Takeoff Ad Absurdum

In the vast hierachy of stupid pilot tricks, perhaps none surpasses an accident caused by intentional operation of an aircraft with a serious known mechanical defect. Case in point: the attempted takeoff of an Aerospatiale SN-601 bizjet last March at Portland, Oregon, despite the pilot's inability to get the right engine started. The aircraft never got out of ground effect before it crashed, which was probably the only reason the four occupants escaped injury. What makes this accident particularly memorable is the fact that the entire fiasco was captured verbatim on the bizjet's CVR, including the disbelieving protestations of the right-seater (an unrated private pilot) when he realized what the captain was about to try. We hereby offer the full NTSB factual report, CVR transcript and all.

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NTSB Identification: SEA98FA047.
Accident occurred MAR-19-98 at PORTLAND, OR
Aircraft: Aerospatiale SN-601, registration: N600RA
Injuries: 4 Uninjured.

History of Flight

SafetyOn March 19, 1998, at 0918 Pacific standard time, an Aerospatiale SN-601 Corvette,N600RA, owned by R. L. Riemenschneider Enterprises of Redmond, Oregon, and operated byRedmond Flight Center of Redmond, Oregon under contract to the aircraft owner, experienceda loss of control during an attempted takeoff from runway 10L at Portland InternationalAirport, Portland, Oregon, and impacted signs, lights, and terrain on the airportproperty. The aircraft slid upright for approximately 1/2 mile following initial groundcontact and came to rest on airport property southeast of the runway 10L departure end.The airplane, a transport-category aircraft equipped with two Pratt & Whitney CanadaJT15D-4 turbofan engines and a seating configuration of two flight crew and 10 passengerseats, was substantially damaged in the occurrence. The commercial pilot-in-command andthree passengers escaped the aircraft without injury; there was no qualifiedsecond-in-command aboard. The pilot reported to an on-scene FAA investigator that theflight was a 14 CFR 91 executive/corporate transport flight, and the flight was proceedingunder visual flight rules (VFR) to Redmond, Oregon. Visual meteorological conditionsprevailed at the time of the accident.

Recordings of Portland air traffic control (ATC) tower communications disclosed thatthe flight originally received an instrument flight rules (IFR) clearance to Hermiston,Oregon. After taxiing out from the parking ramp at Flightcraft, Inc. (a fixed-baseoperator [FBO] serving Portland International Airport), the pilot called Portland groundcontrol and stated he wanted to return to Flightcraft. The aircraft was cleared to do soand returned to Flightcraft. In a post-accident interview with NTSB investigators on April3, 1998, the pilot stated he did not know why he returned to Flightcraft after the initialtaxi out.

Witnesses at Flightcraft reported that after returning to the Flightcraft ramp, theairplane shut down and opened its main entry door, and that one of the aircraft occupantstold Flightcraft ground service personnel the aircraft had an engine problem. Witnessesreported that, at that time, they saw the pilot of the aircraft in the cockpit, talking ona cellular telephone (a cellular phone service record provided by the pilot revealed thata call was placed from his phone to the Redmond Flight Center at 0910; this call tookplace during a 3 minute and 22 second power interruption to the accident aircraft’scockpit voice recorder.) Flightcraft personnel reported that the pilot did not ask for anyassistance from them after returning to the Flightcraft ramp, and that Flightcraft did notprovide any assistance to the aircraft at that time. The witnesses reported that afterreturning to the Flightcraft ramp, the aircraft remained there for approximately 5minutes, then started back up and taxied back out. In the April 3, 1998 interview with theNTSB, the pilot stated he could not recall what (if anything) was done to resolve thesituation for which the airplane returned to Flightcraft. The witnesses stated they couldnot tell whether or not the airplane started both engines prior to taxiing back out.

After taxiing out from Flightcraft the second time, the pilot canceled his IFR flightplan to Hermiston with ATC, and requested and received a VFR clearance to Redmond, wherethe accident aircraft was based. In the April 3, 1998 NTSB interview, the pilot statedthat the destination changed from Hermiston to Redmond because "somethingchanged", but stated he did not know what changed to cause the change in destination.The Redmond Flight Center employee who took the 0910 cellular phone call from the pilotwas contacted and told investigators that during that call, the pilot instructed him toprepare N37HB (a Piper PA-31T Cheyenne twin-engine turboprop airplane also owned by R.L.Riemenschneider Enterprises and operated by the Redmond Flight Center for that company)for flight.

