DCA08MA098

NTSB accident investigation · Learjet LR60 · Columbia, SC · September 20, 2008

Accident · FatalClass 1 · MajorFinal report
Date
September 19, 2008, 23:53 local (Sep 20, 2008, 03:53 UTC)
Place
Columbia, SC
Injuries
4 fatal, 2 serious
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N999LJLearjet LR60
Defining event
Takeoff-rejected takeoff: Runway excursion
Weather
Visual (VMC) · Night
Status
Completed · report July 16, 2010
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
AAI-100
Safety recommendations
Yes
FAA report
20080919846669A
Case key
68960

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

The operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures. Contributing to the accident were (1) deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of critical systems in the wheel well area to result in uncommanded forward thrust that increased the severity of the accident; (2) the inadequacy of Learjet’s safety analysis and the FAA’s review of it, which failed to detect and correct the thrust reverser and wheel well design deficiencies after a 2001 uncommanded forward thrust accident; (3) inadequate industry training standards for flight crews in tire failure scenarios; and (4) the flight crew’s poor crew resource management (CRM).

Findings · 14

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Landing gear system: tire casingAircraft › Aircraft systems · Incorrect service/maintenanceLearjet 60: 1 caseAll aircraft: 36 casesProbable cause
Landing gear system: tire casingAircraft › Aircraft systems · FailureLearjet 60: 1 caseAll aircraft: 36 casesProbable cause
Oversight: oversight of maintenanceOrganizational issues › Support/oversight/monitoring · OperatorLearjet 60: 1 caseAll aircraft: 28 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · PilotLearjet 60: 1 caseAll aircraft: 397 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · PilotLearjet 60: 1 caseAll aircraft: 191 casesProbable cause
Design: equipment designOrganizational issues › Development · ManufacturerLearjet 60: 1 caseAll aircraft: 35 casesProbable cause
Selection/certification/testing: equip certification/testingOrganizational issues › Development · FAA/RegulatorLearjet 60: 1 caseAll aircraft: 21 casesProbable cause
Selection/certification/testing: personnel selection/trainingOrganizational issues › Development · Not specifiedLearjet 60: 1 caseAll aircraft: 3 casesProbable cause
Communication (personnel): cRM/MRM techniquesPersonnel issues › Task performance · Flight crewLearjet 60: 1 caseAll aircraft: 26 casesProbable cause
Oversight: equipment monitoringOrganizational issues › Support/oversight/monitoring · ManufacturerLearjet 60: 1 caseAll aircraft: 7 casesProbable cause
Oversight: equipment monitoringOrganizational issues › Support/oversight/monitoring · FAA/RegulatorLearjet 60: 1 caseAll aircraft: 7 casesProbable cause
Engine exhaust: thrust reverserAircraft › Aircraft power plant · DesignLearjet 60: 1 caseAll aircraft: 8 casesProbable cause
Performance/control parameters: powerplant parametersAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleLearjet 60: 1 caseAll aircraft: 81 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The NTSB’s full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-10/02. On September 19, 2008, about 2353 eastern daylight time, a Bombardier Learjet Model 60, N999LJ, owned by Inter Travel and Services, Inc., and operated by Global Exec Aviation, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport, Columbia, South Carolina. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured. The nonscheduled domestic passenger flight to Van Nuys, California, was operated under 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed.

Factual narrative

The NTSB’s full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-10/02. On September 19, 2008, about 2353 eastern daylight time, a Bombardier Learjet Model 60, N999LJ, owned by Inter Travel and Services, Inc., and operated by Global Exec Aviation, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport, Columbia, South Carolina. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured. The nonscheduled domestic passenger flight to Van Nuys, California, was operated under 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed.

Aircraft

Registration
N999LJ
Reported as
Learjet LR60
Category
Airplane
Airframe hours
108
Engines
Pratt & Whitney Canada PW305A, 4,600 lbs thrust, turbo fanPratt & Whitney Canada PW305A, 4,600 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Global Exec Avaition
Registered owner
Inter Travel and Services
Airworthiness certificate
Standard, Transport
Departed
KCAE · Columbia, SC
Destination
KVNY · Van Nuys, CA
Flight plan
IFR
Airport
KCAE · Columbia Metropolitan, runway 11, 8,601 × 150 ft, asphalt

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.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Injuries
Fatal
Certificate
Airline transport
Seat
Left
Role
Co-pilot
Injuries
Fatal
Certificate
Airline transport
Seat
Right

Weather

Conditions
Visual (VMC) · Night
Wind
60° at 7 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
None
Temperature
19 °F, dew point 14 °F
Altimeter
30.22 inHg
Observed at
CAE

Docket · 44

The files NTSB released with the investigation on August 7, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 62.0 MB in all.

