NTSB Preliminary N300ER Challenger 300 Dana Hyde

LINKS:
NTSB Report: s3.documentcloud.org/documents/23722207/report_era23la135_106816_3_24_2023-10_09_31-am.pdf
AD: s3.documentcloud.org/documents/23722809/faa-airworthiness-directive-bombardier-032423.pdf
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[@glippert07]

Challenger 350 guy here.... basically the same airplane, but with IRS instead of AHARS. Juan, you mentioned at 3:50 that you introduce a lot of problems without a full system restart... you are ABSOLUTELY CORRECT. Whenever we have a mechanical fault or some kind of CAS message on the ground, our very first (and best) troubleshooting tactic is to do a full cold and dark reset of the entire jet. I'm talking shut down the apu, all busses, and disconnect the batteries for 30 seconds. At 6:50 you mention that the V-Speeds were not set. Another reason the crew should've realized that the speeds were not set, is that the CL-30 flight director requires the flaps to be set and THE V-SPEEDS SET FOR TAKEOFF. Otherwise, the vertical mode on the flight director will default to PITCH mode instead of TO. at 9:00 You mention the 'PRI STAB TRIM FAIL' Message. This airframe has a known problem with runaway trim... not every tail does it, but it's something that Bombardier has been trying to chase down and figure out. With this problem, we have a number of stabilizer trim tests we do before every flight and additional QRC items... the first and most important one is this 'PRI STAB TRIM FAIL' message. The ONLY ITEM on that QRC checklist is to TURN OFF THE STABILIZER TRIM AND LEAVE IT OFF. The QRH2 which contains all of our emergency procedures tells you to turn on the SECONDARY stabilizer trim and fly with that (if it works). you will not have the autopilot, but you're still flying and still able to trim the stabilizer. At 13:30 you mention all of the stabilizer trim inputs that the FDR recorded. This is what I imagine was kicking off the autopilot in the beginning of the flight. With this airframe any pitch trim inputs will disconnect the autopilot. this is again regarding the runaway trim issue that Bombardier has been trying to chase down: They are pretty sure the issue is in the stabilizer trim switch and that might be an issue that this aircraft was experiencing... but I'm just speculating. This report hit me pretty hard when I read it a few days ago. The amount of poor airmanship is astounding. Thanks for the video Juan.

[@FamilyManMoving]

Ctrl-Alt-Delete works with turbo/jets, too? I fly little GA planes...we just get out and kick the frame, swear a little, then get back in and hope the ground in front of us is soft. Actually...I go back and get it looked at. I've considered not flying for the smallest things. As some other commenter stated above, I am a devout coward when it comes to airplane problems.

[@rmf1981]

@@FamilyManMoving There's a saying about "old and bold" pilots. Nothing wrong with favoring being an "old" pilot.

[@sx300pilot5]

Having been on the CL35 for quite a few years now, a couple points of contention: -Our fleet has been extremely reliable, and our POI has adamantly stated that a batteries disconnected reset is NOT a legal maintenance procedure. Not that we really have needed to. We rarely see an issue if the power-up was completed properly. -the V-speeds may have been set initially. A RTO will normally automatically drop the V-speeds -I’m not sure where the ‘known runaway trim’ comes from. Having worked for probably one of the largest operators of 350s, it’s not been an issue. We’ve had more issues with dumping both hydraulic systems due to a seal in the flap motor valve failing though. -although I have seen the Pri Stab Trim Fail msg a couple of times, most times it’s on final and a self-induced condition caused by former Citation pilots who rapidly push the A/P disconnect button multiple times. A software update has mostly corrected it, but it still pops up from time to time.

[@glippert07]

@@sx300pilot5 "-Our fleet has been extremely reliable, and our POI has adamantly stated that a batteries disconnected reset is NOT a legal maintenance procedure. Not that we really have needed to. We rarely see an issue if the power-up was completed properly. " This isn't a maintenance procedure, its a troubleshooting procedure. Every time something comes up where we have to call our mechanic, the first thing he says is "did you do a full reset?" "-the V-speeds may have been set initially. A RTO will normally automatically drop the V-speeds" all I was saying here is that during the SECOND takeoff where the vspeed's were NOT set, the flight director not engaging in TO mode should've been a pretty obvious hint to the pilots after they pulled their pitot cover off.

[@clifgee]

So I gather there is no correlation to pitch trim failure and and mismatched airspeed (pitot cover). Or could this have contributed somehow?

[@pilottou]

Been flying corporate for awhile. Once all the pax are on board, I do one last quick walk around. Chocks, covers, panels, etc. I don’t care how much of a hurry they are in, 45 seconds it takes to walk around is cheap insurance.

[@rich.cicciu3273]

I'm a mechanic that has been working then Challenger 300/350 series aircraft for 20 years +, it's a solid platform, looks pretty clear to me, fdr said AP was initiated 3 times, and trimmed out fine in manual, should have left it in manual and got on the ground asap, especially with RUDDER TRIM FAULT cas posting, that is a grounding item, not deferrals for good reason, 2 big mistakes here, after aborted TO, complete shutdown should have been accomplished and checklists should have been complied with from step 1, chances are had that been done aircraft would have been fine, crew familiarity seems to be an issue, RE the passenger probably wasn't wearing seat belt or had the table open or something, Good Job, BL, thoughts and prayers to the family...

[@realdizzle87]

Something you missed here: the flight crew did not execute the proper checklist for the AP Stab Trim fault. There is a checklist specifically for the Auto-Pilot Stabilizer Trim Failure. They started running the checklist for Primary Stabilizer Trim Failure... they are different procedure for different conditions. In this case, it seems likely that the crew failed to enter the proper data into the PFC during their pre-flight. This explains both why they didn't have v-speeds on the takeoff and why they got the trim warnings. They never entered the weight and balance data in the PFC before the flight. Because the AP didn't know how the aircraft was loaded, once they got airborne and engaged the auto-pilot, once the plane got to the 6,000 ft it was original cleared to - the AP tried to trim for straight and level flight. But, because it didn't have the actual weight and balance data, the AP reached it's authority limit for adding nose-down stab-trim and said "Caution: I've added all the trim that I'm allowed to add and the plane still is holding a nose-up attitude." The AP says: "Okay, based on the weight and balance data that I have, I'm not allowed to add any more stab-trim but I do want to get the plane to level flight. So, I'm going to start adding elevator inputs to hold the nose down and, I'm going to let you know that by giving you another Caution message that literally tells you: I'm holding the nose down." This was just a complete comedy of errors by a crew that clearly wasn't sufficiently trained on this aircraft.

[@seanraymond4336]

Spot on!

[@johnbriggs3916]

I think you mean Tragedy of Errors.

[@kamakaziozzie3038]

Excellent analysis. Thank you

[@jamesprice6381]

Wrongful death suit..............................

[@br4nd0nh347]

Get-there-itis strikes again?

[@AgentJayZ]

It seems to me that your analysis of these events is the best and most detailed anywhere. You even help explain what's between the lines in the NTSB reports. Thank you blancolirio!

