CHI01MA006

NTSB accident investigation · Canadair CL600-2B16 · Wichita, KS · October 10, 2000

Accident · FatalClass 1 · MajorFinal report
Date
October 10, 2000, 14:52 local (19:52 UTC)
Place
Wichita, KS
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
CFTBZCanadair CL600-2B16
Weather
Visual (VMC) · Not reported
Status
Completed · report April 13, 2004
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Parties
GE Aircraft Engines, Transport Canada, Bombardier Aerospace, Federal Aviation Administration
Case key
50426

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the pilot’s excessive takeoff rotation, during an aft center of gravity (c.g.) takeoff, a rearward migration of fuel during acceleration and takeoff and consequent shift in the airplane’s aft c.g. to aft of the aft c.g. limit, which caused the airplane to stall at an altitude too low for recovery. Contributing to the accident were Bombardier’s inadequate flight planning procedures for the Challenger flight test program and the lack of direct, on-site operational oversight by Transport Canada and the Federal Aviation Administration.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightTakeoff - initial climb
Inadequate surveillance,insufficient staffFaa(organization)Factor
Rotation - excessivePilot in commandCause
Fuel system - otherCause
Procedure inadequateCompany/operator managementFactor
Inadequate surveillance,insufficient staffOther govt organizationFactor
Stall - inadvertentPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground
Altitude - lowCause

Analysis

The Board's full report is available at http://www.ntsb.gov/publictn/2004/AAB0401.pdf

On October 10, 2000, at 1452 central daylight time, a Canadair Challenger CL-600-2B16 (CL-604) (Canadian registration C-FTBZ and operated by Bombardier Incorporated) was destroyed on impact with terrain and postimpact fire during initial climb from runway 19R at Wichita Mid-Continent Airport (ICT), Wichita, Kansas. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as an experimental test flight. The pilot and flight test engineer were killed. The copilot was seriously injured and died 36 days later.

Factual narrative

The Board's full report is available at http://www.ntsb.gov/publictn/2004/AAB0401.pdf

On October 10, 2000, at 1452 central daylight time, a Canadair Challenger CL-600-2B16 (CL-604) (Canadian registration C-FTBZ and operated by Bombardier Incorporated) was destroyed on impact with terrain and postimpact fire during initial climb from runway 19R at Wichita Mid-Continent Airport (ICT), Wichita, Kansas. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as an experimental test flight. The pilot and flight test engineer were killed. The copilot was seriously injured and died 36 days later.

Aircraft

Registration
CFTBZ
Reported as
Canadair CL600-2B16
Category
Airplane
Serial number
5991
Airframe hours
1,226.8
Engine
General Electric CF34-3B, 9,300 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Flight test · Part 91
Registered owner
Bombardier Inc., Canadair
Airworthiness certificate
Special, Experimental (Special)
Last inspection
100 hour · September 21, 2000 · 24.3 hours before
Departed
ICT · KS
Destination
ICT
Flight plan
VFR
Airport
ICT · Wichita Mid-Continent, runway 19R, 10,301 × 150 ft, concrete

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
March 29, 2000
Seat
Left
Toxicology
Performed
Flight hours
6,159 total · 96 in the last 90 days · 55 in the last 30 days · 2 in the last 24 hours
Role
Pilot
Age
43
Injuries
Serious
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
June 6, 2000
Seat
Right
Flight hours
6,541 total · 88 in the last 90 days · 17 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Not reported
Wind
180° at 20 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 12 °F
Altimeter
30.00 inHg
Observed at
ICT

