ONRecord Question of Command In the absence of SOPs, authority for a land/go-around decision was uncertain. BY MARK LACAGNINA The following information provides an aware- precision markings that were in good condition. ness of problems in the hope that they can be It was equipped with a precision approach path avoided in the future. The information is based indicator [and] a medium-intensity approach on final reports by official investigative authori- lighting system with sequenced flashers.” ties on aircraft accidents and incidents. Weather conditions included surface winds from 270 degrees at 7 kt, scattered clouds at JETS 1,800 ft, broken clouds at 2,500 ft and an over- cast ceiling at 3,800 ft. Reported visibility was 1 Captains Did Not Designate a PIC 1/4 mi (2,000 m) in light rain and mist. How- Israel Aircraft Industries Astra SPX. Substantial damage. One minor injury. ever, the visibility decreased to 1/2 mi (800 m) in heavy rain and fog as the pilots conducted the oth pilots conducting the business flight ILS approach. from Coatesville, Pennsylvania, U.S., to The Astra was descending on the glideslope BAtlanta the evening of Sept. 14, 2007, were when the PM announced that he had the ap- qualified as captains in the Astra. They routinely proach lights in sight. The PF replied that he took turns flying the airplane from the left seat; also had the lights in sight and disengaged the however, they did not formally decide who had autopilot. “The [PF] then attempted to continue authority as pilot-in-command (PIC) for each and land visually, though they were flying in flight, said the report by the U.S. National Trans- moderate to heavy rain,” the report said. portation Safety Board (NTSB). The PF told investigators that he initially The right-seat pilot, the pilot monitoring had “good visual contact” with the approach (PM), was the aviation department’s chief pilot. lights but lost sight of the lights shortly after He held type ratings in several business jets and activating his windshield wiper. The PF said that had 10,800 flight hours, including 2,200 hours he announced this to the PM and considered in the Astra (now called the Gulfstream G100). initiating a missed approach but did not go The left-seat pilot, the pilot flying (PF), also held around because the PM replied that he still had several business jet type ratings and had 16,042 the approach lights in sight. (The Astra has two flight hours, including 1,500 hours in the Astra. windshields, each with its own wiper.) As the airplane neared Atlanta’s DeKalb- Cockpit voice recorder (CVR) data indicated Peachtree Airport, the pilots were cleared to that the PM then began to direct the PF, saying, conduct the instrument landing system (ILS) “Just follow the glideslope … little bit to the approach to Runway 20L, which is 6,001 ft right, little to the right. … There it is. You got (1,829 m) long and 100 ft (30 m) wide. “The it?” The PF replied, “Yep, I got it.” Seconds later, threshold was displaced 1,000 ft [305 m] due to however, the PM again began providing direc- obstructions,” the report said. “The runway had tions, saying “Okay, to the left, left, left, left.” The WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2009 | 57 ONRecord PF asked, “I’m on the runway now, right?” The The CVR then recorded the sounds of the PM replied, “Yeah. … I got it.” lavatory smoke detector and the fire warning The PM took control of the airplane, but bell. The first officer reported the fire to air traffic both pilots realized that there was only about control (ATC) and requested aircraft rescue and 1,000 ft of runway remaining. “We’re not going fire fighting (ARFF) service. Unable to use the to make it,” said the chief pilot, now the PF. The main door or service door because of the proxim- other pilot said, “I don’t know what to do.” ity of the intensifying smoke and flames, the pilots The Astra was substantially damaged when it evacuated through their cockpit window exits. overran the runway, struck the localizer antenna The NTSB report said that ARFF personnel Both pilots realized complex and traveled several hundred feet be- arrived about four minutes after the first offi- fore coming to a stop near the airport fence. The cer reported the fire. They were unable to open that there was only chief pilot sustained minor injuries; the left-seat the airplane’s doors because of fire damage and pilot and the two passengers were not hurt. initially used skin-penetrating nozzles to fight about 1,000 ft of Investigators found that the Astra’s wind- the fire. The fire was contained within about 25 runway remaining. shields had not been maintained in accordance minutes and extinguished about 18 minutes later. with the manufacturer’s recommendations to Examination of the airplane