[@blancolirio]

Thanks JayZ!

[@devinfreeman4580]

In the challenger we have a slew of memory EP's. This particular procedure is not one of them. This was not runaway trim, it was a failure of the autopilot trim function. I've seen a few mentions that they should have just clicked off the autopilot from muscle memory and that's simply incorrect. The problem is that the checklist used was not appropriate for the failure. (from what I can tell with the information presented in the preliminary) There were several messages posted but of the three the driving failure was the "AP STAB TRIM FAIL." There is a specific checklist for this and it contains a warning directing the crew to have all passengers seated and belted prior to any action as there can be abrupt changes in control force once the autopilot is disengaged.

[@toddrader1698]

This was always emphasized in my Initial and Recurrent training.

[@j_taylor]

Thank you for explaining.

[@elderbob100]

There does seem to be a similarity in the checklist names. Could be confusing in a high workload environment. Sounds like crappy software. Pretty easy to fix that. Not trying to cover for the pilots, just pointing out jargon that doesn't need to be there. Are the checklists provided on the glass displays, or do they require the pilots to find them elsewhere?

[@boeingav8tr525]

Exactly!! This is not a memory item. Read the QRH and apply the CORRECT checklist. They rushed, picked a similar checklist and went for a wild ride because it was the wrong checklist

[@jeffxjet]

@@elderbob100 There is nothing wrong with the checklist verbiage, you just have to be able to accurately identify which problem you have. Amber cautions are NOT time critical. You take your time, analyze the problem and execute the correct checklist. The emergency and caution checklists are in a separate book located in a open pocket just under the copilots right arm. It's literally just under your resting arm while we are flying. You don't even need to look to find it, you just reach under your elbow.

[@bks252]

So many things telling them to stop, take a breath, start over. Something I learned from 28 years in Army aviation is often the aircraft is trying to tell you something if only you’ll listen.

[@andym11395]

First time commenting, but have followed the channel for years and watched every video. As always, job well done. Unfortunately, this accident highlights just how good Airline philosophy really is. At my airline (and all prior to this) we are not allowed to depart with an unresolved ECAM/EICAS message (A320 currently). As you stated, the airplane is trying to tell you something. This reminds me of a situation I had while flying the E175. After a rejected takeoff we had all data drop from the box, and subsequent “A/P 1/2 FAIL, FLT CNTL NO DISP, and multiple other faults appear on our EICAS. We had to RTG and completely shut down and restart the aircraft. To clarify that is not a normal reaction to a RTO, but the aircraft behaved normally after the reset. Again, not being allowed to depart with a know EICAS alert made it an easy decision for us not to continue. I know these part 91/135 Ops have much tighter margins and pax schedules. But money spent on a MTX delay and a few angry pax is a lot cheaper than someone’s life. Thanks again Juan.

[@jeffreywonser3241]

"we are not allowed to depart with an unresolved ECAM/EICAS message" And there's a REALLY good reason why this is the case!

[@sblack48]

In corporate operations one does not always have the luxury of access to ground support by people who know your aircraft type. If a 737 or a320 breaks down in O’Hare there will be dozens of techs available. Corporate guys are on their own. I’m sure this is a common occurrence

[@dashriprock4308]

The most important thing was that that pitot cover was still on. Had to be embarrassing for both pilots. If that had happened to me, I would have shut down, reviewed all data and started over slowly. Bad things happen because of little uncorrected mistakes, creating a snowball effect. Been demonstrated time and again and is psychological. The illumination of the next light would have prompted me to abort everything until thoroughly checked out by a mechanic. This was a bad day. Gremlins happen, just like in the Bugs Bunny cartoons. Expect it. It is the little things that will get a crew in trouble.

[@johncox4273]

Juan, As usual, excellent analysis of the incident. I’ve been following your channel for several years now, and I so appreciate what you have to say on many subjects. Thank you for doing what you do so we’ll. I operated for over 40 years in the corporate world flying airplanes and helicopters. In retirement I work part time at one of the large training centers, and have a couple of comments about incidents such as these. A through preflight is so important. I flew an EMS helicopter for awhile, and it was company policy to walk around the helicopter before EVERY start to check its condition. I do the same with the airplanes, even though I have already done a through preflight. Looking for any doors open, fuel caps not secured, anything dripping, and chocks removed. Only takes a minute and is a good final check. I’ve had a few passengers in a hurry that have questioned this practice, but when I explain it’s for their safety they understand. Checklist use is so important. How many accidents could have been avoided by using one religiously in all phases of flight. Having (and USING) a proper SMS (safety management system) can increase safety so much. Finally the FAA is coming around, and will be requiring part 91 companies to develop and use them. Both these pilots had good flight experience but not much experience in the aircraft type. I tell people with a new type rating that now they have a license to learn. Much like we tell a new private pilot, experience is a wonderful teacher. The simulators we use for training are fantastic, but actually flying the aircraft is certainly educational. If they had flown this aircraft more perhaps they would have had a better understanding of its systems and proper operating procedures. Memory items. The aircraft I’m currently working with has 18 items that must be memorized for the type rating check ride. Once they leave the training facility I tell people to go over them every so often in cruise, or when sitting in the FBO waiting. Some are life or death items, such as depressurization, fire or smoke, and must be run from memory, then backed up by a checklist. Luckily many modern aircraft have electronic checklists on the displays that one can bring up quickly without consulting the QRH. On the Legacy if a CAS message comes up we can just click on it to bring up the correct checklist. Very handy. As you know, recurrent training is vital. At the company I flew with for 23 years we went every six months, and it kept your aircraft knowledge and flying skills sharp. Could be a pain sometimes, but I always learned something every time. I don’t know if the young lady was wearing her seatbelt or not, but from her injuries I suspect not. Keeping passengers in their seats can be a challenge in the corporate world, as we often fly the same people and they would usually get up after take off to get coffee, food or use the Lav in spite of the seatbelt sign. If we expected turbulence after take off we would brief them ahead of time and they would then stay in their seats until we said it was safe. We also recommended that they keep their seatbelt fastened anytime their in the seat. Just common sense. Juan, I am well aware that the 121 world has a much better safety record than 91 and 135, and that we need to do a better job in training and operations. I watch your accident analysis all the time, and see how much we need to improve. I’ve been very lucky in my career. The corporate 91 operators I’ve worked for have all been very safety conscience and have never pressured me to do anything I thought unsafe, and have given me the best training possible. Must have worked-43 years and 18,000 hours without putting a scratch on an aircraft! Again, thank you for your excellent channel, and all the best to you and your family. I’ll be watching😃

[@johncox4273]

Thanks Joe-appreciate that! I’ve always tried to do my job the correct and safe way.

[@jena880]

I found SMS training incredibly interesting and challenging to implement at times. Being part of creating and incorporating was very educational on so many levels. Mostly challenging with non crew and non maintenance individuals.

