DCA05MA003

NTSB accident investigation · Canadair CL-600 · Jefferson City, MO · October 14, 2004

Accident · FatalClass 1 · MajorFinal report
Date
October 14, 2004, 00:00 local (04:00 UTC)
Place
Jefferson City, MO
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N8396ACanadair CL-600
Status
Completed · report April 25, 2007
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20041014026829A
Case key
60339

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

On this page

Probable cause

(1) the pilots’ unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots’ inadequate training; (2) the pilots’ failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and (3) the pilots’ improper management of the double engine failure checklist, which allowed the engine cores to stop rotating and resulted in the core lock engine condition. Contributing to this accident were (1) the core lock engine condition, which prevented at least one engine from being restarted, and (2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.

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 engine power(total) - nonmechanicalCruise
Aircraft handling - improperFlightcrewCause
Improper use of procedureFlightcrewCause
Air/ground communications - delayedFlightcrewCause
Improper decisionFlightcrewCause
In-flight planning/decision - improperFlightcrewCause
Procedures/directives - not followedFlightcrewCause
Checklist - improper use ofFlightcrewCause
Planning/decision - delayedFlightcrewCause
Condition(s)/step(s) insufficiently definedCompany/operator managementFactor
Procedure inadequateCompany/operator managementCause
Procedure inadequateManufacturerCause
Instructions,written/verbal - inadequateManufacturerFactor
Condition(s)/step(s) insufficiently definedManufacturerFactor
Turbine assembly,seal - clearanceFactor
Turbine assembly,seal - lockedFactor
Aircraft manuals,procedure information - inadequateFactor
Aircraft manuals,performance information - inadequateFactor

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-07/01.

On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport (JEF), Jefferson City, Missouri. The airplane was on a repositioning flight from Little Rock National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport, Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured. The flight was operating under the provisions of 14 Code of Federal Regulations Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-07/01.

On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport (JEF), Jefferson City, Missouri. The airplane was on a repositioning flight from Little Rock National Airport (LIT), Little Rock, Arkansas, to Minneapolis-St. Paul International Airport (MSP), Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

Flight 3701 departed LIT about 2121. The flight plan indicated that the company-planned cruise altitude was 33,000 feet. About 5 seconds after takeoff, when the airplane was at an altitude of about 450 feet mean sea level (msl) (about 190 feet above ground level), the first of three separate pitch-up maneuvers during the ascent occurred when the flight crew moved the control column to 8º airplane nose up (ANU), causing the airplane's pitch angle to increase to 22º and resulting in a vertical load of 1.8 Gs. The rate of climb during this pitch-up maneuver was 3,000 feet per minute (fpm). Immediately afterward, the flight data recorder (FDR) recorded stick shaker and stick pusher activations, a full airplane-nose-down (AND) control column deflection, a decrease in pitch angle, and a drop in vertical load to 0.6 G.

About 2125:55, when the airplane was at an altitude of about 14,000 feet, the flight crew engaged the autopilot. The air traffic control (ATC) transcript and FDR data showed that the flight crewmembers changed seats in the cockpit during this time, but the ATC transcript did not indicate the reason for the seat change. About 2127:15, when the airplane was at an altitude of about 15,000 feet, the flight crew disengaged the autopilot.

About 2127:17, when the airplane was in level flight at an altitude of 15,000 feet, the second pitch-up maneuver began when the flight crew moved the control column to 3.8º ANU, causing the airplane's pitch angle to increase to 17º and resulting in a vertical load of 2.3 Gs. The rate of climb during this pitch-up maneuver reached 10,000 fpm briefly. Between about 2128:40 and about 2128:43, the flight crew made a left rudder input of 4.2º, a right rudder input of 6.0º, and a left rudder input of 0.4º, resulting in lateral loads of -0.16 G, 0.34 G, and -0.18 G, respectively. About 17 seconds later, the flight crew made a right rudder input of 7.7º. About 2132:40, when the airplane was in level flight at an altitude of 24,600 feet, the third pitch-up maneuver began when the flight crew moved the control column to 4º ANU, which increased the airplane's pitch angle to more than 10º and resulted in a vertical load of 1.87 Gs. The rate of climb during this pitch-up maneuver reached 9,000 fpm briefly.

The ATC transcript showed that the captain requested a climb to 41,000 feet, which is the Canadair regional jet (CRJ) maximum operating altitude, about 2135:36 and received clearance to climb to that altitude about 2136:13. The cockpit voice recorder (CVR) recording began about 2144:44 with the captain and the first officer discussing the climb to 41,000 feet. About 2148:44, the first officer stated, "man we can do it. Forty one it." About 2151:51, the first officer stated, "there's four one oh my man." About 2152:04, the CVR recorded the first officer laughing as he stated, "this is great." FDR data showed that, about 2152:08, the airplane was in level flight at 41,000 feet. FDR data also showed that the airplane climbed from 37,000 to 41,000 feet at an airspeed that decreased from 203 knots/0.63 Mach at the start of the climb to 163 knots/0.57 Mach as the airplane leveled off. The FDR data further showed that the autopilot vertical speed mode was engaged during the climb with a commanded vertical speed of 500 fpm and that the airplane's angle of attack (AOA) at 41,000 feet was initially 5.7º.

