20091008023229I

Incident · Minor damage

FAA incident report · Cessna 550 · San Diego, CA · October 8, 2009

Date
October 8, 2009 · 05:06 local
Place
San Diego, CA
Airport
North Island Nas /Halsey Field
Phase of flight
Takeoff
Operating rules
General operating rules (Part 91)
Damage
Minor damage
Aircraft
N6776T
Reported as
Cessna 550
People aboard
2
Fatal injuries
0
Other injuries
0
Pilot’s flight hours
5,100 total1,100 in this make and model66 in the last 90 days

From the FAA’s Accident/Incident Data System (AIDS), through its Aviation Safety Information Portal, as reported. The NTSB investigates accidents separately, and its record of an accident is the fuller one. The aircraft is matched to the registry by N-number and event date, checked against the reported make and model; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

What happened

The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.

Pilot was conducting pre-dawn takeoff on rwy 18 at nzy. Weather was VMC. Runway c/l lights were set to low intensity. Ambient light level was low. SIC was focused inside aircraft conducting pre-takeoff checks as pilot taxied onto rwy 18. Pilot taxied aircraft across runway and actually lined aircraft up on western edge of rwy 18 for takeoff. Pilot and SIC realized position error approximately one thousand feet into takeoff roll as jet passed 7000 ft. distance marker and SIC realized the plane was on the edge of the runway. He called for the pilot to correct to the left. The pilot corrected back to the centerline and continued the takeoff. After the takeoff checks were completed, the PIC noticed the starboard anit-collison lights were not operating. Upon inspection of the wing with a flashlight, he noted damage to the leading edge and wingtip of the starboard wing. The pilot decided to immediately return to nas north Island for landing. The pilot landed on runway 29 without further incident. The pilot contacted nasni ATC and requested a check of runway 18 for damage and debris. ATC advised that the 7000 ft. runway remaining sign, and one taxiway light, had been damaged. Subsequent investigation of this incident revealed that PIC salter and SIC bryant had reported for work shortly before 2200 local time on oct. 07. They departed nasni in N6776T at 2300 for a 1.9 hour flir patrol mission and had returned to nasni at aprroximately 0055 on oct. 08. SIC bryant flew left seat while PIC salter conducted a flir search from the right seat during this flight. After this flight, agent salter rested in his cubicle beginning at 0215. Agent salter was awakened by cdo (dispatch) at 0315 for a possible mission flight to the yuma area. The decision was made not to proceed with the mission and agent salter returned to crew rest. The crew was a wakened by cdo again at 0420 and told to launch for the flight to yuma. N6776T taxied from the ramp at O5O3. Agent salter was designated PIC and was in the left seat. Agent bryant was designated SIC, and was in the right seat. A cbp agent/ technician was onboard to operate equipment in the cabin. N6776T was cleared to taxi to runway 18. At the hold short line the PIC and SIC both visually cleared the runway for traffic. The SIC then focused his attention inside the aircraft as the pilot taxied onto, and across the runway. It is this inspector’s opinion that the probable cause of this incident was the pic’s lack of situational awareness resulting from fatigue. Contributung factor’s were the sic’s lack situational awareness resulting from the distraction of completing pre-takeoff checks as the airplane proceeded on to the runway instead of prior to taking the runway. It is this inspector’s opinion that the breakdown in situational awareness and crew resource management was primarily caused by fatigue, and was exacerbated by the crew’s desire to launch as quickly as possible and to accomplish the mission based on investigation of this incident, and tel-cons with privacy data omitted, acting director of safety for cbp, no adverse action (e.g., 44709 or eir) is planned or recommended for the PIC or SIC. Cbp has removed both pilots from flight status during its own internal safety investigation, and pending the conduct of a crewmember evaluation board. Both pilots will probably be returned to flight status following recurrent trainng and testing. Cbp contracts with flight safety international for recurrent training and checking of its pilots. privacy data omitted Was advised that instead of initiating re-examination of (PIC) salter, the FAA requests that cbp advise this office of agent salter’s recurrent traning and checking dates. This will give the FAA the opportunity to observe agent salter’s training and re-checking in the CE-500-550 jet. privacy data omitted Agreed to advise this office when training dates have been scheduled.