Witnesses who observed the accident sequence from the Flightcraft ramp reported thatthe airplane’s nose lifted off at about taxiway A4 (about 4,100 feet down the 8,000-footrunway), and that the airplane subsequently became airborne with its wings rocking,reaching a maximum altitude of about 5 to 10 feet above the ground. The Flightcraftwitnesses, one of whom stated he had seen the accident aircraft operating out of Portlandon previous occasions, remarked that the airplane seemed to be going much more slowly thanusual at rotation, and seemed much quieter than usual during the takeoff attempt. Thewitnesses stated the aircraft subsequently settled back to the ground and entered anupright slide. The aircraft struck and demolished the A1 taxiway sign during the event.Immediately following the event, the pilot radioed the Portland tower on the groundcontrol frequency, stating he had experienced an engine failure.

In an initial written statement to the on-scene FAA investigator immediately followingthe accident, the pilot stated: "[At] V1 started to rotate just lifted off when[right engine] failed causing enough yaw put aircraft back down tried to get control ranoff runway surface, tried to keep aircraft as straight as possible, came to stop….Saw a[generator] light come on (R.H.) at time we started to rotate, I think the right [engine]failed at that time. Everything else was a [blur.]" In the April 3, 1998 NTSBinterview, the pilot stated that during the takeoff attempt, everything was "goingfine" until he pulled back on the wheel at rotation speed, and that the next thing hecould recall was sitting in the grass. The pilot stated to NTSB investigators that he wasnot sure whether or not an engine failed on takeoff. The pilot reported that he used thetakeoff flap setting for the takeoff (a modification incorporated to the accident aircraftalso allows takeoffs with flaps at 0 degrees.)

One of the passengers was in the copilot’s seat during the accident, but stated he didnot perform any copilot duties. This passenger holds a private pilot certificate with anairplane single-engine land rating only, and as such did not meet the requirementsspecified by Federal Aviation Regulations (FARs) to act as second-in-command of theaccident aircraft, which specify (among other requirements) that the second-in-commandmust hold appropriate category and class ratings for the aircraft. (The minimum flightcrew for the SN-601 is two, consisting of a pilot and copilot.) This passenger, who wasinterviewed by telephone on March 24, 1998, stated he first noticed about halfway down thetakeoff roll that the airplane was to the right of the runway centerline, and that"somewhere during the takeoff roll, we must have lost power on one of theengines." He stated that the airplane subsequently went off the runway into thegrass.

The two passengers seated in the rear of the aircraft did not answer requests by theNTSB to provide written statements describing the accident sequence.

The accident aircraft was equipped with a cockpit voice recorder (CVR). The CVR wasremoved from the accident aircraft and sent to the NTSB CVR Laboratory in Washington,D.C., where a transcript of the CVR recording was prepared. Pertinent details of the CVRtranscript are presented in the FLIGHT RECORDERS section below.

The accident occurred during the hours of daylight at approximately 45 degrees 35.2minutes North and 122 degrees 34.6 minutes West.

Other Damage

During the accident sequence, the aircraft struck taxiway lighting, and struck anddestroyed the A1 taxiway sign adjacent to Portland International runway 10L.

Personnel Information

The pilot-in-command’s business card identified him as the director of operations ofthe Redmond Flight Center (which was a 14 CFR 135 on-demand air taxi certificate holder;however, the accident aircraft was not listed on Redmond Flight Center’s 14 CFR 135operating certificate.) At the time of the accident, the pilot held a commercial pilotcertificate with airplane single- and multiengine land ratings, an instrument-airplanerating, and an SN-601 type rating. He received his SN-601 type training through RoyalAviation of Mesa, Arizona, and completed the practical test for his SN-601 type rating inCalifornia in October 1997. The pilot also held a flight instructor certificate withairplane single engine and airplane multiengine ratings at the time of the accident. Thepilot reported his flight experience as 4,500 hours total including 4,400 hourspilot-in-command, 3,000 hours multiengine, and 125 hours in type.