revealed preserve their water-shedding coating. The extensive thermal damage to the cockpit, the report said that this contributed to the left-seat entrance/service compartment and the two pilot’s loss of visual references after activating forward cargo containers in the main deck cargo his windshield wiper. compartment. “[The operator] reported that the The report said that during post-accident substantial damage to the airplane resulted in a interviews, when queried about who was in hull loss,” the report said. command, “the [chief pilot] stated that he was Investigators determined that the fire most confused as to who was the PIC and that he and likely began when a short circuit in adjacent the [left-seat pilot] were ‘co-captains.’ When electrical wiring penetrated the hose for one of asked about standard operating procedures the three supplemental oxygen masks stowed in (SOPs), the [chief pilot] advised that they [i.e., the entrance/service compartment and ignited the aviation department] did not have any. They a metal spring inside the hose. The oxygen and had started out with one pilot and one airplane, the polyvinyl chloride hose material, a plastic and they now had five pilots and two airplanes. that chemically decomposes when exposed to “The [chief pilot] later stated that they prob- heat, fueled the fire. ably should have gone around when the flying NTSB concluded that the probable causes of pilot could not see out the window.” the accident were the design of the supplemental oxygen system hose and “the lack of positive Short Circuit Breaches Oxygen Hose separation between electrical wiring and electri- Boeing 767-200. Substantial damage. No injuries. cally conductive oxygen system components.” he freighter had been loaded, and the pilots The investigation generated several recom- were preparing to start the engines for depar- mendations regarding aging oxygen hoses, the Tture from San Francisco International Airport proximity of oxygen system components to elec- the night of June 28, 2008, when they heard a loud trical wiring, smoke detection systems in cargo pop and hissing sounds. The first officer said, aircraft, and other issues (ASW, 7/09, p. 10). “Hey, there’s something going on in the back.” He opened the cockpit door and saw black smoke Wind Shear Strikes on Short Final and flames near the ceiling of the entrance/service Boeing 747-400. Substantial damage. No injuries. compartment, which is between the cockpit and isual meteorological conditions (VMC) the main deck cargo compartment. He told the prevailed at Manchester (England) Airport captain, “We’ve got a fire … a big fire.” Vthe night of March 1, 2008, but the surface 58 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2009 ONRecord winds were strong and gusty. The flight crew of on the runway. Investigators traced the tire the 747, inbound on a cargo flight from Dubai, failure to a malfunction of an anti-skid control was cleared to conduct the ILS approach to valve that had prevented the wheel brake from Runway 23R. The automatic terminal informa- releasing. tion system reported winds from 280 degrees at “There were no abnormal indications on the 25 kt, gusting to 42 kt, and moderate to severe engine instruments, and after an external check turbulence on approach to Runway 23R. by the airport fire fighting and rescue service, The aircraft did not encounter signifi- the aircraft taxied on to a stand,” the report said. cant turbulence during the approach, but the enhanced ground-proximity warning system Engine Cowling Separates, Strikes Tail (EGPWS) generated a wind shear warning Canadair CRJ200. Substantial damage. No injuries. when the aircraft was 500 ft above ground level hile holding for takeoff from Capital (AGL). The crew conducted a go-around and City Airport in Lansing, Michigan, U.S., requested and received ATC radar vectors for Wthe night of April 7, 2007, the flight another ILS approach. “The second approach crew received indications that the left thrust was described as smoother but still with a reverser was unlocked. “The captain cycled the strong wind from the northwest, resulting in reverser and had decided to return to the gate a crosswind from the right which was close to when the messages cleared,” the NTSB report the operator’s limit for landing this aircraft,” said. “With the issue apparently resolved, he said the report by the U.K. Air Accidents Inves- elected to take off.” tigation Branch (AAIB). The crew felt a slight vibration during The report said that the second approach climb-out and suspected that it was caused by was stable until the commander disengaged the thrust reverser. Later, during cruise flight at the autopilot and autothrottle system at 220 ft 16,000 ft, the crew heard a loud bang, and the AGL.