CHI93MA276

NTSB accident investigation · Canadair CL-600-2B19 · Byers, KS · July 26, 1993

Accident · FatalMajor investigationFinal report
Date
July 26, 1993, 13:52 local (18:52 UTC)
Place
Byers, KS
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
CFCRJCanadair CL-600-2B19
Weather
Visual (VMC) · Day
Status
Completed · report April 29, 1994
Report
Approved by Office Director
Safety recommendations
Yes
Case key
9333

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 captain's failure to adhere to the agreed upon flight test plan for ending the test maneuver at the onset of prestall stick shaker, and the flightcrew's failure to assure that all required switches were properly positioned for anti-spin chute deployment. A factor which contributed to the accident was the inadequate design of the anti-spin chute system which allowed deployment of the chute with the hydraulic lock switch in the unlocked position. (When in the unlocked position, the hooks clasping the chute shackle to the airframe are open.)

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 flightManeuvering
Procedures/directives - not followedPilot in commandCause
Stall/spin - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Safety system(other) - inadequateFactor
Acft/equip,inadequate designManufacturerFactor
Safety system(other) - unlockedCause
Miscellaneous equipment - improper use ofPilot in commandCause
Miscellaneous equipment - improper use ofCopilot/second pilotCause
Safety system(other) - separationCause

Analysis

The crew was performing a lateral & directional stability test. Changes from earlier tests combined new leading edge fairing, new flap setting, lower reference airspeed, and trial settings for the stall protection system (shaker & pusher). Engineers had briefed the crew data would be sufficient if the steady heading sideslip (shss) maneuver ended at a 15 deg sideslip, or at onset of stall warning; crew agreed to end at stall warning. During the test the capt continued past stall warning to 21 deg sideslip at full rudder. The airplane rolled rapidly through 360 deg & entered a deep stall. The copilot attempted to deploy the anti-spin chute. However, all the chute system cockpit switches were not properly preset; instead of assisting recovery, the chute parted from the airplane. Full control was not regained before impact. The chute system design allowed deployment of the chute even when the hyd lock switch was in the unlocked position & the hooks clasping the chute shackle to the airframe were open. System tested ok before flight.

Factual narrative

History of flight

On July 26, 1993, at 1352 central daylight time, a Canadair CL-600-2B19 airplane, Canadian registry C-FCRJ, departed controlled flight while maneuvering, and descended to ground collision near Byers, Kansas. The two test pilots and flight test engineer aboard were fatally injured. The airplane was destroyed by impact and postcrash fire. Visual meteorological conditions existed. The airplane was operated by the manufacturer on a performance improvement test, designated as flight 388. The flight originated at 1331 from Wichita, Kansas and operated VFR under 14 CFR 91; a flight plan had not been filed with the FAA.

The test flight was part of the Regional Jet Performance Improvement Flight Test Program (Canadair report number RAG-601R-106). The program was to repeat all portions of certification testing which pertained to configuration changes or expanded capabilities. At its conclusion, Canadair would apply to Transport Canada (TC) and present the test data for amendment to the airplane's type certificate. On the accident flight, tests encompassed a new flap setting, a leading edge fairing to smooth the sweep transition at wing station (WS) 148, and a lower reference operating speed (1.13 Vs) allowed by TC and the FAA.

Before flight, an engineering brief convened among flight crew, engineers, technicians and aerodynamicists. The captain chaired the briefing; the chief test pilot attended to observe. Topics included airplane configuration, load, maintenance status, and instrumentation. The flight test engineer briefed an outline he had written, called the flight plan. The flight plan bundled tests from RAG-601R-106 and was conditioned on preceding accomplishment of other tests. The flight plan listed tests to be conducted, their sequence, conditions, and data to be obtained.

Flight 388 was the first on which any of the operator's pilots attempted a steady heading sideslip (SHSS) maneuver at 1.13 Vs with flaps 8 degrees and WS148 fairing. The SHSS is a trial of lateral and directional stability in a configuration. It is performed at constant speed with aft center-of-gravity (CG), by deflecting rudder while opposing with aileron to hold heading. In the maneuver, increasing rudder deflection should generate proportionate sideslip (beta), and control force should not drop off. The maneuver concludes with releasing control deflections. The low wing's rising at aileron release indicates positive static lateral stability; nose movement toward center at rudder release indicates positive static directional stability.

The stall protection system (SPS) shaker and pusher activation points for flaps zero, 20, 30 and 45 degrees were based on natural stalls without sideslip in an airplane without the WS148 fairing. Activation points for flaps-8 were based on engineering estimates of lift improvement from the WS148 fairing, and were at higher angles-of-attack than would be interpolated from points for other flap settings. Sideslip influence on angle-of-attack sensors for the SPS had not been established at the new flap setting and was to be refined with data from the flight.