The occupant of the copilot’s seat at the time of the accident held a private pilotcertificate with an airplane single-engine land rating only, issued on June 26, 1991. Thecopilot’s seat occupant submitted copies of his pilot logbook to the NTSB. Most entries inthe submitted logbook excerpts were incomplete, but indicated that the copilot’s seatoccupant had logged approximately 615 hours of single-engine airplane time. Additionally,although he was not multiengine rated, the copilot’s seat occupant had logged 17 hours ofmultiengine airplane time, including 5.0 hours of flight time in N37HB, the PA-31TCheyenne aircraft also owned by R.L. Riemenschneider Enterprises. The most recent entry inthe copilot seat occupant’s pilot logbook was dated July 23, 1997.

Aircraft Information

The accident aircraft (Aerospatiale SN-601, serial number 36) was manufactured inFrance in April 1978. The aircraft was originally operated under French registration, andsubsequently operated under Mexican registration, prior to being imported into the U.S. in1994 by R.L. Riemenschneider Enterprises. The aircraft entered the U.S. in July 1994 undera ferry permit with its original U.S. registration number, N601RC, at Montgomery Field,San Diego, California, where work was begun on the aircraft at Crownair, Inc. in order toobtain original U.S. airworthiness certification. Prior to this work being finished byCrownair, a decision was made by the aircraft owner to finish the work at a differentfacility, and the aircraft was issued a ferry permit to fly from Montgomery Field to Mesa,Arizona. The aircraft was flown to Mesa in December 1994, where the work required to bringthe aircraft into compliance with its U.S. type certificate (number A37EU) was completedat Royal Aviation. Following a test flight for the purpose of demonstrating compliance anda conformity inspection by an FAA-designated airworthiness representative (DAR), anoriginal U.S. transport-category standard airworthiness certificate was issued for theaircraft on May 1, 1995. The aircraft’s registration number was changed to N600RA inAugust 1995. Daily aircraft time sheets supplied by the operator with the aircraftmaintenance records indicated that as of March 14, 1998 (five days before the accident),the aircraft had 2,305.2 hours total time in service.

The aircraft was equipped with two Pratt & Whitney Canada (P&WC) JT15D-4turbofan engines, each rated at 2,500 pounds sea-level takeoff static thrust. The aircraftrecords indicated that the installed engines (serial numbers PCE 70057 on the left and PCE70078 on the right) were the original engines delivered with the aircraft when new. Theright engine was overhauled by P&WC on June 23, 1994 at 1,782.3 hours and 1,624 cyclessince new.

Each engine is equipped with a 10.5 kilowatt, 28.5 volts direct current (VDC)starter-generator driven through the engine high-pressure (N2) spool. Thestarter-generator installed on the accident aircraft’s right engine bore a data plateidentifying it as being manufactured by SEB of Boulogne-Billancourt, France, in July 1976.The data plate identified the unit as a type 8046-1, serial number 145. The most recententry in the right engine log pertaining to starter-generator installation stated that onOctober 13, 1995, an overhauled starter-generator, serial number 77097A52, was installedon the right engine by Royal Aviation of Mesa, Arizona. There was no associatedhours-in-service entry made with this logbook entry. The serial number 77097A52 referencedin this log entry did not match any numbers observed anywhere on the installedstarter-generator.

The aircraft log indicated that the airplane was to be inspected and maintained inaccordance with the manufacturer’s (Aerospatiale’s) recommended program, document number601A.100.10F, in accordance with 14 CFR 91.409(f)(3). The referenced document,Aerospatiale’s maintenance planning document (MPD) for the SN-601, gives requirements forA, B, and C (minor maintenance) and D (major maintenance) checks at specified intervals offlight hours and/or calendar months. According to the aircraft log, the most recentaircraft inspection was an A check, signed off by a Redmond Flight Center mechanic, onOctober 1, 1997 at 2,159.9 hours in service. Additionally, A, B, and C, and D inspectionswere signed off as complied with by the same Redmond Flight Center mechanic on March 15,1997 (there was no associated hours in service entry made with this signoff.) Based oncomparison of these log entries with copies of the MPD inspection cycle supplied by theoperator, the aircraft was in compliance with the MPD inspection cycle at the time of theaccident and was due for A check not later than April 30, 1998 or 2,379.9 hours inservice, and for B check not later than May 31, 1998.

