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NTSB: decision to attempt a go-around late in the landing roll with insufficient runway remaining caused fatal BAe 125 accident in Owatonna
16 March 2011

The U.S. National Transportation Safety Board (NTSB) determined that the probable cause of the 2008 BAe-125 plane crash at Owatonna Degner Regional Airport, Owatonna, Minnesota, was the captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining.

Contributing to the accident were the pilots’ poor crew coordination and lack of cockpit discipline; fatigue, which likely impaired both pilots’ performance; and the failure of the Federal Aviation Administration (FAA) to require crew resource management training and standard operating procedures for Part 135 operators.

On July 31, 2008, East Coast Jets flight 81, a BAe 125-800A registered N818MV, crashed while attempting a go-around after touchdown and during the landing rollout at Owatonna Degner Regional Airport. The flight was a nonscheduled passenger flight. An instrument flight rules flight plan had been filed and activated; however, it was cancelled before the landing. Visual meteorological conditions prevailed at the time of the accident. The two pilots and six passengers were killed.

The following safety recommendations were issued to the FAA:

  1. Require manufacturers of newly certificated and in-service turbine-powered aircraft to incorporate in their Aircraft Flight Manuals a committed-to-stop point in the landing sequence (for example, in the case of the Hawker Beechcraft 125-800A airplane, once lift dump is deployed) beyond which a go-around should not be attempted.
  2. Require 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and Part 142 training schools to incorporate the information from the revised manufacturers’ Aircraft Flight Manuals asked for in Safety Recommendation [1]  into their manuals and training.
  3. Require 14 Code of Federal Regulations Part 135 and 91 subpart K operators to establish, and ensure that their pilots adhere to, standard operating procedures.
  4. Require principal operations inspectors of 14 Code of Federal Regulations Part 135 and 91 subpart K operators to ensure that pilots use the same checklists in operations that they used during training for normal, abnormal, and emergency conditions.
  5. Require manufacturers and 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to design new, or revise existing, checklists to require pilots to clearly call out and respond with the actual flap position, rather than just stating, “set” or “as required.”
  6. Work with the National Weather Service to revise Advisory Circular 00-24B, “Thunderstorms,” by including explanations of the terms used to describe severe thunderstorms, such as “bow echo,” “derecho,” and “mesoscale convective system.”
  7. Revise regulations and policies to permit appropriate use of prescription sleep medications by pilots under medical supervision for insomnia.
  8. Require 14 Code of Federal Regulations Part 135 and 91 subpart K pilots to receive initial and recurrent education and training on factors that create fatigue in flight operations, fatigue signs and symptoms, and effective strategies to manage fatigue and performance during operations.
  9. Review the policy standards for all common sleep-related conditions, including insomnia, and revise them in accordance with current scientific evidence to establish standards under which pilots can be effectively treated for common sleep disorders while retaining their medical certification.
  10. Increase the education and training of physicians and pilots on common sleep disorders, including insomnia, emphasizing the need for aeromedically appropriate evaluation, intervention, and monitoring for sleep-related conditions.
  11. Actively pursue with aircraft and avionics manufacturers the development of technology to reduce or prevent runway excursions and, once it becomes available, require that the technology be installed.
  12. Inform operators of airplanes that have wet runway landing distance data based on the British Civil Air Regulations Reference Wet Hard Surface or Advisory Material Joint 25X1591 that the data contained in the Aircraft Flight Manuals (and/or performance supplemental materials) may underestimate the landing distance required to land on wet, ungrooved runways and work with industry to provide guidance to these operators on how to conduct landing distance assessments when landing on such runways.
  13. Require that 14 Code of Federal Regulations Part 135 pilot‑in‑command line checks be conducted independently from other required checks and be conducted on flights that truly represent typical revenue operations, including a portion of cruise flight, to ensure that thorough and complete line checks, during which pilots demonstrate their ability to manage weather information, checklist execution, sterile cockpit adherence, and other variables that might affect revenue flights, are conducted.
  14. Require Part 121, 135, and 91 subpart K operators to ensure that terrain awareness and warning system-equipped aircraft in their fleet have the current terrain database installed.

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