As the FAA filed it

PILOT WAS CONDUCTING PRE-DAWN TAKEOFF ON RWY 18 AT NZY. WEATHER WAS VMC. RUNWAY C/L LIGHTS WERE SET TO LOW INTENSITY. AMBIENT LIGHT LEVEL WAS LOW. SIC WAS FOCUSED INSIDE AIRCRAFT CONDUCTING PRE-TAKEOFF CHECKS AS PILOT TAXIED ONTO RWY 18. PILOT TAXIED AIRCRAFT ACROSS RUNWAY AND ACTUALLY LINED AIRCRAFT UP ON WESTERN EDGE OF RWY 18 FOR TAKEOFF. PILOT AND SIC REALIZED POSITION ERROR APPROXIMATELY ONE THOUSAND FEET INTO TAKEOFF ROLL AS JET PASSED 7000 FT. DISTANCE MARKER AND SIC REALIZED THE PLANE WAS ON THE EDGE OF THE RUNWAY. HE CALLED FOR THE PILOT TO CORRECT TO THE LEFT. THE PILOT CORRECTED BACK TO THE CENTERLINE AND CONTINUED THE TAKEOFF. AFTER THE TAKEOFF CHECKS WERE COMPLETED, THE PIC NOTICED THE STARBOARD ANIT-COLLISON LIGHTS WERE NOT OPERATING. UPON INSPECTION OF THE WING WITH A FLASHLIGHT, HE NOTED DAMAGE TO THE LEADING EDGE AND WINGTIP OF THE STARBOARD WING. THE PILOT DECIDED TO IMMEDIATELY RETURN TO NAS NORTH ISLAND FOR LANDING. THE PILOT LANDED ON RUNWAY 29 WITHOUT FURTHER INCIDENT. THE PILOT CONTACTED NASNI ATC AND REQUESTED A CHECK OF RUNWAY 18 FOR DAMAGE AND DEBRIS. ATC ADVISED THAT THE 7000 FT. RUNWAY REMAINING SIGN, AND ONE TAXIWAY LIGHT, HAD BEEN DAMAGED. SUBSEQUENT INVESTIGATION OF THIS INCIDENT REVEALED THAT PIC SALTER AND SIC BRYANT HAD REPORTED FOR WORK SHORTLY BEFORE 2200 LOCAL TIME ON OCT. 07. THEY DEPARTED NASNI IN N6776T AT 2300 FOR A 1.9 HOUR FLIR PATROL MISSION AND HAD RETURNED TO NASNI AT APRROXIMATELY 0055 ON OCT. 08. SIC BRYANT FLEW LEFT SEAT WHILE PIC SALTER CONDUCTED A FLIR SEARCH FROM THE RIGHT SEAT DURING THIS FLIGHT. AFTER THIS FLIGHT, AGENT SALTER RESTED IN HIS CUBICLE BEGINNING AT 0215. AGENT SALTER WAS AWAKENED BY CDO (DISPATCH) AT 0315 FOR A POSSIBLE MISSION FLIGHT TO THE YUMA AREA. THE DECISION WAS MADE NOT TO PROCEED WITH THE MISSION AND AGENT SALTER RETURNED TO CREW REST. THE CREW WAS A WAKENED BY CDO AGAIN AT 0420 AND TOLD TO LAUNCH FOR THE FLIGHT TO YUMA. N6776T TAXIED FROM THE RAMP AT O5O3. AGENT SALTER WAS DESIGNATED PIC AND WAS IN THE LEFT SEAT. AGENT BRYANT WAS DESIGNATED SIC, AND WAS IN THE RIGHT SEAT. A CBP AGENT/ TECHNICIAN WAS ONBOARD TO OPERATE EQUIPMENT IN THE CABIN. N6776T WAS CLEARED TO TAXI TO RUNWAY 18. AT THE HOLD SHORT LINE THE PIC AND SIC BOTH VISUALLY CLEARED THE RUNWAY FOR TRAFFIC. THE SIC THEN FOCUSED HIS ATTENTION INSIDE THE AIRCRAFT AS THE PILOT TAXIED ONTO, AND ACROSS THE RUNWAY. IT IS THIS INSPECTOR’S OPINION THAT THE PROBABLE CAUSE OF THIS INCIDENT WAS THE PIC’S LACK OF SITUATIONAL AWARENESS RESULTING FROM FATIGUE. CONTRIBUTUNG FACTOR’S WERE THE SIC’S LACK SITUATIONAL AWARENESS RESULTING FROM THE DISTRACTION OF COMPLETING PRE-TAKEOFF CHECKS AS THE AIRPLANE PROCEEDED ON TO THE RUNWAY INSTEAD OF PRIOR TO TAKING THE RUNWAY. IT IS THIS INSPECTOR’S OPINION THAT THE BREAKDOWN IN SITUATIONAL AWARENESS AND CREW RESOURCE MANAGEMENT WAS PRIMARILY CAUSED BY FATIGUE, AND WAS EXACERBATED BY THE CREW’S DESIRE TO LAUNCH AS QUICKLY AS POSSIBLE AND TO ACCOMPLISH THE MISSION BASED ON INVESTIGATION OF THIS INCIDENT, AND TEL-CONS WITH ^PRIVACY DATA OMITTED^, ACTING DIRECTOR OF SAFETY FOR CBP, NO ADVERSE ACTION (E.G., 44709 OR EIR) IS PLANNED OR RECOMMENDED FOR THE PIC OR SIC. CBP HAS REMOVED BOTH PILOTS FROM FLIGHT STATUS DURING ITS OWN INTERNAL SAFETY INVESTIGATION, AND PENDING THE CONDUCT OF A CREWMEMBER EVALUATION BOARD. BOTH PILOTS WILL PROBABLY BE RETURNED TO FLIGHT STATUS FOLLOWING RECURRENT TRAINNG AND TESTING. CBP CONTRACTS WITH FLIGHT SAFETY INTERNATIONAL FOR RECURRENT TRAINING AND CHECKING OF ITS PILOTS. ^PRIVACY DATA OMITTED^ WAS ADVISED THAT INSTEAD OF INITIATING RE-EXAMINATION OF (PIC) SALTER, THE FAA REQUESTS THAT CBP ADVISE THIS OFFICE OF AGENT SALTER’S RECURRENT TRANING AND CHECKING DATES. THIS WILL GIVE THE FAA THE OPPORTUNITY TO OBSERVE AGENT SALTER’S TRAINING AND RE-CHECKING IN THE CE-500-550 JET. ^PRIVACY DATA OMITTED^ AGREED TO ADVISE THIS OFFICE WHEN TRAINING DATES HAVE BEEN SCHEDULED.