Docket · 69

The files NTSB released with the investigation on September 10, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 100 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 359 KBOperations Factual Report of Group ChairmanItem 2 · .PDF · 1.9 MBStructure's Group Chairman's Factual ReportItem 3 · .PDF · 16 photos · 12.4 MBSystems and Powerplants Group Chairman's ReportItem 4 · .PDF · 15 photos · 2.1 MBHuman Performance Study ReportItem 5 · .PDF · 378 KBFlight Data Correlation StudyItem 6 · .PDF · 109 KBChallenger 600-2B16 Wichita Pitch Control System StudyItem 7 · .PDF · 983 KBChallenger 600-2B16 Simulation StudyItem 8 · .PDF · 135 KBChallenger 600-2B16 Simulation Study - Appendix AItem 9 · .PDF · 167 KBChallenger 600-2B16 Simulation Study - Appendix BItem 10 · .PDF · 434 KBChallenger 600-2B16 Simulation Study - Appendix CItem 11 · .PDF · 13.4 MBChallenger 600-2B16 Wichita Integration & Radar StudyItem 12 · .PDF · 85 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 13 · .PDF · 82 KBWitness StatementsItem 14 · .PDF · 2.6 MBWreckage DiagramItem 15 · .PDF · 219 KBWeather InformationItem 16 · .PDF · 139 KBATC TranscriptsItem 17 · .PDF · 178 KBSimulator VideoItem 18 · .PDF · 22 KBPilot Blue Ribbon Certification RecordItem 19 · .PDF · 13.8 MBCo-Pilot Blue Ribbon Certification RecordItem 20 · .PDF · 13.4 MBAirplane InformationItem 21 · .PDF · 1.3 MBAFFTC Instruction 91-5Item 22 · .PDF · 3.5 MBBasic Guide To System SafetyItem 23 · .PDF · 350 KBFAA Order 4040.26AItem 24 · .PDF · 1.3 MBFlight Test Safety In Civil CertificationItem 25 · .PDF · 912 KBFlight Test TrainingItem 26 · .PDF · 4 photos · 496 KBICAO Human Factors DigestItem 27 · .PDF · 5.9 MBMIL-STD-882CItem 28 · .PDF · 2.5 MBStall Protection Computer Evaluation/TestItem 29 · .PDF · 11 photos · 9.3 MBFAR 25.775 Windshields & WindowsItem 30 · .PDF · 263 KBAirworthiness DirectivesItem 31 · .PDF · 357 KBToxicological ReportItem 32 · .PDF · 89 KBStatement of Party Representatives to NTSB InvestigationItem 33 · .PDF · 332 KBSurvival Factors 6 - Factual Report of Group ChairmanItem 34 · .PDF · 744 KBSurvival Factors 6 - Attachment A - Cover Sheet for 24 PhotographsItem 35 · .PDF · 10 KBSurvival Factors 6 - Attachment A - Photo 1. Left Yoke turned to right. Instrument Panel displaced aft.Item 36 · .PDF · 141 KBSurvival Factors 6 - Attachment A - Photo 2. Possible impact from yoke onto multifunction display. (Looking forward)Item 37 · .PDF · 126 KBSurvival Factors 6 - Attachment A - Photo 3. Right Rudder Pedal jammed against forward bulkhead. (Looking forward)Item 38 · .PDF · 113 KBSurvival Factors 6 - Attachment A - Photo 4. Left Rudder Pedal jammed against forward Bulkhead, multiple separations at wall and instrument panel. (Looking forward)Item 39 · .PDF · 130 KBSurvival Factors 6 - Attachment A - Photo 5. Pilot seat back separations. Note pilot and co-pilot control yokes and seatback separations. (Looking forward)Item 40 · .PDF · 155 KBSurvival Factors 6 - Attachment A - Photo 6. Pilot seat back separations two places. (Looking down toward seat)Item 41 · .PDF · 194 KBSurvival Factors 6 - Attachment A - Photo 7. Co-pilot station-composite photo. Note displaced instrument panel and control column displaced forward and yoke turned to left. (Looking forward)Item 42 · .PDF · 299 KBSurvival Factors 6 - Attachment A - Photo 8. Co-pilot station fire damage. Left arm rest displaced downward and bulkhead destroyed. (Looking outboard)Item 43 · .PDF · 179 KBSurvival Factors 6 - Attachment A - Photo 9. FTE Station - Burn through fuselage. (Looking outboard)Item 44 · .PDF · 162 KBSurvival Factors 6 - Attachment A - Photo 10. FTE seat separations - 4 Places. Note emergency hatch inplace. (Looking outboard)Item 45 · .PDF · 128 KBSurvival Factors 6 - Attachment A - Photo 11. Close-up of FTE seat separations - 4 Places (Looking outboard)Item 46 · .PDF · 153 KBSurvival Factors 6 - Attachment A - Photo 12. FTE Station - Fire damage to top outboard portion of work table.Item 47 · .PDF · 119 KBSurvival Factors 6 - Attachment A - Photo 13. FTE Seat with 5-point restraint system attached to seat. Right armrest displaced outboard (Looking down) and burn damage.Item 48 · .PDF · 147 KBSurvival Factors 6 - Attachment A - Photo 14. FTE Seat - View from left side.Item 49 · .PDF · 129 KBSurvival Factors 6 - Attachment A - Photo 15. Flight test engineer's crew seat outside left side of airplane.Item 50 · .PDF · 677 KBSurvival Factors 6 - Attachment A - Photo 16. FTE seat outside left side of airplane.Item 51 · .PDF · 172 KBSurvival Factors 6 - Attachment A - Photo 17. FTE seat installed in a test airplane. Note work table. (View looking forward)Item 52 · .PDF · 154 KBSurvival Factors 6 - Attachment A - Photo 18. FTE seat floor attachments in a test airplane.Item 53 · .PDF · 155 KBSurvival Factors 6 - Attachment A - Photo 19. FTE restraint system as found.Item 54 · .PDF · 142 KBSurvival Factors 6 - Attachment A - Photo 20. FTE restraint system. Fitting released for right side that was permanently fastened.Item 55 · .PDF · 118 KBSurvival Factors 6 - Attachment A - Photo 21. FTE seat lapbelt attachment left side.Item 56 · .PDF · 160 KBSurvival Factors 6 - Attachment A - Photo 22. FTE seat lapbelt attachment right side.Item 57 · .PDF · 137 KBSurvival Factors 6 - Attachment A - Photo 23 - Passenber boarding door exterior handle - unstowed.Item 58 · .PDF · 158 KBSurvival Factors 6 - Attachment A - Photo 24. Passenger boarding door exterior handle - maximum counter-clockwise movement that was possible.Item 59 · .PDF · 149 KBSurvival Factors 6 - Attachment B - Toxicology AnalysisItem 60 · .PDF · 151 KB
All 69 files on NTSB’s docket