The SN-601 MPD identifies the starter-generators as utilization limits items, withspecific maintenance tasks including bearing replacement specified at 750-hour intervals.Additionally, there is a 1,200-hour time between overhauls (TBO) interval on thestarter-generators. No service tracking records pertaining to any of the utilizationlimits items listed in the SN-601 MPD were found in the aircraft maintenance recordssupplied by the operator to investigators.

The aircraft records indicated that the accident aircraft was fitted with modificationM.1382, which provided a maximum gross weight increase to 7,000 kilograms (15,432 pounds).The pilot reported a takeoff gross weight of 5,703 kilograms (12,573 pounds) including afuel load at takeoff of 320 U.S. gallons, or 2,144 pounds.

Performance information in the SN-601 airplane flight manual (AFM) indicated that underconditions approximating those of the accident (airplane gross weight 5,700 kilograms or12,569 pounds; temperature 10 degrees C or 50 degrees F; pressure altitude 0 feet; flapsat takeoff setting; 7 knots tailwind component; and anti-ice off), the following values oftakeoff data existed: V1 (critical engine failure speed) 103 knots indicated airspeed(KIAS); VR (rotation speed) 109 KIAS; V2 (takeoff safety speed) 115 KIAS; and balancedfield length 1,245 meters or 4,084 feet. The airplane’s maximum nose gear steering speedis 70 KIAS, and its inflight minimum control speed (VMC) is 93 KIAS with flaps at takeoffsetting and 110 KIAS with flaps at 0 degrees. Stall speed at a gross weight of 5,700kilograms (12,566 pounds) is 97.5 KIAS with flaps at takeoff setting and 108 KIAS withflaps up.

Performance data in the AFM further indicated that under the takeoff conditions givenabove, and with failure of one engine at V1, the SN-601 is capable of a net climb gradient(defined as actual climb capability minus 0.8 per cent) of 4.5 percent during firstsegment (liftoff to 35 feet above the takeoff surface) with landing gear down, and 6.3percent during second segment (35 feet above takeoff surface to 400 feet above takeoffsurface) with landing gear up.

The minimum flight crew for the aircraft is two, consisting of one pilot and onecopilot.

Meteorological Information

The 0856 Portland hourly observation gave conditions pertinent to computation oftakeoff performance as: winds from 300 degrees magnetic at 7 knots; temperature 11 degreesC (52 degrees F); and altimeter setting 30.07 inches Hg. Visual meteorological conditionswere reported, and the pilot gave the runway condition as dry in his accident report.

Aerodrome and Ground Facilities

Portland International runway 10L is an 8,000 by 150 foot grooved asphalt runway. Theairport elevation is 27 feet above mean sea level (MSL), with both ends of runway 10Lbeing 25 feet above MSL.

Flight Recorders

The accident aircraft was equipped with a Fairchild model GA-100 CVR, serial number1622, which was installed in the aft fuselage bay. An FAA aviation safety inspector fromthe Hillsboro, Oregon, Flight Standards District Office took possession of the CVR at theaccident site. The CVR was then shipped to the NTSB CVR Laboratory in Washington, D.C.,where a transcript of the last 23 minutes of the CVR recording was prepared. The exteriorof the CVR showed no signs of impact damage, and no signs of any fire or heat damage werenoted. The CVR laboratory reported that the CVR recording contained three channels of goodquality audio information, consisting of one channel from the cockpit area microphone(CAM) and two channels of audio information obtained from the captain’s and firstofficer’s radio/hot mike intercom selector panels (HOT-1 and HOT-2, respectively.) The CVRtranscript indicated that the sequence of events was recorded as follows.

At 0856, the pilot called Portland clearance delivery and requested and received an IFRclearance to Hermiston. The CAM then recorded sounds of an engine starting between 0857:56and 0858:24. At 0900:24, the pilot called for taxi and received taxi clearance.

The CAM then recorded the sound of an engine starter being activated two times, at0901:08 and again at 0902:15. At 0902:31, the copilot’s seat occupant asked, "youstartin’ the right engine?" The pilot replied, "yeah tryin’ to." Thecopilot’s seat occupant then said, "right generator, right pressure." At0904:07, the CAM recorded the sound of an engine starter being activated a third time.

