Torqued: Montrose report provides more questions than answers
Many of you may remember that there was an accident involving a Challenger 600 in Montrose, Colo., in November 2004. (See story on page 95.) According
to the NTSB final report, this was an on-demand Part 135 charter flight that started in Los Angeles and was heading to Indiana with a stop in Montrose. The flight from the Los Angeles area to Montrose was uneventful, and the crew landed in winter conditions with snow on the ground and snow showers throughout the area.
The aircraft was parked on the ramp for about 45 minutes while wet snow fell, with temperatures just below freezing. Employees of the FBO indicated that they observed snow on the upper wing surfaces of the aircraft while it was parked on the ramp. They did not see either the captain or the first officer perform a tactile inspection of the wing surfaces. Statements from the surviving passengers supported these observations. The aircraft was not de-iced before takeoff.
Moments after liftoff the aircraft rolled abruptly from side to side and crashed. There were six occupants on board. The captain, the flight attendant and one passenger were killed, and the first officer and two passengers were seriously injured. The aircraft was destroyed.
This aircraft was equipped with a cockpit voice recorder that contained information on the takeoff and on about 16 minutes that the aircraft was parked on the ramp. The Challenger was not equipped with a flight data recorder nor was it required to be.
The FAA requires under FAR 135.227 that a pre-takeoff contamination check must be completed within five minutes of takeoff when conditions are such that contamination might reasonably be expected to adhere to the airplane. Neither the captain nor the first officer had any winter weather flying experience.
Moreover, their pre-takeoff discussions demonstrated their failure to recognize multiple winter weather performance planning considerations, as well as several crew resource management deficiencies. These were not low-time or inexperienced crewmembers. The captain had more than 10,000 hours, with a considerable amount of time in type. The first officer also had considerable flying experience but not a lot in type.
We should all be aware of the added burdens that ground operations in the winter and the extra vigilance we must exercise to ensure a safe operation. This is nothing new to any pilot who operates an aircraft into an airport that experiences snow or ice during the winter months. However, the NTSB discussed at length the experience of this flight crew and the fact that, according to their logs, they did not have any experience operating in these conditions.
Based on the cockpit voice recorder, the NTSB believes that the crew did not comply with the requirement to perform a pre-takeoff contamination check.
The cockpit voice recorder also revealed that the crew did not make use of the aircraft performance data for a contaminated runway takeoff. I am told that these contaminated runway performance charts would have shown that there was insufficient runway length for takeoff.
The NTSB listed the pilots as the probable cause of the accident. However, the Board chose to leave buried in the report a number of other issues worthy of discussion and actions to correct. I waited for a discussion on several other issues, but it never materialized. For example, what factors could have influenced the crew’s decision not to de-ice the aircraft? This was a professional flight crew with considerable flying experience and they had been in contact with dispatch, yet there was no discussion about the role of dispatch in this event. Were any concerns about the cost of de-icing communicated to the flight crew?
Another question that is causing much concern throughout our industry centers around the practices used in the charter business. The methods used by firms that broker aircraft into charter companies so they can deliver on their commitments to fly are all done without the knowledge or consent of the person chartering the aircraft. In fact, the person who chartered this flight used a company that agreed to operate using the highest standards for both their flight crews and their aircraft.
However, when it looked for another company to fly a trip that it was unable
to handle itself, it did not apply the same standards to the company actually providing the service.
It is unfortunate that the NTSB chose not to explore these and other issues stemming from this accident, but that has been the way it has operated for the last couple of years. It seems that more was missed than acted upon.
But that may be changing as there is a new chairman designee, and there are indications that things will change. I believe that will be welcomed by all, especially
in the general aviation community, which has felt that its issues have been swept aside for the past few years. This is a work in progress, and we will be watching.