[@fazole]

Part 121 world, we do a walk around inspection before EVERY flight. If the new crew has not showed up when we are leaving, we must do a post flight inspection too. Post flight inspection also required if leaving the aircraft overnight to be flown next morning.

[@frank_av8tor]

Haven't flown passengers in over 20 years, but before troubleshooting any flight control problems one should probably ensure all passengers are seated and have their seat belts on. Haven't heard if the fatally injured passenger was strapped in or not, does the preliminary report include this information? Also if you're going to turn off the pitch trim (regardless of type), you need to have both hands firmly holding the yoke. What a sad, tragic event.

[@jamesw.123]

Sounds like a pretty sensible suggestion!

[@j_taylor]

Well said.

[@silmarian]

I don’t think it includes the information on if she was belted in. But even if she was rapid G changes of near 7 Gs could make something hit her head with enough force to kill her, or even strike something inside the plane particularly if she wasn’t facing forward. I just looked up the typical interior layout of this plane and it’s pairs of seats, one facing forward and one aft, with a table in between, so if she was seated and belted it could easily have been either flying debris or hitting her head on the table or bulkhead. It is distressingly easy to die from head or spine trauma especially without extremely prompt medical attention and we know it was over 10 minutes (probably well over) before she was seen by EMS given that the CVR backup power was exhausted after that time.

[@ikefork2606]

@@silmarian The instantaneous, rapidly changing G-load forces ("whiplash") applied to the accident victim's neck - nearly 6.5 Gs instantaneous net change or "delta G" - could have caused severe damage to her spinal cord and killed her...........even in the absence of striking her head on a blunt object.

[@dsSpitfiremk4]

Good points. 7g is mighty dangerous even without an impact.

[@johnhirtle4300]

Not a pilot and rarely fly, but this channel, along with Mentour Pilot and 74 Gear fascinate me. Keep the great content coming!

[@kitburns1665]

Same here. I watch those too!

[@TitaniumTurbine]

Wow, I follow the same channels. 74Gear’s video/radio commentary and Mentour Pilot’s full length incident walkthroughs are top tier.

[@chrisclarke4775]

Add Jimmy's World and Fly with Owen and that is about my same Aviation subscription list as well. @@kitburns1665

[@BanjoZZZ]

Yep, maybe your a pilot inside.

[@paulholterhaus7084]

Should read.."You're'..............ATP should be trained in English.............Paul

[@deantait8326]

I was a passenger on an early Challenger about 89-90 several times and although the Corp pilots didn’t care for the fly-by-wire design compared to the companies older G-2’s. The Chairman of this company was very safety cautious 2 multi qualified pilots and the “host” was a company certified mechanic. He also told all of the pilots, if you’re not 100% confident of the aircraft’s safety - don’t fly it, no matter what the senior most management, onboard wanted. I felt very confident on our planes and I was a nervous flyer.

[@willemhaifetz-chen1588]

highest leadership sets the safety culture every time

[@michaeln3527]

* for the record, challengers are not fly-by-wire. Neither the early 600 series you rode back then, nor the brand new 3500 series coming off the assembly line this week, nor anything in between

[@bigdog8891]

Juan. Thanks for the report. This happened in my neck of the woods. Glad to see your subscription count has been steady going up

[@maxmcvicker]

Challenger 300 and 350 pilot here. This may be as simple as not resetting the trim after landing. The negative G limit is -1.0 flaps up.

[@scotts6503]

Former CL30 instructor with 2000+ hrs in the airplane. The rudder limiter cas is a no-go item. During training sessions I would routinely engage the stick pusher from the instructor panel while crew flying on autopilot. This would cause the trim to move without an audible warning. Crew would then receive a cautionary auto pilot holding nose up message. The takeaway from the lesson was that before the autopilot was disconnected the pilot flying must hold the yoke firmly as the out of trim condition can yank the yoke out of your hands and cause an uncontrollable condition.

[@Milkmans_Son]

Which rudder limiter message are you referring to? If both, why have two?

[@markhwirth7718]

Thanx Juan good presentation! Ya know one of the main reasons I became an airline pilot was my love for aviation! I realized early on that safe habit patterns need to be developed into my operations of aircraft . When I flew part 91 and 135 charters there were to many situations where I had to pull rabbits out of a hat ! My best flying times were FAR 121 where everything is spelled out in the Training and SOP ,same airplane, same routes, same approaches , same faces throughout my career! I’ve got 25000 hrs doing the same old thing ! But I never got bored because there still surprises ! Two engine failures , gear wouldn’t come down , total electrical Failure ECT . But nothing that wasn’t spelled out how to deal with . Right now if you put me in a strange airplane i surely would be a hazard ! What I’m trying to say is aviation can be very safe but very unforgiving. And all these pilots coming up thru the ranks don’t get to have it so easy as I have had ! If your going to fly a new airplane , a new route , in unfamiliar weather , ECT I hope your good at pulling rabbits out of a hat when things go wrong ! I never wanted to be put in this situation so I built most of my Time building years as an instructor with the same old routine ! Don’t get me wrong some people are good at pulling rabbits out of hats but not me ! Some people would not like routine flying with the airlines ! Just make sure you know which person you are with or with out the pressures of an emergency. Good luck all of you young and old aviators . Sincerely Captain Mark H Wirth

[@anniechrisbendy6000]

I was on a falcon900 test flight ( cabin ) with lap strap on during overspeed checks ..... and was close to exiting the seat. Tremedous force . A sad story well told as usual... thank you mr browne.

[@RealRickCox]

Seems to me like there were a whole series of issues that should have grounded the flight long before this tragedy. Seems like there are still a LOT of unanswered questions... thank you for covering this.

[@kevint1910]

seems to me a very convenient 'accident' for a person who's bio says absolutely nothing about what it is she did other than working for foreign aid NGO and lately a 'think tank' ... that BIO has spook stamped all over it and she was a high up spook at that given the associations she had

[@NicolaW72]

Indeed, exactly!

[@brianschaer]

There was absolutely NOTHING wrong with the aircraft other than a pitot tube cover left on. NOTHING.

[@RealRickCox]

@@brianschaer If there was NOTHING wrong, what was the point of the AD?

[@brianschaer]

@@RealRickCox that AD is from long ago and most certainly applied to the subject aircraft. It is related to the PAWL brake assembly being installed upside down. A LOT has to fail for it to come into play. HAD NOTHING TO DO WITH WHAT HAPPENED THAT DAY. I CAN ASSURE YOU.

[@robertscranton8293]

Best Aviation channel...period.

[@marcocasati6953]

Hey Juan, forgetting pitot covers has happened also in commercial airline operations, go see the incident of Malaysia airlines on July 2018 where not only they forgot the covers on but the pitot heat melted them, fortunately the outcome was a safe return with no injuries.

[@frankfielder]

Aeroperú flight 603 crashed into Pacific ocean on October 2nd 1996 because maintenance worker forgot to remove tape from pitot tubes. This is easy to miss because tape is not flagged like the pitot tube covers. 70 people lost their lives. Write up in wikipedia if you want more information.