At 0904:27, the pilot stated: "It’s not runnin." The copilot’s seat occupantreplied, "at all", then said "fuel’s on I take it." At 0904:53, thepilot called ground control and requested and received clearance to taxi back toFlightcraft.

At 0905:23, the copilot’s seat occupant asked, "normally like in the Cheyenne whenyou start it you see the fuel spraying, you know it goes ch ch ch it’s not even doing thatis it?" The pilot replied, "nah uh, it’s like we’ve got no starter." Thecopilot’s seat occupant asked, "like the starter-generator maybe?" The pilotreplied, "yeah." The copilot’s seat occupant subsequently asked, "we’ve gottwo brand new ones on here don’t we?" The pilot replied, "well I’d thoughtthey’d replaced that one on the right." A discussion between the pilot and thecopilot’s seat occupant then ensued for approximately one minute (until 0906:51),consisting mainly of questions by the copilot regarding starter-generator system operationand the pilot’s attempts to resolve the problem, and associated replies by the pilot. At0908:28, the CAM recorded the sound of engine shutdown. Power was then interrupted to theCVR for approximately 3 minutes and 22 seconds, from 0908:41 to 0912:03.

At 0912:03, the CAM recorded the sound of an engine starter being activated a fourthtime. The CAM then recorded the pilot saying, "nothin." The CAM then recordedthe copilot’s seat occupant saying, "that’s that", and the pilot replying,"that’s that." The CAM then recorded the pilot stating "hear it runnin’ -it’s not -", and the copilot’s seat occupant asking, "what is it that’srunnin?" The CAM then recorded the pilot replying, "well I think it’s just thegenerator side it’s not engaging the starter." At 0912:25, the CAM recorded the soundof an engine starter being activated a fifth time, then the copilot’s seat occupantsaying, "hmm." The CAM then recorded the sound of an engine starter beingactivated two more times, at 0912:39 and again at 0912:43. At 0912:46, power to the CVRwas again interrupted, for approximately 16 seconds.

At 0913:02, the CAM recorded the sounds of engine starter and ignition being activated,and at 0913:12, the sound of an engine starting. The CAM then recorded one of the rearseat passengers asking, "do you have to compression start it?" The CAM thenrecorded the pilot’s reply, "might be", and the sound of a laugh. At 0913:27,the pilot called ground control for taxi and received taxi clearance to runway 10L. At0913:58, the pilot asked the ground controller to cancel his IFR clearance to Hermiston,and stated that he wanted VFR to Redmond.

At 0914:48, the CAM recorded an unidentified aircraft occupant asking, "did youget the right engine started?", and the pilot’s reply, "no." The CAM thenrecorded an unidentified aircraft occupant asking, "are you gunna", and thepilot’s reply, "I doubt it." The CAM then recorded an unidentified aircraftoccupant asking, "(it’s able to) fly on one engine isn’t it?", and anunidentified aircraft occupant replying, "yeah." At 0915:00, the CAM recordedthe sound of an engine starter being activated for the eighth time.

At 0915:06, the copilot’s seat occupant asked, "why?" and the pilot replied,"well we’re not going to get any were [sic] sittin’ here." The copilot’s seatoccupant asked, "have some, we can have somebody bring the Cheyenne can’t we?"At 0915:16, Portland ground control called the pilot and gave the pilot a VFR clearance toRedmond.

At 0916:00, the pilot said, "should be able to compression start it once it getsin the air." The copilot’s seat occupant replied, "seriously?", and thepilot stated, "yeah." The copilot’s seat occupant asked, "why would, whywould you say that? I mean is there something that the air will do that you can’t do hereon the ground?" The pilot replied, "yeah it ah it turns the blades over."The copilot’s seat occupant asked, "when will, when will you start it?" Thepilot replied, "well we’re gunna pull the ignition on as soon as we start ah as soonas we get rolling." (NOTE: The SN-601 AFM abnormal procedures section specifies thatN2 RPM be greater than 50% for use of the immediate engine relight procedure, and theminimum airspeed in the normal relight envelope for a normal engine relight withoutstarter is 200 KIAS.) At 0916:48, the pilot called the tower, stating he was ready fordeparture. The tower cleared the flight for takeoff on runway 10L at 0917:01.