Pilot-operator aircraft accident report NTSB form 61201Item 1 · PDF · 11 pages · 859 KBOperations 2-factual report of operational factors-human performance group chairmanItem 2 · PDF · 27 pages · 191 KBOperations 2-attachment 1-interview summariesItem 3 · PDF · 57 pages · 241 KBOperations 2-attachment 2-GEA crewmember logbook reportItem 4 · PDF · 4 pages · 251 KBOperations 2-attachment 3-GEA operations specification A096-actual weight programItem 5 · PDF · 3 pages · 475 KBOperations 2-attachment 4-Bombardier Learjet advisory wire 32-045Item 6 · PDF · 3 pages · 89 KBOperations 2-attachment 5-Bombardier Learjet 60-60X temporary flight manual changeItem 7 · PDF · 11 pages · 257 KBOperations 2-attachment 6-FAA interpretation tire pressure checkItem 8 · PDF · 4 pages · 307 KBOperations 2-attachment 7-taxi routeItem 9 · PDF · 2 pages · 760 KBOperations 2-attachment 8-GEA takeoff profileItem 10 · PDF · 2 pages · 180 KBOperations 2-attachment 9-GEA aborted takeoff profilesItem 11 · PDF · 3 pages · 255 KBATC 3-excerpts from FAA ATC accident packageItem 12 · PDF · 18 pages · 857 KBATC 3-runway turn note documentationItem 13 · PDF · 9 pages · 300 KBATC 3-CAE 180 turns-atc trainingItem 14 · PDF · 2 pages · 79 KBAirworthiness mapping and maintenance factual report of group chairmanItem 15 · PDF · 43 pages · 21.3 MBAirworthiness group chairman's factual addendum engines and thrust reversersItem 16 · PDF · 64 pages · 2.4 MBAirworthiness group chairman's factual addendum and study for tires and landing gearItem 17 · PDF · 105 pages · 8.5 MBAirworthiness factual addendum lightbulb re-examinationItem 18 · PDF · 34 pages · 3.0 MBSurvival factors 6-factual report of group chairmanItem 19 · PDF · 24 pages · 350 KBSurvival factors group factual-attachment 1-passenger information cardItem 20 · PDF · 5 pages · 1.1 MBSurvival factors factual report-attachment 2-NOTAMSItem 21 · PDF · 7 pages · 375 KBSurvival factors factual report-attachment 3-RSA dataItem 22 · PDF · 7 pages · 408 KBSurvival factors group factual-attachment 4-friction surveyItem 23 · PDF · 8 pages · 489 KBSurvival factors factual report-attachment 5-CAE letterItem 24 · PDF · 2 pages · 71 KBSurvival factors factual report-attachment 6-ARFF statementsItem 25 · PDF · 21 pages · 1.2 MBPowerplants 8-factual reportItem 26 · PDF · 31 pages · 3.5 MBCockpit voice recorder 12-factual report of group chairmanItem 27 · PDF · 40 pages · 569 KBCockpit voice recorder 12-errataItem 28 · PDF · 1 page · 82 KBSound spectrum study cockpit voiceItem 29 · PDF · 12 pages · 5 photos · 798 KBSound spectrum study cockpit voice-12-addendum 1Item 30 · PDF · 4 pages · 96 KBSound spectrum study 12-errataItem 31 · PDF · 1 page · 15 KBSound spectrum study cockpit voice 12-errata 2Item 32 · PDF · 1 page · 15 KBAircraft performance 13-CHAIRMAN'S airplane performance study rev 11-2-09Item 33 · PDF · 4 pages · 41 KBAircraft performance 13-CHAIRMAN'S airplane performance study attachment 1 rev 11-2-09Item 34 · PDF · 1 page · 10.1 MBMaterials laboratory 15-materials laboratory factual report 08-134Item 35 · PDF · 3 pages · 114 KBMaterials laboratory 15-materials laboratory factual report 08-134 addendumItem 36 · PDF · 5 pages · 488 KBNTSB safety recommendations A-09-055 through-060Item 37 · PDF · 7 pages · 158 KBHearing notices-no hearing action reportItem 38 · PDF · 1 page · 102 KBOther pertinent forms and reports-icao notificationItem 39 · PDF · 1 page · 24 KBStatement of party representatives to NTSB investigationItem 40 · PDF · 3 pages · 717 KBMiscellaneous-misc errata sheetItem 41 · PDF · 2 pages · 66 KBReports from parties to the investigation-learjetItem 42 · PDF · 60 pages · 885 KBReports from parties to the investigation-columbia airportItem 43 · PDF · 2 pages · 20 KBOther pertinent forms and reports-pratt and whitney Canada review letterItem 44 · PDF · 2 pages · 30 KB

FAA reports on this event · 1

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