[@janvanhaaster2093]

Birginair flight 301 is a good example what happens when a pitot tube is blocked, 189 killed...

[@miguelfreedom9864]

Juan, I think the detail you’re missing is that the AP was using the elevator to correct for the manual trimming of the stab (nose-down trim against nose-up elevator).There wasn’t enough back-pressure on the AP servo to cut it out automatically, but as soon as the master disconnect was pushed, the elevators returned to neutral and the nose went directly back to the trimmed position. The pilots probably didn’t even have hands on the yoke at this point. The second pitching of the nose down was their reaction to the correction after AP disconnect.

[@brianschaer]

Everything was a result of a) the pitot cover left on and b) using the wrong checklist (STAB PRI TRIM FAIL vs the correct AP STAB TRIM FAIL)

[@realdizzle87]

@@brianschaer You are definitely correct about the fact this crew ran the wrong freakin checklist in the air. And that's pretty terrible in and of itself. But, there were two fuck-ups by this crew during their pre-flights. Obviously the first was not taking off one of the pitot sleeves. But, the second mistake was - the crew didn't enter their weight and balance data into the FC. The dead give-away for that is the fact that they didn't have v-speeds on takeoff. Without entering the specific Weight & Balance numbers, the AP defaults to a standard profile in which it assumes the CoG is more or less over the wings. But with the passengers and baggage on this flight, they were flying a plane that was significantly tail-heavy. Once they engaged the AP on climb-out, the AP did exactly what it was supposed to do and tried to climb them to the 6,000 MSL that they original had been cleared to. But, as they got up there and the AP tried to get back to level flight, it ran out of stab-trim authority. The AP was thinking the plane was pretty well balanced and so if shouldn't take a ton of nose-down stab-trim to hold attitude. It applied all the trim it was programmed to be allowed to input in those conditions and said: Uh-oh... I've added all the stab-trim I'm allowed to and I still can't hold level attitude (that's what threw the AP Stab-Trim Fail caution). Then the AP said, if I can't trim the nose down, I am going to have to add elevator input to get back to level flight. That's what threw the "AP Holding Nose Down" Caution. Literally the auto-pilot was telling them - I'm using elevator input to force the nose-down. And, somehow, those two idiots decided it would be smart to take an airplane that is telling them it's forcing the nose down and flip the switch that deactivates the entire stabilizer trim system.

[@brianschaer]

@@realdizzle87 no, the speeds reset when you abort and the boards come up. Need to resend. Which they didn't do. Also, you cannot select TO/TO on the PFD with no speeds so they blasted off with no flight director.

[@brianschaer]

@@realdizzle87 stab trim would have been at the same position as on the 1st attempt. Unlikely they changed it. CG was never an issue.

[@jimpalmer1969]

Juan, thanks for bringing up the relationship to the MAX accidents. I'm not a pilot but I worked for Boeing for 43 years including 11 years in Flight Test. Memory items are so important. Despite having a quick reference handbook, Boeing airplanes rely on memory items. The QRH has a dozen sections and each section can have many checklist procedures. On Boeing airplanes the procedure for a runaway stab is the same. Turn the electric stab trim off and manually set the stab trim using the hand wheel. On the Lion Air accident there was a third pilot in the jump seat. He was the only one who knew the memory procedure to shut off the electric trim. Once the trim was shut off the upset was recovered and the airplane continued its flight to the destination and safely landed. Lion Air maintenance replaced the AOA vane but failed to properly rig it. This vane is used on multiple models and must be rigged to the airplane it is installed on. The very next flight had the same upset with the runaway stab trim. On this flight the flight crew could not diagnose the problem and the aircraft was lost. The same thing happened on the Ethiopian flight. That means of the seven pilots who were confronted with this problem only one of them knew how to respond. And the Ethiopian accident occurred after the pilots having specific training to deal with a runaway stab on the MAX.

[@dcxplant]

This is why operators should (and in the case of airline ops, never do) operate with two low time in type pilots together. Experience matters a great deal.

[@billtodd6509]

Your clips are so informative and interesting. I learned to fly by an Allegheny Air Lines pilott who was laid off during the early seventies when the recession set in and they were selling off a lot of their planes and he was instructing to keep his hours going and food on the table. He was super professional and drilled those small important details into me such as doing my check lists thoroughly and if I screwed up on my walk around, he would end my day before we got off the ground. You sound like him. I hope the snows over for you.

[@paulreider8321]

Juan, thank you for your in-depth explanations...RIP Dana Hyde 💔

[@bt5762]

“Rudder limit fault” = No Go. QRH#2 go/no go guide.

[@jameshennighan8193]

Yep.....!

[@bradmarcum2927]

@@jameshennighan8193 hey James.

[@toddrader1698]

Sure does! I wonder if they even checked the Go/No Go guide. It would almost be worse if they checked it and then flew anyway.

[@B1900pilot]

YUP! It’s what is trained..( I hope ).??? Furthermore, Part 91 or not, you cannot depart until the item is deferred ( MEL ) or fixed...VERY frustrating this crew was so lacking in discipline and INCOMPETENT.

[@silmarian]

@@B1900pilot Woefully under trained, I’ll grant you. Quite possibly in that deeply unfortunate window everyone encounters when they think they’re more competent than they are, only for most of is the results aren’t fatal for anyone. I can’t help but think this would have been prevented of either of them had more hours on type and what their rest status was. We need to make sure the culture of the company that employed the pilots isn’t or hasn’t put more people at risk. The pilots were ultimately at fault because they made the choice to take off despite the warnings on the ground, but I sincerely hope the NTSB doesn’t end its investigation there and makes sure the company that employed the pilots (which wasn’t the plane owner) is being safe.

[@guyver268]

Speaking as a medic, I would be interested to see the medical report on the injuries. I doubt whether the differential G loading on the body would be the issue but rather blunt force head or neck trauma from an unrestrained passenger forcefully hitting the ceiling as a result of the negative G.

[@ytc9265]

Local group for scanner traffic reported 4 inch laceration to her head. Pt in cardiac arrest upon landing, was resuscitated by fd/paramedics and breathing on her own prior to transport to hospital. Succumbed to her injuries later that day.

[@jase9951]

@@ytc9265 broken neck from hitting the roof perhaps?

[@ytc9265]

@@jase9951 did not hear one way or the other, so I’d only be speculating. But something had to have caused the arrest.

[@jerseyshoredroneservices225]

The negative g or the subsequent positive g when she wasn't expecting it or restrained. -3 to +4 would lift a person to the ceiling and then slam them back down, not necessarily properly in the seat

[@brinkee7674]

Blunt force trauma head, neck, body and extremities. Believe she was unbelted and hit ceiling then slammed to floor. She experienced a swing of over 6 gs. Had heard she may have been in the lav. Plane is owned by a company her husband is a partner with. She was with her family at the time looking at schools in New England

[@daveluttinen2547]

I found that when doing a checklist, if for some reason got distracted and then could not specifically identify each step as having been executed correctly, go back to the first step and start over. I could not in good conscience proceed without being absolutely sure everything was done correctly. Maybe that is overkill, but boy howdy the more complex the system, the more important each step becomes. How awful for the deceased and the families.

