilot would use to fly an airplane, and the “threshold of stick activation for the shaker was 7 percent above stall, and the pusher was 1 knot above stall.” Another CAE Lear 35A instructor said the AOA indicator green to yellow indication was about 7% above the stall, and the yellow to red was about 1% above the stall. The speed the indicator went through the color bands, which may change based on loads on the airplane, but it was still measuring the margin and not AOA

What kind of instructors are these? CAE did not train for accelerated stalls?

According to interviews, one CAE Simuflite Lear 35A instructor, when asked if there were any wind additives on the approach in the Lear 35A, said they would fly VREF plus the steady state wind plus ½ the gust factor. Another CAE Simuflite Lear 35A instructor, when asked the same question, said he would add 5 knots “or so” to the approach speed if it was windy, but there was no specific amount of additive for winds on the Lear 35A.

These guys didn't even know what the wind additive for the airplane they were teaching in was! The actual answer for the Lear (according to the NTSB report) is: increase Vref by 1/2 the gust factor.

Less reacting, more planning. Nobody seems to have a picture of where they want this airplane to be in the next minute, or the minute after that...

This exactly. I don't know what this crew talked about in the FBO before they stepped to the jet, but it obviously wasn't about the flight. This was a 90 mile journey in high-density airspace. This should have all been talked about at the FBOs weather computer station. What approach to expect, how it's going to look. What to expect...

At work we have a trip that goes from Birmingham to Manchester (UK). It's an 18 minute, 65 mile leg. It is by far the busiest segment I've flown. There is a lot to get done in those 18 minutes. But, we mitigate that by briefing the whole thing on the ground at 0 knots and 1 G. We talk about the departure, the routing, the expected arrival, and approach that we'll probably get. We brief gotcha's that we may run into. I also fly it slower than flight planned. Flying at 290 kts vs the 335 that it's planned at isn't really going to make a difference for the freight, but those couple of extra minutes buy us some time to make sure we're all squared away and ready for the arrival and approach. Just like @denverpilot said, these guys were poorly prepared for the leg that they were about to fly. They had no clue as to what they were going to be doing five minutes from now and the Captain just let things happen instead of being "in command."

 

[mryan75]

I'm a freaking instrument student with 200 hours, and had I been number two in this cockpit I would have been telling the captain to stop yapping and focus on what we're doing, not the other way around. Jeez.

 

[mryan75]

Here's something just thought of: the 1,500-hour rule is supposed to save lives. How many lives do you think it's going to wind up costing? More than it saves?

 

[MauleSkinner]

There is a lot of discussion about this general issue on the professional boards. Unfortunately, it isn’t positive.

The issue/chief complaint is that while the the sim schools try to provide good training, in the end, their goal is to qualify the student. That is what the 135 company is paying them for. So whereas with standard pilot certificate check rides, if you don’t meet the PTS, you get a notice of failure, with the sim schools, for the most part, they just give you extra training/sessions until you pass.

Except that the 135 operator has to approve the extra expenditure in sim time, so basically they're telling the sim school "we want you to qualify this pilot, almost (but not quite) regardless of how long it takes.

 

[Ted]

Regarding the sim trainers, I’ve been generally unimpressed with the knowledge of the instructors and frequently the material. With that said, I think most pilots benefit from the training even if imperfect. But I’ve avoided going to the sim for the 414 after my initial where the instructor had never so much sat in a Twin Cessna, barely any twin time, and I was making corrections in the material.

Still benefit for many pilots though.

Regarding approving extra sim training or second chances, I can’t agree with a one time fail you’re fired policy. Everyone has a bad day and sometimes sim slots will be all over the map time wise leaving your sleep completely screwed up. One of the best pilots I know failed his initial checkride for that reason. He got a second chance and the pilots said “What the **** happened the first time? You’re as good as any line pilot we have.”

But when you look at these two with a chronic history of failures, that indicates a bigger problem than a bad day that should be addressed.

 

[weilke]

But when you look at these two with a chronic history of failures, that indicates a bigger problem than a bad day that should be addressed.

Reminds me of the Wellstone crash. Weak captain paired with green SIC and the plane has to fly itself.