About 2152:22, the CVR recorded the captain asking the first officer whether he wanted something to drink and then the first officer responding that he wanted a soda. CVR evidence indicated that the captain left his seat shortly afterward to get the drink.

About 2153:28, the CVR recorded the captain stating, "look how high we are." About 2153:42, a controller at the Kansas City Air Route Traffic Control Center (ARTCC) asked the pilots whether they were flying a CRJ-200. The captain confirmed this information, and the controller stated, "I've never seen you guys up at forty one there." About 2153:51, the captain replied, "we don't have any passengers on board so we decided to have a little fun and come on up here." About 2153:59, the captain added, "this is actually our service ceiling."

About 2154:07, the captain told the first officer, "we're losing here. We're gonna be coming down in a second here." About 3 seconds later, the captain stated, "this thing ain't gonna hold altitude. Is it?" The first officer responded, "it can't man. We (cruised/greased) up here but it won't stay." About 2154:19, the captain stated, "yeah that's funny we got up here it won't stay up here." About 2154:32, the captain contacted the controller and stated, "it looks like we're not even going to be able to stay up here look for maybe three nine oh or three seven." About 2154:36, the FDR recorded the activation of the stick shaker. FDR data showed that, at that point, the airplane's airspeed had decreased to 150 knots, and its AOA was about 7.5º.

The FDR recorded activations of the stick shaker and the stick pusher three times between 2154:45 and 2154:54. FDR data showed that, after the second activation of the stick shaker and stick pusher, the No. 1 (left) and No. 2 (right) engines' N1 (fan speed) and fuel flow indications began decreasing. FDR data also showed that, at the time of the second stick pusher activation, the airplane's AOA had increased to 12º and that, after the stick pusher activated for the third time, the pitch angle decreased from 7º to -20º.

About 2154:57, the FDR recorded the fifth activation of the stick shaker and the fourth activation of the stick pusher. Even with the stick pusher's activation, the motion of the airplane continued to increase its AOA to the maximum measurable value of 27º. The pitch angle increased to 29º, and the airplane entered an aerodynamic stall. Afterward, a left rolling motion began, which eventually reached 82º left wing down, the airplane's pitch angle decreased to -32º, and both engines flamed out. About 2155:06, the captain stated to the controller, "declaring emergency. Stand by." FDR data showed that, during the next 14 seconds, the flight crew made several control column, control wheel, and rudder inputs and recovered the airplane from the upset at an altitude of 34,000 feet. During the recovery, the CVR recorded a sound similar to decreasing engine rpm, and FDR data showed that the No. 1 and No. 2 engines' N1 indications continued to decrease and that the engines' fuel flow indications were at zero.

About 2155:14, the controller told the pilots to descend and maintain an altitude of 24,000 feet; about 5 seconds later, the captain acknowledged the assigned altitude. About 2155:20, the FDR stopped recording because normal a.c. power to the airplane was lost. (The CVR had a different source of power and continued to record.) The last reliable N2 (core speed) recorded by the FDR before it stoppe

Aircraft

Registration
N8396A
Reported as
Canadair CL-600
Category
Airplane
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Operator
Pinnacle Air Inc
Departed
LIT · Little Rock, AK
Destination
MSP · Minneapolis, MN
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Docket · 159