[@j_taylor]

Well stated

[@dananichols1816]

Absolutely -- a few seconds to re-start and be sure/press on. That sound habit carries over to doing a thorough walk-around, as well.

[@misguidance__]

A while back there was a Qantas flight from Aus which took off with all pitot tube covers still installed which caused incorrect air speed and they took off using the groundspeed. Mentour Pilot did a great video on it if your interested. Keep up the amazing work here, I love these videos

[@gordonsinclair9947]

Not QANTAS - correct spelling - Malaysian at Brisbane. Mentour pilot report here: kzbin.info/www/bejne/nGmTiKqmg9qUrsk

[@misguidance__]

@@gordonsinclair9947 apologies. Spelling corrected.

[@Bywater-S]

And this flight your talking about returned to the airport safely if I remember.

[@misguidance__]

@@Bywater-S it actually continued the 14 hour flight from Melbourne to Los Angeles. Nothing of note happened apart from the unreliable airspeed due to the covers, but I wanted to mention the flight as it shows the same mistake from this flight can also happen to anyone.

[@Biscaynedave]

Having worked for a company that ran a half dozen CL300s i know they are very finicky and many times in order to clear a message we instructed by Bombadier tech ops to shut the plane down to black and even to go back and disconnect both batteries for 2 min. reconnect batteries and start over, all this with Pax sitting in the back with black cabin, very frustrating.

[@jonesbugattis]

While working in my Dad's hangar in about 1986, I noticed that a T-28 Trojan was heading for the runway with all the red flags in place. I hopped on my scooter and got in their way at the last second before the roll. The PIC Dick Sprague ( former AT-6 Sky-typer team leader) and a local doctor that was learning to fly his new plane, stayed in their cockpit as I removed petot cover and landing gear locking pins. They then wen't ahead with their departure as if nothing had happened! If they had lifted off with the gears locked down, they very likely would have stalled and crashed. It blew me away that they didn't taxi back and at least see what else they missed on the pre-flight inspection. About a week later, they were both fish food in the Atlantic after low level stunt didn't go well. Sometimes you can see a disaster before it happens..

[@bwalker4194]

Excellent stuff, Juan. Here's a little hint I learned from a long-time pilot: If you fly any light plane with electric trim only, get a red circuit breaker cap for the trim CB so you can find and pull it without delay. The trim's electric linear actuator in my Velocity was middling too fast in its actuation so seconds counted. I never had to pull the breaker but was glad for the advice.

[@jackjetpilot]

Talk about a learning moment... these pilots have found themselves with many moments.

[@GLEX234]

You got this wrong, Juan. The crew went to the wrong checklist. The EICAS messages indicted a checklist titled AP STAB TRIM FAIL. The stab trim was operational in PRI mode manually using the control switches. There’s no manual trim wheel. The trim wasn’t running away, more accurately the AP wasn’t trimming while the airspeed increased. That’s the caused the pitch upset, trimmed for a lower speed than was actual IAS at the point the PRI TRIM was incorrectly selected to OFF.

[@MikeKobb]

PPL here, no actual jet knowledge, but from reading the report as an interested bystander, it's not completely clear to me that this is a trim runaway so much as a trim malfunction. Seems to me that a likely explanation here is: - There was a fault with the stab trim, so the AP couldn't trim away control forces. - Because it couldn't trim away those forces, the AP pitch servo was applying a lot of torque (thus that EICAS message about holding the nose down) - When the stab trim system was turned off per the QRH, the AP disconnected. Now it's not holding nose down anymore, and the pilot is handed an out-of-trim aircraft, causing the pitch excursions. I have seen a pro jet pilot opine that actually ensuring that the pax are belted before troubleshooting a flight control issue is a good idea. It's seat belts full-time in my bug smasher so I hadn't considered that, but it makes sense.

[@MatthijsvanDuin]

Some comments in other threads by people who seem to know the plane indicate that the AP wasn't trimming the plane because it involves the same system responsible for rudder trim and it was in a fault state due to the extreme airspeed difference earlier. That fault would have been cleared by a power cycle, but they never shut down the plane after the aborted take-off.

[@jeffxjet]

You nailed it exactly. See my long post for a very in depth description. There was no problem with the trim, there was an interface problem between the autopilot and trim servo.

[@jonasasplund1423]

I flew the Challenger and agree totally. They probably induced a stab trim fault by leaving the pitot tube cover on. That would have produced a cyan EICAS message like the rudder did. If they had checked the QRH for either of these messages it was a no dispatch item. They made a fatal assumption that only red or amber messages support a no dispatch condition.

[@artrogers3985]

Could Orville and Wilbur ever imagined how complicated their little flying machine would become?

[@Parkhill57]

The only reason Orville survived his crash, is that Lt. Selfridge broke his fall. Even so, his sister had to empty his bedpan for 6-months...

[@wstubbs8556]

I stay buckled up on all my GA flights including the Lear 45XL I flew on a few months ago.as well as my 121 flights as much as practical. Even in my Business class pod on Air France, I buckle while sleeping vertically.

[@N1120A]

She was apparently in the lav

[@jserra17]

In 1996, Aeroperu flight 603 crashed killing all on board due to failure of multiple flight data systems. The cause was determined to be duct tape that had been placed over pitot tubes to protect them while the aircraft was being washed. A supervisor, line maintenance technician and the pilot doing preflight inspection had all failed to detect the tape.

[@shoersa]

Silver duct tape no doubt!

[@371stone]

It was the static not pitot that was covered and not detected.

[@davestarr7112]

Very good rundown, Jaun, but you touched on the most important point first ... if the airplane is talking to you, LISTEN!

[@SimonWallwork]

On the Embraer its a memory. "Control column: Hold firmly." "AP disc button, press and hold".

[@rickpilot601]

On pretty well any aircraft, if there is an autopilot out of trim message, the first item before disengaging, is" Hold the yoke firmly, then disengage" since the force the autopilot servos are exerting must be replaced by manual effort. This item is usually on the POH. Since this inept crew didn't recognise the impact of the out of trim message, and perhaps didn't realise that manual trim input, or switching off the trim, would cause the autopilot to disconnect , they were caught by surprise. I have not flown the 300 series, but have over 4000 hours PIC on 600 series, including training and checking both in simulator and airplane. They are short-coupled aircraft, with a powerful trim system, and the first thing in training is to get the pilot to set attitude then trim, not fly with the trim, which will lead to PIO. Basic flying, but too many learn to fly their 152 constantly fiddling with the trim

[@TIO540S1]

See Malaysia Airlines Flight 134 for an example of a passenger airliner with passengers aboard taking off with pitot covers NOT removed. The crew noted the airspeed discrepancy during the takeoff roll below V1 and took the airplane into the air anyway. After fighting the situation for a protracted period, they ultimately landed safely. There are multiple videos about the incident. The best, as usual, is from Mentour Pilot.

