WPR09LA151

NTSB accident investigation · Gates Learjet Learjet 55 · Casper, WY · March 17, 2009

Accident · No injuriesLimited investigationFinal report
Date
March 17, 2009, 15:26 local (21:26 UTC)
Place
Casper, WY
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
C-GCILGates Learjet Learjet 55
Defining event
Takeoff-rejected takeoff: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report March 23, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
Case key
73507

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 NTSB’s determination of the probable cause, and any contributing factors.

The flight crew's failure to follow the manufacturer’s aircraft flight manual emergency procedures following a rejected takeoff that required a high energy stop inspection. Contributing to the accident was the flight's exceedence of the aircraft's maximum brake energy weight.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The flight crew reported that during their initial takeoff the air traffic control tower controller transmitted that he thought he saw smoke originating from the airplane. The flight crew aborted the takeoff as the airplane was accelerating through 80 knots. Upon exiting the runway, the flight crew verified normal operation of both engines. The captain reported that he had no reason to suspect hot brakes due to minimal use and taxied back to the active runway where the flight was subsequently cleared for takeoff. During the second takeoff, which was initiated about 5 minutes and 43 seconds after the initial rejected takeoff, the flight crew heard and felt a loud bang followed by a sudden yaw to the right; the flight crew immediately aborted the takeoff. Shortly after, the flight crew heard a second loud bang, followed by a more severe yaw to the right. The flight crew slowed the airplane and exited onto a taxiway at the end of the runway. Upon exiting the airplane, the captain observed a fire near the left main landing gear and immediately evacuated the airplane. Examination of the airplane by a Federal Aviation Administration inspector revealed that the left main landing gear exhibited fire damage and that the tire was blown. A punctured hole within the right side of the fuselage was observed just aft of the cockpit. The flight crew reported that at the time of the accident the airplane weighed 20,772 pounds. Review of emergency procedures within the aircraft flight manual revealed that a high energy stop inspection of the aircraft was required following the initial rejected takeoff due to the aircraft exceeding the maximum brake energy weight at the time of the initial rejected takeoff. The maximum brake energy weight was calculated to be 20,300 pounds.

