AINsight: Do I Need To Go Around?

 - July 31, 2020, 12:57 PM

Last week, the NTSB released information on the August 2019 crash of a Cessna Citation Latitude at the Elizabethton Municipal Airport in Tennessee. Highlighted in the docket is a detailed account of a highly unstable approach that led to a botched landing and runway excursion.

The aircraft, owned by retired race car driver Dale Earnhardt Jr, was destroyed by a post-crash fire. Earnhardt, his wife, and daughter escaped the wreckage with only minor injuries, while the two pilots were uninjured.

Weather at the time of the accident was nearly perfect with visual meteorological conditions (VMC) and calm winds. Recordings from the aircraft data acquisition unit and cockpit voice recorder paint a picture of a flight that was anything but perfect. During this flight, several mismanaged threats and errors and poor crew resource management resulted in a serious crash.

In this case, a quick 20-minute flight in daytime VMC conditions did have a few underlying, perhaps unrecognized threats, such as high terrain near the airport, a relatively short runway, and operations at an uncontrolled airport. These threats, however, are not insurmountable and can be easily mitigated and managed by a professional crew flying a highly capable business jet.

As highlighted in the released documents, many of these threats resulted in errors. Likewise, there were distinct opportunities to “reset” and either discontinue the approach or go around, rather than continue making additional “unforced” errors.

Early, during the initial phase of the visual approach to Runway 24, while descending towards a ridgeline, there was an opportunity to discontinue the approach when the terrain awareness system (TAWS) excessive closure rate caution and warning alerts (“terrain, terrain” followed by “whoop, whoop, pull up”) sounded. At this point, the aircraft had descended to within 710 feet of the terrain. The crew continued.

Throughout the remainder of the approach, the TAWS system would sound four additional alerts. The next at approximately 1,400 feet agl and 201 kias when the excessive descent rate alert (“sink rate”) would sound as the rate of descent reached -2,440 fpm. This alert was followed by three rate of terrain closure alerts (“caution terrain,” “caution terrain,” followed by “whoop, whoop, pull up”) all below 1,000 feet agl; the maximum rate of descent during this period was -1,700 fpm. Following each TAWS alert, the crew elected to continue the approach.

One of the last opportunities to go around occurred late in the approach. At approximately 500 feet above the runway, as full flaps (35 degrees) were selected (at 174 kias) the first officer (pilot monitoring) said, “And I don’t need to tell ya, we’re really fast.” The captain (pilot flying) replied, “I’m at idle,” followed three seconds later by, “Do I need to go around?” The first officer responded, “No.”

The computed approach speed (Vref) for this landing was 108 knots; the crew stated that the target speed for the approach would be 112 kias. Following the above exchange between the crew, the flying pilot—at Vref+66 knots—then extended the speed brakes for an additional five seconds to further slow the aircraft. He was committed to land. The aircraft crossed the runway threshold at 127 kias (Vref+19); the thrust levers were at idle for nearly two minutes before touchdown.    

The aircraft touched down initially at 126 kias (Vref+18) at 1.4 vertical g; the aircraft would then “bounce” three more times each with a higher recorded vertical g (1.6, 1.7, and 3.2. During the final bounce, the aircraft would reach a height of 24 feet and the airspeed decreased from 119 to 91 kias. The aircraft, eight seconds after the last touchdown, departed the end of the runway.

Observations from Textron Aviation in its Engineering Review pointed out that “airspeed management was a significant issue during the approach.” The report added, “The need for speed reduction was evidently apparent to the crew throughout the descent, as seen by the partial extension of the speed brakes and the extension of landing gear and flaps immediately after each of their limit speeds was reached.”

Textron further cited distractions based on terrain and navigation as a contributing factor. The crew of the accident flight planned and flew a visual approach to Elizabethton’s Runway 24; there are no IFR approaches available to this runway. Terrain avoidance and navigation might have been easier had the crew elected to fly the RNAV GPS approach to Runway 6; this would add both lateral and vertical guidance to the runway, while providing terrain clearance. 

Lastly, from the CVR transcript there were no standard approach callouts from the first officer (PM). Industry best practices recommend, at a minimum, a callout at both 1,000 and 500 feet above the airport elevation. These callouts provide an awareness and crosscheck of proper altitude, airspeed, and configuration to meet stabilized approach criteria (another best practice).

Active callouts—where the PM calls out “stable” or “unstable” at these altitudes—also reinforce “no fault go-around” policies that promote discontinuing an unstable approach without retribution. Likewise, an operator must also provide guidance to pilots to respond immediately to TAWS alerts—any alert below 1,000 feet agl should warrant a go around.  

Pilot, safety expert, consultant, and aviation journalist - Kipp Lau writes about flight safety and airmanship for AIN. He can be reached at stuart.lau3@gmail.com.