[@42captjoey]

Great think about that noisy trim wheel in the old 737 was you always knew what it was doing. I think the memory item was. Control column grasp and hold. Auto pilot disengage. If runaway continues elec trim switches off.

[@jeffxjet]

It wasn't a runaway trim. And if the trim runs for more than 3 seconds(runaway) you get a very loud audible clacker sound that is unmistakable and very annoying.

[@42captjoey]

@@jeffxjet I wasn’t really diagnosing this flight. Juan mentioned memory items. This was meant more for him to take us down memory lane.

[@dennissoderholm6603]

You make these accidents so interesting you explain it so well 👍😮

[@squishybear5728]

A good portion of pax flying corporate don’t fasten their seatbelts. Even after the pilot has briefed them, they still won’t buckle in. or will buckle in briefly then remove the seat belt. Some lay on the divan etc. the pilots are busy flying and can’t be running back there to make sure people are fastened in. I agree with others that she was probably not buckled in.

[@Travelair2000]

It’s true and they have to share some responsibility for those actions. If you own a jet, you’re not Joe Blow off the street. I try like crazy to provide the “champagne ride” to my owners, even taking extra fuel and going way around bad weather. With the airlines it was always “don’t be late, penetrate”! I don’t miss those days.

[@78XT500]

That moveable Stab is a very powerful control surface…….the most powerful in fact. Any control surface malfunction annunciation is a serious condition, but any Stab malfunction must be treated with huge respect and crew proficiency. We often gloss over Stab issues in our training and checking, but really should be as well understood as reading a TAF. This accident reminds me of the Falcon 900 Arthur Q Stab unit failure that was mishandled by the crew, and also resulted in in-flight fatalities. Crews…know your Stab systems well.

[@michaelimbesi2314]

The last time I was this early, Oroville Dam still needed a new spillway

[@imaPangolin]

Crj guy here. Stab trim disconnect is a button on the yoke. When you do this the Ap kicks off. There IS NO MANUAL PITCH TRIM in the crj. It’s electric. It stab trim is off you can’t trim the plane. In the crj manual trim will d/c autopilot.

[@easttexan2933]

Condolences to family, loved ones and friends. Such a freak accident. Great report Juan.

[@nickalan4516]

Juan, your breakdowns are always so thorough and educational. Thank you for making these!

[@needleonthevinyl]

Wow, you weren't kidding about the upset being violent. It doesn't take much imagination to see how a swing from -2.3G to +4.2G could cause fatal injuries to any person.

[@NicolaW72]

Indeed.

[@FamilyManMoving]

Especially if they were not strapped in. Report was quiet on that point, but it seems logical she may have been moving about. I've been caught moving about -- digging for a laptop or something in a bag somewhere - when we hit sudden turbulence. Almost lost footing a few times. Can see how an innocent action like that could be at play. Bad timing. Wish the pilots had warned everyone they were playing with the AP. When I fly people, I warn newbies when we're about to turn more than 3deg/sec. Of course, I'm flying a much smaller plane. I don't like to surprise people.

[@hiimpercy]

How can the flight crew not have felt this turbulence? I'm confused about that part of the report.

[@jucaesar4961]

@@hiimpercy Apart from the accelerations caused by the accident there was no turbulence in the air itself throughout the flight according to the report.

[@kennyw871]

Especially, when those powerful forces are transferred through brain structures. Sudden acceleration and deceleration forces can result in death related to the brain injury. Recall that except for bridging venous structures holding the brain in a relative fixed position, it is otherwise suspended in CSF. When sudden force is applied, the delicate brain strikes one inner surface (coup) inside the skull and then rebounds (contra coup) against its opposite inner surface. So, it's really two separate injuries the brain is subjected to in this injury pattern. Following initial impact, subsequent swelling and bleeding of the brain inside a closed compartment leads to sudden death, as the swelling forces pressure downward on the brainstem, if not corrected emergently, as in minutes in many cases. Note that these injuries can occur even in the absence of a skull fracture. In the case of Ms. Hyde, it's also possible she suffered a high spinal fracture/subluxation when her head struck the ceiling of the aircraft with that kind of force. However, this is purely speculation on my part, but the aforementiond brain injury mechanism and pathophysiology stand. This reinforces the importance of remaining restrained during air travel.

[@jamesgraham6122]

An excellent response from Gippert07, thnx for that as I'm not a Challenger pilot. It astounds me that an essential item such as stab trim, (and I believe Mach Trim) having failed did not automatically disconnect the A/P. As you quite correctly pointed out, one touch of the manual trim/electric trim control has kicked off the A/P on every a/c I've ever flown.

[@bubbaoriley7864]

I agree this sounds like a stab trim runaway, which would necessitate the QRC action for it and not the Stab Trim failure checklist in the QRH. The first thing in the QRC for stab trim runaway is assume manual control which if performed may have prevented the accident if indeed this was the case. I’m pretty sure the reason Bombardier got away from memory items and went to the QRC is because of the errors associated with memory items not being performed correctly. I suspect this accident may lead to more training across the industry on differentiating between those two checklists.

[@jeffxjet]

It was NOT a stab trim runaway. It was loss of control input from the autopilot to the trim servo.

[@toddav8s]

Great report Juan. I remember the kneeboard days, memory items, stand evals, BOLDFACE. There is no way I would have blasted off after getting the additional messages. I might have tried shutting everything down and restart, but otherwise it’s AOG.

[@sx300pilot5]

I’m always amazed at how most pilots react to flight control issues. It’s not stated, but from experience, my guess is they were at 250kts. SLOW DOWN and make the control surface less effective, thereby reducing control pressures. Of course the yoke is going to jump if you disconnect the autopilot when it’s holding opposing control pressure, especially at a high airspeed!

[@sblack48]

That might not necessarily be the case. If you look at the graph of the rudder travel limiter the max deflection at full pedal INCREASES and lower speed. Some aircraft, including challengers, have variable stuck-to-elevator gearing that desensitizes the stick at high speed. Unless you really know how the airplane works, which might be beyond the scope of a type rating, you might be doing the opposite of what you intend.

[@geofiggy]

Hey JB, thanks for this very detailed update. Just as a FYI, the Challenger made by 🇨🇦 company - the company name is pronounced: Bom-bard-eea (the last portion, treat it as French -iér). Hope it's okay to mention, as I admire how you like to pronounce your places, countries, etc. Very professionally. Love you, take care and fly safe. 🖖🏼🤟🏼

[@elderbob100]

I used to work with a guy that worked there. He never got tired of correcting that pronunciation!

[@grantwhebell7730]

Yes and Bombardier has been subsidized by the Quebec provincial government and this Trudeau Marxist regime to the tune of over two billion dollars Canadian. Nothing for you people to be proud of.

[@AureliusR]

it's actually four syllables, not three ... Bom-bar-d(j)ee-ay

[@geofiggy]

@@AureliusR sorry, was not even thinking "Syllables", was just going for the phonetic approach. Thanks for the clarification.