Factual narrative

The factual narrative1,228 words

On March 17, 2009, about 1526 mountain daylight time, a Gates Learjet Corporation Learjet 55 airplane, C-GCIL, was substantially damaged during an aborted takeoff at the Natrona County International Airport (CPR), Casper, Wyoming. The captain, the first officer who was flying the airplane, and two passengers were not injured. The airplane was registered to and operated by Sunwest Aviation LTD., Calgary, Alberta, Canada, under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the cross-country flight. The flight was originating at the time of the accident with an intended destination of Lafayette, Louisiana. The captain reported that the flight was initially performing a takeoff from runway 3 (a 10,165-foot long asphalt runway). About one-third of the way down the runway, between 60 to 100 knots, he heard the tower controller notify them that he thought he saw smoke originating from the left engine. The captain stated that he immediately called for an aborted takeoff and the first officer initiated the aborted takeoff sequence, "using normal breaking and thrust reverser deployment for a few seconds and continued using thrust reversers only." The flight crew exited the runway onto taxiway Alpha 6, and subsequently performed an engine power check with no anomalies noted. The flight crew then taxied back to Alpha 1 via taxiway Alpha. The captain further stated that he "had no reason at this time to suspect hot breaks due to the minimal use" and "elected to taxi for another takeoff." The captain reported that following a 4 to 5 minute taxi time, the first officer conducted a second takeoff. The captain further reported that during the second takeoff roll on runway 3, between 80 knots and "prior to the V1 call," the flight crew heard and felt a bang as the airplane yawed to the right. The captain called for a second aborted takeoff. As the first officer initiated the second aborted takeoff, a second bang and additional yaw was noted. The captain took control of the airplane, and maintained directional control with reverse thrust and nose wheel steering. The captain further stated that they were able to slow the airplane down and exit the runway onto taxiway Alpha 7. Upon opening the cabin door, they observed a fire near the left main landing gear and immediately evacuated the airplane. The Airport Fire and Rescue team arrived shortly after and extinguished the fire. The first officer reported that during the initial takeoff, about one-third of the way down the runway and shortly after the "80 kt call, the tower controller made a call over the tower frequency that he thought he saw smoke coming from our engine." The first officer stated, "The captain called for an aborted takeoff, and I immediately commenced a rejected takeoff, using normal braking and maximum thrust reversers. Within a few seconds, I let off the brakes and usedthrust reversers to approximately 60 knots, where I returned to using brakes at taxi speed." The first officer further stated that during the second takeoff, between 80 knots and V1, she heard and felt a bang, followed by a yaw to the right. Following the captain's call to abort the takeoff, "I commenced the rejected takeoff and maintained directional control, only to hear a second bang and harder yaw to the right." Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the left main landing gear exhibited fire damage. A punctured hole within the right side of the fuselage was observed just aft of the cockpit. A post-accident check of the runway by the Casper Airport Public Safety Department revealed that numerous amounts of tire debris extended from the area of taxiway Alpha 4 to Alpha 7. The Cockpit Voice Recorder (CVR) was retrieved from the airplane and sent to the National Transportation Safety Board's (NTSB) Vehicle Recorder Division for inspection. The CVR recorded 31 minutes and 56 seconds of usable audio information. The recording revealed that about 16 minutes and 2 seconds after power was applied to the airplane, the flight crew began preparing for flight. At 19 minutes, 27 seconds, the captain requested clearance to taxi from the ground controller. About 2 minutes, 43 seconds later, the captain requested clearance for takeoff from the tower controller. The flight was cleared for takeoff 8 seconds later. During the takeoff sequence, about 8 seconds after the first officer responded to the captain's call of "eighty knots," the tower controller transmitted "appears you have a lot of smoke coming out your engine." At 23 minutes, 28 seconds, the captain called for a rejected takeoff. About 37 seconds later, the first officer stated "the right brake felt funny." Following the aborted takeoff, the captain decided to run up both engines as the first officer was heard briefing the passengers. At 24 minutes, 45 seconds, the tower controller transmitted "it appears the smoke was from the left engine." At 26 minutes, 1 second, the captain requested clearance to taxi to runway 3. At 27 minutes, 18 seconds, the captain stated "both engines are pulling full power" immediately followed by a comment that it was not a high-speed abort since the "aircraft was only through ninety knots." At 28 minutes, 34 seconds, the tower controller cleared the flight for takeoff a second time on runway 3. The sound of increasing engine noise was identified at 29 minutes, 11 seconds, followed by an "eighty knots" call at 29 minutes, 25 seconds. Two loud noises, about one second apart were heard beginning at 29 minutes, 34 seconds. At 29 minutes, 36 seconds, the captain called for a rejected takeoff, followed by the first officer stating "blew a tire." The flight crew reported that at the time of the accident, the airplane weighed 20,772 pounds. The Learjet 55 Aircraft Flight Manual (AFM), Section 3, "Emergency Procedures," page36, states "if rejected takeoff was made at weight above the landing maximum brake energy weight as determined from the applicable LANDING WEIGHT LIMITS chart in Section V, the High Energy Stop Inspection (Chapter 5, Learjet Maintenance Manual) must be performed." The Learjet 55 AFM, Section 5, "Performance Data," page 65, Maximum Landing Weight, states in part "the maximum landing weight (design structural limit for landing) is 17,000 pounds. According to a Bombardier Learjet representative, using the following conditions: temperature 48 degrees Fahrenheit, altitude: 5,530 feet mean sea level, wind: from 030 degrees at 5 knots, runway: runway 3 (0.1 percent gradient), the maximum brake energy weight was calculated to be 20,300 pounds. The Learjet 55 AFM, Section 1, "Limitations," page 13, part "TURN-AROUND LIMITS - Aircraft 55-003 thru 55-076 when not incorporating AAK 55-82-6" states in part "if the turn-around weight limit for brake energy, as determined from the applicable LANDING WEIGHT LIMIT chart (Figures 5-54 and 5-55) in Section V, is exceeded during a landing or rejected takeoff, the following limitations must be observed: The aircraft must be parked for a minimum waiting period of 30 minutes before the next takeoff attempt can be made. After the waiting period is observed, a visual inspection of the main gear tires, wheels, and brakes for condition must be made." The operator of the aircraft reported that the accident airplane was equipped with the AAK 55-82-6 modification, therefore, the 30 minute waiting period did not apply.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
C-GCIL
Reported as
Gates Learjet Learjet 55
Category
Airplane
Serial number
089
Airframe hours
8,213
Engines
Honeywell TPE-731, 3,700 lbs thrust, turbo fanHoneywell TPE-731, 3,700 lbs thrust, turbo fan
Damage
Substantial damage
Fire
On-Ground
Flight
Executive/Corporate · Part 91
Operator
Sunwest Aviation Ltd.
Registered owner
Sunwest Aviation Ltd.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · July 14, 2008
Departed
CPR · Casper, WY
Destination
Layfayette, LA
Flight plan
IFR
Airport
CPR · Natrona County Int Airport, runway 03, 10,165 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
32
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 24, 2008
Seat
Left
Flight hours
6,933 total · 340 in this make and model · 4,505 as pilot in command · 42 in the last 90 days · 15 in the last 30 days · 2 in the last 24 hours
Role
Co-pilot
Age
35
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 24, 2008
Seat
Right
Flight hours
2,422 total · 168 in this make and model · 610 as pilot in command · 56 in the last 90 days · 29 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 28 °F
Altimeter
30.05 inHg
Observed at
CPR

Docket · 7

The files NTSB released with the investigation on November 9, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.9 MB in all.