Aerodynamicists told the crew data would be sufficient if the SHSS terminated at onset of the stall warning or 15 degrees beta.

The latter is a minimum criterion for certification. The pilots' practice in SHSS had been to proceed to full rudder deflection if performance during the maneuver appeared predictable. The aerodynamicists explained that while reviewing data from flight 386 they observed shaker initiation during SHSS. They stated they had never encountered pusher activation during SHSS and did not want one. It was agreed among crew and aerodynamicists to cut off the maneuver at stall warning shaker.

Before taxi, the captain electrically powered and armed the anti-spin parachute system and cycled the hooks which clasp the parachute shackle to the airframe. He cycled them from unlocked to locked and unlocked again. Before takeoff, he briefed the copilot about aborting takeoff, "if I ask for it, you'll lock, deploy the chute."

The flight took off, and the crew completed a longitudinal trim test while flying west to the test area. In the setup for the first SHSS, the test engineer read from the flight plan the conditions: 146 knots (calculated 1.13 Vs), flaps-8, gear up, "to the shaker." The captain and copilot acknowledged.

Commencing about 12,500 feet MSL with idle power, the captain gradually increased right rudder, and the copilot read beta. The captain remarked "buffet starts" after the copilot read 12 beta. The chief test pilot later explained this was random airframe buffet from sideslip, and stated the airplane exhibits little or no aerodynamic buffet before stall.

Shaker onset occurred at 17 beta. The captain remarked shaker and continued without pause. The copilot began reading alpha (angle-of-attack) with beta. At 11 alpha and 19 beta, the captain remarked, "a little bit of pitch instability," then reported, "on the stop" (full rudder). The copilot read 21 beta.

As the captain reported releasing aileron, a tone similar to the stall identification horn sounded. The airplane rolled rapidly right toward inverted. Recorded data show the roll began near time 1351:25.

The copilot told the captain, "just keep going." The roll continued toward upright. Altitude was about 11,500 feet MSL. Angle-of-attack after the roll was at least 35 units (recording limit), and remained there from 1351:32 to :52.

The copilot asked, "want me to release the chute?" The captain's response was unclear on the cockpit voice recorder, "stop (at)" The copilot asked, "at eight?" The captain commanded, "chute out." Five seconds later, the captain asked if the chute were out; the copilot answered, "yeah."

Angle-of-attack decreased below stall angle at 1351:56, with the airplane rolling beyond 60 degrees right wing down, and pitched 60 degrees nose down. Altitude was about 6800 feet MSL, airspeed about 190 knots.

A witness described the airplane heading slowly north before rolling 1 1/2 or 2 1/2 times, during which the nose came down. The airplane changed heading through west, and roll abated near a south heading. The airplane was slightly left wing down, and vapor trailed the wingtips as the nose appeared to rise. The airplane descended from view, and a fireball erupted.

Another witness recounted a parachute issuing from the tail and continuing away from the airplane.

The Pratt County Sheriff department first received telephone notification of the accident from a witness at 1356 CDT.

Other damage

Several acres of grain stubble and standing corn were fuel-soaked and scorched.

Personnel information

The first pilot, as captain, occupied the left pilot seat. He joined Canadair in 1978 as an engineer. He joined the flight test section around 1980 as flight test engineer. At intervals of about 5 years, he advanced to copilot, then to captain. He flew various jet and propeller airplanes in the manufacturer's inventory, lately the CL-600 Challenger and the accident model. The current program was the first for which he had been assigned lead test pilot. He held a Canadian air transport pilot certificate, and FAA commercial pilot certificate with instrument rating. No record was found of flight background in aerobatics or formation, nor formal training in swept wing or jet aircraft. His jet aircraft experience was obtained in the course of flight test involvement. He had 875 total hours in model, about 200 hours as pilot-in-command.

The copilot joined Canadair in 1991 as a test pilot after 9 years in the Royal Canadian Air Force. He had flown Grumman S-2 and Lockheed T-33 airplanes, and had been an instructor and check pilot in the military. He held a degree in mechanical engineering. He held a Canadian air transport certificate. Since joining Canadair, he had flown the Challenger

Aircraft

Registration
CFCRJ
Reported as
Canadair CL-600-2B19 (CL-600-2B1)
Category
Airplane
Serial number
7001
Airframe hours
771
Engine
GE CF-34-3A1, 8,730 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Flight test · Part 91
Registered owner
Canadair
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Continuous airworthiness · June 1, 1993 · 17 hours before
Departed
ICT · Wichita, KS
Destination
ICT · Wichita, KS

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Certificates
Commercial, Foreign
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
3,836 total · 875 in this make and model · 2,699 as pilot in command · 91 in the last 90 days · 24 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 15 knots, gusting 19
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 72 °F
Altimeter
29.00 inHg
Observed at
GBD, 40 nm away