[@huntera123]

Wow. A relatively small pebble resulted in a tragic avalanche. RIP.

[@richc47us]

Because of the G Forces the Challenger experienced will there be an equipment stress inspection?

[@natural-born_pilot]

Thanks Juan for covering the details on this one. I always remember back flying in the Air Force and the physiological training in the chamber experiencing the rapid decompression at altitude. That could happen at any unexpected time and I did not want to be sucked out some small hole in the aircraft at high speed. I also was well experienced in pulling both negative and positive G’s during controlled flight along with unexpected turbulence therefore I always belted in from TO to landing. This may sound funny to some but if I have the need to use the restroom on a long flight I’m uncomfortable unbuckling and trotting to the lavatory. I get in there take care of business and get back to my seat in a heart beat. I also won’t get up and stand in line at the lavatory but instead watch when no standing line and someone exits to race over to use it next. Every time I fly commercial I can’t help but notice a lot of passengers with their seat belts unbuckled. What really upsets me is when parents allow their kids to unbuckle and fidget around. STAY BELTED IN it’s not that painful and dam sure is not forever.

[@x--.]

I forgive us idiot passengers because no one makes the risk clear -- and I'm pretty sure that's by design. If the Captain said, "Please keep your seatbelt fastened because if you don't and we encounter severe turbulence or accidentally whack the yoke you'll be slammed into the floor with enough force to induce severe brain injuries," we'd all be a lot more cautious. Clear risk avoidance requires that the knowledgeable party communicate clearly the actual risk. I've *never* experienced turbulence that could cause fatal injuries so the constant "for your safety" messages induce "boy who cried wolf" fallacy. Sure, I still keep my seat-belt fastened during flights but I'm not living in fear. Airlines and FAA need to decide. You either (a) establish warnings that illicit fear & caution, (b) limit warnings to the most dangerous phases of flight or (c) accept more fault when something goes wrong. I shouldn't be asked to properly assess the risk of flying.

[@apex_ventures]

Excellent analysis. Thanks for breaking things down for us non-pilots.

[@demef758]

Agreed. I don't know the first thing about piloting, but I sure do learn a lot from my computer desk about flying when Professor Browne speaks. He speaks to the pilots in his audience, but he also pauses to teach novices like me about the basics of flight.

[@edwardbentley]

None of the current Challengers and CRJ’s have manual trim. In the event of a disconnect failure the 2 trim circuit breakers are on the F/O’s side and in the event of runaway trim need to be pulled immediately.

[@caddisking]

First day of ground school on Metro 2. Ground instructor, "There are those who have experienced runaway trim on takeoff and there are those will experience runaway trim on this aircraft".

[@Sylvan_dB]

Can we chalk this up to another "in too big of a hurry" incident? It seems to me they correctly detected an omission from original preflight and correctly aborted takeoff. But then instead of doing a complete shutdown and starting over by redoing the original preflight and etc, they tried to do the minimal to resume where they left off.

[@martharetallick204]

Get-there-itis?

[@marlinweekley51]

Sounds like an inexperienced crew - 150 hrs in frame combined?! That inexperience may be a large part of the reason they performed the preflight checklist poorly and certainly a reason they didn’t understand the autopilot operation thoroughly. What airline puts two such inexperienced pilots together? Scary stuff.

[@NicolaW72]

Yes, it seems so.

[@wstubbs8556]

I had an Air Ambulance company and I had clients that were pissed at times because we were devout cowards and would not fly with a squawk, Inclimate weather, etc. My moto was we are not dying to be Heroes.

[@GlamorganManor]

@@marlinweekley51 It wasn't an airline or even a charter at that point. It probably was the plane owner (corporate big wig) calling the shots when transporting a big wig partner in a venture capital firm. Sort of reminds me of all of the musicians who have died on airplanes. Too important to inconvenience.

[@kingaire165]

"BOM-BARD-IER" is how we pronounce the company here in Canada 😁. As always, great Great work Sir!

[@BridMhor]

Bomb_bard_dee_a. It's a French word.

[@MattyEngland]

Bo_mo_ent _ero_deer_a_dierie

[@twister4489]

Nobody gives a fuck about anything from Canada.

[@snakeplisken4119]

@Bríd Ní Fhlatharta Actually someone's last name

[@John-in-Boothbay]

That's how we pronounce it in the USA as well. 🙂

[@petehurd5301]

Excellent and informative as usual. Super minor point, I believe Bombardier is pronounced like BOM-BAR-DEE-YAY. The French last name of the dude who invented the snowmobile (wanted an ambulance that could drive on snow).

[@RoseSharon7777]

This is correct.

[@RoseSharon7777]

​@@jrkorman Its a Canadian company and prouncounced Bom-bar-dee-yay. I worked for them for many years.

[@brianeaton3734]

English translation is Bombardier.

[@InMyBrz]

BOMB-BAR-DEE-AYE

[@lebojay]

…and they STILL make snowmobiles (under the SkiDoo brand) 😊 🇨🇦

[@johnjones7270]

The crew continued to climb out with multiple flight control EICAS messages from 6000' to over 22000? As you said, the plane was trying to tell them something multiple times

[@NicolaW72]

Indeed.

[@GarrisIiari]

Curious why the initial trim warning is an advisory and not a caution. As a non pilot but as a flight simmer it would seem to me that almost any possible trim issue could be existential.

[@180mph9]

No trim wheel in this thing, seems clear that there’s much more emphasis from the PIC to complete the mission no matter what instead of having a concern for everyone’s safety.

[@richb313]

Thanks for your reporting on this complicated issue.

[@whosyourcaddy]

Not sure it was runaway trim. I think the AP didn’t trim out of the takeoff setting, hence the pitch up when the trim was turned off at a high airspeed.

[@brianschaer]

It was NOT runaway. Takeoff trim is V2 optimized. At 250kts I can't imagine what the rate of climb would be. Obviously excessive.

[@GarrisIiari]

​@@brianschaer and what happens if the system has no V2 speed set? I really want to know what happened during the 3 AP on off sessions during climb.

[@brianschaer]

@@GarrisIiari V2 speed is just where stab trim is set prior to takeoff. Without a functioning AP TRIM computer it will just stay where it is, AP remains on (pretty sure). Then as IAS increases, AP elevator forces produced amber AP HOLDING NOSE DN. They went to the wrong checklist (AP PRI STAB TRIM FAIL). The Rudder limiter computer and AP pitch trim computer are tied together (or one unit, not sure). RUDDER LIMITER FAIL Cyan was cause by > 20kias difference between ISI and primary ADCs. This was a noob crew, horrible management situation.

[@brianschaer]

@@GarrisIiari it's not about setting "V2". It's about setting the takeoff stab trim. That setting is based off of weight. That setting results in a neutral trim force at v2. That's how they are related. V2 is the single engine, second segment climb speed. You want the stab trimmed to that condition to make the single engine situation more manageable.

