CEN24LA328

The flight crew’s failure to properly configure the airplane for takeoff in a high-density altitude environment, which resulted in a loss of control and a subsequent runway excursion. Contributing to the accident was the flight crew’s failure to use checklists.

The airplane landed at the high-elevation airport and the passengers disembarked. For the subsequent departure on the 7,111 ft-long runway, the pilot calculated that a takeoff roll of 6,800–6,900 ft would be needed with the wing flaps extended to 15°. The copilot was flying the airplane during the takeoff. During the departure takeoff roll on the dry asphalt, the airplane did not attain 75% of the planned takeoff speed about halfway down the runway, so the copilot decided to abort the takeoff. The brakes, air brakes, and thrust reversers were used to slow the airplane; however, the airplane did not slow down. Maximum braking was then applied, and the airplane began to depart from the runway to the right. The airplane traveled over the engineered material arresting system (EMAS) and came to rest upright. After exiting the airplane, the pilot saw the wing flaps were fully retracted and were not extended to 15°. The airplane sustained substantial damage to the lower fuselage. A review of the cockpit voice recorder (CVR) data found that during the startup, taxi, and attempted takeoff from runway 27, there was no discussion of checklist usage or configuration settings for the airplane. A review of the airplane flight manual (AFM) found two checklists where the flight crew sets and confirms the flap position before takeoff. Postaccident examination of the airframe confirmed flight control continuity. The flap handle and the flap mechanical indicator on the pedestal were found in the fully up position (0°). Both engines were found to be operating and responding to power lever inputs throughout the takeoff roll and the accident sequence. Airframe to engine control continuity for both engines was established. At the time of the accident, the estimated density altitude for the airport was 11,244 ft msl. A review of video footage from an automated weather observing system (AWOS) camera facing east showed an extended windsock with an east wind during the takeoff and subsequent aborted takeoff. The wind was from 120° at 12 kts, with gusts to 17 kts, which exceeded the airplane’s maximum tailwind component for takeoff. According to the FAA-approved AFM, for a field pressure altitude of 9,000 ft, a takeoff weight of 24,000–25,000 lbs, and an outside air temperature of 20°C, the runway length needed for takeoff would have been 6,448–7,035 ft with 15° flaps. For a field pressure altitude of 9,000 ft, a takeoff weight of 24,000–25,000 lbs, and an outside air temperature of 20°C, the runway length needed for takeoff would have been 7,912–9,308 ft with 0° flaps. Based on the available evidence, it is likely that the flight crew did not properly configure the airplane for the takeoff in the high-density altitude environment, as the flaps were found at 0° instead of 15°. Additionally, the flight crew attempted to take off with a tailwind that exceeded an operational limitation for the airplane. If the flight crew had used their checklists, the flaps would have been appropriately set during the before takeoff checks and the lineup checks.