The CAM recorded the sound of increasing engine noise at 0917:12. At 0917:46, thecopilot’s seat occupant said, "there’s seventy." At 0918:03, the pilot said,"come on." Three seconds later, at 0918:06, the CAM recorded the sound of abeeping horn starting; the beeping horn sound continued to the end of the recording. At0918:10, the CAM recorded the start of a rumbling sound, which continued until therecording ended six seconds later, at 0918:16.

Wreckage

The airplane wreckage was examined at the accident site and on the parking ramp atPortland International Airport on March 19 and 20, 1998. Initial on-site examinationrevealed a 10 to 20 foot long skid mark going off the right side of runway 10L, at a pointapproximately 5,600 feet down the runway from the approach end. A series of scuff marksalong with taxiway light debris was found on the A1 taxiway (at the departure end ofrunway 10L, to the right of the runway between the runway and parallel taxiway A), and theA1 taxiway sign, located northwest of and adjacent to the intersection of taxiways A1 andA, was completely demolished. The aircraft had come to rest on its belly approximately1,100 feet southeast of the runway 10L departure end, approximately 1/2 mile from theinitial skid mark observed on the runway.

Examination of the aircraft following the accident revealed the principal damage to theaircraft to be to its belly, both wing tip fuel tanks, and the leading edge of the rightwing. The aircraft was otherwise largely undamaged. The landing gear and flaps wereobserved to be in the up position. The aircraft’s elevator and rudder were found to befunctional. The control wheels were bound in roll; the left aileron and spoileron had goodmovement but the linkage to the right aileron and spoileron was observed to be broken inthe same general area of the wing as other right wing damage.

No significant external damage was noted to either engine. Both engines would rotatefreely through 360 degrees by hand, with good N1 (fan to power turbine) rotationalcontinuity and with no binding or unusual noises noted. Both engines contained an adequatequantity of clean oil. The right engine inlet was observed to have grass in the fan andgrass seed in the bypass duct. The left engine did not have any grass in any of theseareas. No significant problems with the right engine were noted during a cowl-openinspection of that engine. The fuel line from the right engine fuel-cooled oil cooler wasremoved, and fuel was found in this line.

Inside the cockpit, the left engine oil temperature indicator was observed to becaptured at an indication of 72 degrees C (approximately midrange in the normal operatingarc), with the right engine oil temperature indicating approximately at bottom of scale,less than 20 degrees C (in the yellow arc at bottom of scale.) (NOTE: The oil temperatureindicators are powered by 28 VDC.) Flightcraft personnel reported that they found thelanding gear handle in the up position at the site, and placed it to the down positionwhile attempting to lower the gear during post-accident aircraft recovery operations.

Investigators from the FAA and P&WC removed the starter-generator from the accidentaircraft’s right engine during a follow-up examination in Portland on March 24, 1998. Uponremoval of the starter-generator, the starter drive shaft was found to be fractured, withthe starter drive shaft separated from the starter input spline portion of the startershaft. Upon removal of the small splined portion of the fractured starter shaft from theengine accessory gear box, the engine accessory drive could be rotated via the startergear using a turning tool, and the engine rotated with no unusual noises. Theinvestigators then took the starter-generator to Flightcraft’s maintenance shop, whereelectrical power was applied to the unit for a function check. The starter-generatoroperated normally when electrical power was applied.

The starter-generator and fractured input shaft section were subsequently sent to theNTSB Northwest Regional Office in Seattle, Washington, where the NTSBinvestigator-in-charge visually examined the shaft fracture surfaces. The shaft wasfractured on a 45-degree plane to its axis of rotation, with two separate zones ofscalloping observed.

An on-aircraft functional check of the aircraft’s right engine oil temperatureindicating system was conducted at Portland on April 13, 1998, under FAA supervision. Thischeck revealed the right engine oil temperature indicating system to be functional.

Medical and Pathological Information

Post-accident toxicology tests on the pilot and copilot’s seat occupant were notperformed.

Additional Information

The airplane wreckage was released to Mr. Robert L. Riemenschneider of Redmond, Oregon,on April 13, 1998. Mr. Riemenschneider is the president of R.L. RiemenschneiderEnterprises, which owns the accident aircraft.

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