The files NTSB released with the investigation on June 13, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Order of hearing_1AItem 1 · PDF · 1 page · 42 KBNotice of designation of chairman of board of inquiry_1BItem 2 · PDF · 1 page · 48 KBDesignation of hearing officer_1CItem 3 · PDF · 1 page · 51 KBDesignation of parties to the hearing_1DItem 4 · PDF · 1 page · 45 KBNotice of hearing_1EItem 5 · PDF · 1 page · 41 KBPublic hearing exhibit list_1FItem 6 · PDF · 3 pages · 70 KBPublic hearing order of proceedings issues list and participantsItem 7 · PDF · 11 pages · 296 KBOperations 2-factual report of group chairmanItem 8 · PDF · 19 pages · 373 KBOperations 2-errata to operations factual reportItem 9 · PDF · 3 pages · 18 KBOperations 2-list of attachmentsItem 10 · PDF · 1 page · 64 KBOperations 2-attachment 1 interview summariesItem 11 · PDF · 176 pages · 585 KBOperations 2-attachment 2 double engine failure proceduresItem 12 · PDF · 7 pages · 369 KBOperations 2-attachment 3 jet upset trainingItem 13 · PDF · 6 pages · 467 KBOperations 2-attachment 4 jet upset student guideItem 14 · PDF · 23 pages · 2.6 MBOperations 2-attachment 5 FMS limitationsItem 15 · PDF · 3 pages · 220 KBOperations 2-attachment 6 performance chartsItem 16 · PDF · 5 pages · 389 KBOperations 2-attachment 7 Bombardier all operator messageItem 17 · PDF · 3 pages · 165 KBOperations 2-attachment 8 climb proceduresItem 18 · PDF · 13 pages · 1.1 MBOperations 2-attachment 9 pinnacle alert bulletinItem 19 · PDF · 2 pages · 108 KBOperations 2-attachment 10 revised jet upset instructor guideItem 20 · PDF · 43 pages · 4.8 MBOperations 2-attachment 11 revised jet upset student guideItem 21 · PDF · 34 pages · 3.9 MBOperations 2-attachment 12 stall trainingItem 22 · PDF · 8 pages · 339 KBOperations 2-attachment 13 instructor guide revisionItem 23 · PDF · 25 pages · 2.9 MBOperations 2-attachment 14 FAA poi policyItem 24 · PDF · 2 pages · 79 KBOperations 2-attachment 15 FAA documentsItem 25 · PDF · 10 pages · 634 KBOperations 2-attachment 16 evaluation reportItem 26 · PDF · 68 pages · 6.6 MBOperations 2-attachment 17 FAA interviewsItem 27 · PDF · 9 pages · 1.0 MBOperations 2-attachment 18 court reporter transcriptItem 28 · PDF · 32 pages · 52 KBOperations 2-attachment 19 court reporter transcriptItem 29 · PDF · 48 pages · 73 KBOperations 2-attachment 20COURT reporter transcriptItem 30 · PDF · 25 pages · 38 KBOperations 2-attachment 21 court reporter transcriptItem 31 · PDF · 51 pages · 78 KBOperations 2-attachment 22 court reporter transcriptItem 32 · PDF · 36 pages · 57 KBOperations 2-attachment 23 court reporter transcriptItem 33 · PDF · 47 pages · 73 KBOperations 2-attachment 24 court reporter transcriptItem 34 · PDF · 23 pages · 38 KBOperations 2-attachment 25 court reporter transcriptItem 35 · PDF · 26 pages · 42 KBOperations 2-attachment 26 court reporter transcriptItem 36 · PDF · 64 pages · 100 KBOperations 2-attachment 27 court reporter transcriptItem 37 · PDF · 12 pages · 20 KBOperations 2-attachment 28 court reporter transcriptItem 38 · PDF · 31 pages · 51 KBOperations 2-attachment 29 court reporter transcriptItem 39 · PDF · 103 pages · 159 KBOperations 2-attachment 30 court reporter transcriptItem 40 · PDF · 52 pages · 81 KBOperations 2-attachment 31 court reporter transcriptItem 41 · PDF · 44 pages · 70 KBOperations 2-attachment 32 court reporter transcriptItem 42 · PDF · 104 pages · 168 KBOperations 2-attachment 33 court reporter transcriptItem 43 · PDF · 43 pages · 68 KBOperations 2-attachment 34 court reporter transcriptItem 44 · PDF · 16 pages · 27 KBOperations 2-attachment 35 court reporter transcriptItem 45 · PDF · 52 pages · 84 KBOperations 2-attachment 36 court reporter transcriptItem 46 · PDF · 21 pages · 33 KBOperations 2-attachment 37 court reporter transcriptItem 47 · PDF · 79 pages · 123 KBOperations 2-attachment 38 court reporter transcriptItem 48 · PDF · 5 pages · 10 KBOperations 2-attachment 39 FAA letterItem 49 · PDF · 2 pages · 105 KBOperations 2-AC 120-82 foqaItem 50 · PDF · 78 pages · 371 KBOperations 2-exhibit 2E proposed pinnacle dual engine failure checklistItem 51 · PDF · 5 pages · 133 KBOperations 2-840010 chg 30 foqaItem 52 · PDF · 16 pages · 101 KBOperations 2-pinnacle foqa data collection formItem 53 · PDF · 2 pages · 181 KBOperations 2-addendum 1-part 91 operationsItem 54 · PDF · 2 pages · 89 KBOperations 2-exhibit 2M letter to tc from FAAItem 55 · PDF · 2 pages · 179 KBOperations 2-exhibit 2N pinnacle presentationItem 56 · PDF · 4 pages · 85 KBOperations 2-dual engine failure checklist-bombardierItem 57 · PDF · 13 pages · 62 KBOperatons 2-exhibit 2P-original AFM checklist-bombardierItem 58 · PDF · 8 pages · 293 KBOperations 2-exhibit 2Q pinnacle absence from the cockpitItem 59 · PDF · 1 page · 66 KBOperations 2-exhibit 2R pinnacle crew compositionItem 60 · PDF · 1 page · 53 KB
All 159 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.