On July 20, 2024, about 1339 mountain daylight time, a Hawker Beechcraft Corporation Hawker 900XP airplane, N526FC, sustained substantial damage when it was involved in an accident near Telluride, Colorado. The pilot and the copilot were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. The airplane was owned by Swamp Bird, Coral Gables, Florida. The airplane was operated by Foreshore Capital, Coral Gables, Florida. The airplane was managed by Corporate Air Charters, Miami, Florida, who provided the two flight crewmembers for the airplane. According to ADS-B data, the airplane landed earlier in the day on runway 9 at Telluride Regional Airport (TEX), Telluride, Colorado. The accident flight was a positioning flight without passengers, returning to Miami Executive Airport (TMB), Miami, Florida. TEX is located at 9,069 ft mean sea level (msl) on a 1,000-ft mesa, with rising, mountainous terrain in all quadrants. The FAA Chart Supplement included the following airport remarks for TEX at the time of the accident: “Rwy 09–27 recommended tkf Rwy 27, land Rwy 09 and avoid populated areas. Rwy 09–27 grade –.08 on rwy ends, –1.3 to approximately midpoint then +.75.” The pilot reported the planned runway for departing on the positioning flight was runway 27 (7,111 ft length and 100 ft width). The flight crew entered the airport’s AWOS information into the airplane’s flight management system. Performance calculations performed by the flight crew showed that a takeoff roll of 6,800–6,900 ft would be needed with the wing flaps extended to 15°. The copilot was flying the airplane during the takeoff. During the takeoff roll on the dry asphalt, the airplane did not attain 75% of the planned takeoff speed about halfway down the runway, so the copilot decided to abort the takeoff. The brakes, the air brakes, and the thrust reversers were used to slow the airplane, however the airplane “wasn’t slowing down.” Maximum braking was then applied, and the airplane began to depart the runway to the right. The airplane traveled over the EMAS and stopped about 150 ft from the runway threshold. The EMAS, which had a length of 292 ft and a width of 122 ft, sustained impact damage from the runway excursion. After the airplane came to rest partially on the EMAS and partially on a grass field, the flight crew attempted to stop the two turbofan engines by closing the high-pressure (HP) and low-pressure (LP) fuel flow controls; however, the engines continued to operate. The pilot and copilot egressed from the main cabin door, located on the front left side of the fuselage, without incident. After exiting the airplane, the pilot saw the wing flaps were fully retracted and were not extended to 15°. TEX personnel disconnected the airplane batteries in an attempt to stop the engines, without success. The engines finally stopped when the pilot manually adjusted the fuel control unit (via the power lever angle) under the direction of a mechanic on the telephone. A review of CVR data found no discussion of checklist usage or a briefing during the approach to runway 9 on the previous flight. During the startup, taxi, and attempted takeoff from runway 27, there was no discussion of checklist usage or configuration settings for the airplane. The airplane sustained substantial damage to the lower fuselage. Postaccident examination of the airframe confirmed flight control continuity. The flap handle and the flap mechanical indicator on the pedestal were found in the fully up position (0°). The nose landing gear was pushed up into the lower fuselage, and the HP and LP controls on the pedestal were damaged and could not be moved into their respective cutoff positions. Airframe to engine control continuity for both engines was established. Postaccident download of the two Honeywell N1 digital electronic engine control units revealed that both engines were operating and responding to power lever inputs throughout the takeoff roll and the accident sequence. Airplane maintenance records showed that with the onboard fuel weight and an estimated weight of the two flight crewmembers, the airplane weighed about 24,374 lbs at the time of the accident. According to the Hawker 900 XP AFM, for a field pressure altitude of 9,000 ft, a takeoff weight of 24,000–25,000 lbs, and an outside air temperature of 20°C, the runway length needed for the takeoff would have been 6,448–7,035 ft with 15° flaps and 7,912–9,308 ft with 0° flaps. The AFM before-takeoff checklist included “Flaps – Set” and the lineup checklist included “FATS – Checks flaps, airbrakes, trims, and V speeds.” The Corporate Air Charters checklist for the airplane included the same information for the before-takeoff checklist and the lineup checklist as found in the AFM. The AFM also specified that the maximum tailwind component for takeoff and landing was 10 kts. At the time of the accident, the estimated density altitude at TEX was 11,244 ft msl. A review of video footage from an AWOS camera at TEX (located just to the north of the runway and facing east) showed an extended windsock with an east wind during the takeoff and subsequent aborted takeoff. About four minutes before the accident, the AWOS reported the wind originated from 120° at 12 kts, with gusts to 17 kts. A postaccident functional check of the AWOS revealed that the system was functioning normally within standard operating tolerances. A review of the AFM did not find any guidance on how to shut down the engines if the shutdown checks and the emergency evacuation procedures do not work, nor is such guidance required by the FAA. A previous accident with N21SA (a Hawker Siddeley HS 125-600A airplane) in Bromont, Quebec, Canada, found that the flight crew was unable to shut down the left side Honeywell TFE731-3 engine using the AFM guidance due to the damage sustained to the fuselage in the accident sequence.