[@brianschaer]

@@GarrisIiari whatever AP on/off/on/off they did was not discussed in the prelim report and was not relevant to the situation other than the grossly out of trim situation for the speed they were traveling at.

[@bobroberts2371]

One counter to memorizing an emergency procedure and using computer / printed procedures: If there is a software update that changes the procedure, the pilot might, under stress , revert to an out of date memorized procedure.

[@paulsherman51]

Which is precisely why we, in software technology development, need a *new* metric of goodness: fewer versions is better than more. Microsoft introduced concept of selling Beta-releases as versions, to $ell more and make more profit. Taking more time to carefully do a job right needs to prevail. The programmer must be proud when they see their 20+ year app working well at the same version as when it was made. Can capitalist America start making money by offering software and products at vintage version levels? I'll pay big bucks to still have my iPhone 3G working well. Only then will human memorization of procedural cards work.

[@rickdozier3609]

As an Pilot, A&P, IA, I have had AP out of control situation a few times. usually older non digital units.. You need to learn how to uncouple the AP, FAST , like you said, In Memory or muscle memory.

[@shoersa]

ONE switch to go to complete manual flying the airplane.

[@jakejacobs7584]

I wonder if the wings or fuselage have any wrinkles? That probably would have been mentioned in the report though.

[@StrongDreamsWaitHere]

Preliminary. May not have fully examined the aircraft. Is it still flying?

[@bryanford1139]

@@StrongDreamsWaitHere Nope, grounded at Bradley last I saw....

[@k53847]

It appears the maximum maneuvering load factor is +2.6g to -1.0g.

[@WatPoh]

CL 300/350 - Pitch Axis Uncommanded Motion/Trim Clacker Tone - Master disconnect (MSW) - PRESS AND HOLD - Proceed to FCTL 07-16. Memory item straight from the QRC. First part before the slash being the important part in this situation.

[@johningram9081]

Most excellent report. You are always on top of the game.

[@deuce38]

Like your analysis of accidents. Not a pilot but an aviation buff since I was a kid and worked on F-9, TA4J and F-4J in the Navy.

[@ironmanballer4868]

Not sure the weather at arrival of the aircraft prior to the accident flight. I’ve noticed if the weather is clear and a forecast of clear pilots will typically leave the covers off with the challenger however they have to pin the aircraft for it to be towed otherwise I’ve noticed a lot of crews don’t cover them unless it’s going to be in a position to have something block it.

[@ironmanballer4868]

Second thing was the FAR also issued for the 350 and or any of the 600 series? I know the challengers and some of the CRJ share similar systems.

[@nancychace8619]

Thanks for sharing. Wasn't able to give this my completely undivided attn. but it sure didn't sound good. I liked the observation about the importance of listening to your aircraft. My gut instinct would have been to turn off everything that was automated and just fly the airplane. Hope lessons are learned. RIP.

[@jeffxjet]

Your gut instinct would have been wrong. As was this crew's. They went with their instinct instead of analyzing the situation and following the correct checklist which would have prevented this accident. See my complete response for details.

[@nancychace8619]

@@jeffxjet Like I said, I wasn't able to listen to all of it. It sounded reminiscent of what happened with the mcas systems on the Maxes. If that or the autopilot wasn't functioning properly I would think your best bet would be to turn them off and fly the plane yourself. Just sayin - Kind of like with dysfunctional gps systems that have gotten people stuck in the wilderness. If they had turned the danged things off and looked at a stupid map they might not have gotten in so much trouble.

[@jeffxjet]

@@nancychace8619 yes, but in this case there was nothing wrong with the autopilot or the trim. The problem was the interface between the autopilot and the trim. The autopilot had control of the airplane, it was physically overpowering the out of trim airplane. The CAS message AP HOLDING NOSE DOWN is a clue to the pilots that the AP is reaching the limits of it's control over the plane and some manner of pilot intervention is needed to help out. Once they turned the autopilot off, the heavily mis-trimmed airplane pitched violently up. If they had done nothing except slow the airplane down, literally nothing would have happened. The accident was directly caused by turning the autopilot off at the wrong time, in the wrong manner, using the wrong checklist.

[@bigjeff1291]

My seatbelt is on before taxiing and until engine shutdown…

[@truegret7778]

Great breakdown, again. Is it fair to say, though, if/when you rely on memory doesn't that work if you continuously train and keep current? Or to the changes in procedures not change that significantly? Apparently, they did not follow even the most basic of checklists which is the walk around where they missed the pitot sock. So sad.

[@russell3380]

Thank you Juan. I have come to the realization that we are in dire need of a Blancolirio News Network. I have no stomach for our present News Media, minus about two non-mainstream outlets. I can hear it now, "BNN, We Don't Blow Smoke, Up or Down".

[@gratefulpilot]

I’m glad I finally found this analysis. I flew to Keene that day for my first long, solo XC after getting my PPL. I saw that jet on the ramp. When I got home I heard about the incident. To your point about the news ruling it turbulence at first there were TURB HI airmets and that area gets some good mountain waves. Even so, I was still perplexed at how it could have been so bad as to cause a fatality. Now I know it wasn’t turbulence at all.

[@billdewahl7007]

Did I hear that right? 6g differential twice? I wonder how quickly they went from peak positive to peak negative.

[@snakeplisken4119]

I was taught by my dad a pilot from a very early age, always both put on your seat belt the moment you sit down, and were it the entire flight As I spent an entire career(1000s of hrs)as an passenger in both fixed and rotor wing aircraft its advice I fathfully followed. .Simple, life-saving advice, that in this case may not have been followed.

[@FlightSimulatorXATC]

Not a Challenger guy but a Bombardier guy. The V speeds will drop out after a reject.

[@Travisesty]

Awesome video Juan. I’m still trying to absorb this tragedy esp having to do a complete pwr off on the software on this particular airframe. I’m with you, memory memory memory along with checklists. Sully made his landing in the Hudson thanks to quick thinking-memory. Great video

[@registrationhater]

What pre-flight inspection?? You missed the big red streamer swinging in the breeze??

[@terrancestodolka4829]

Great in-depth analysis... The complexity of these systems shows how not executing a full cautious analysis can lead to overlooked complications. Such a sad case study of really not knowing what is going on by the pilots...

[@blueyonder1233]

4.2K views and only 504 likes. Come on guys Juan puts so much into these video's the least you can do is show the most minimal appreciation by clicking the thumbs up button. 👍

[@sweep2112]

fair point, well made. I often forget.

[@pwschuh]

Juan, thanks for the detailed analysis. What wasn’t covered was what was going on in the cabin. Was Dana unbuckled? Were other passengers completely unharmed? Was any of this info in the NTSB report? Thanks.

[@porkrind]

FDR systems typically have a 5G impact switch on them to kill the recording as 5Gs is well outside the normal operating forces of this type of aircraft. Its very possible the aircraft exceeded 5Gs and the FDR wasn't able to record it.

[@sbreheny]

I wonder why the FDR would not be designed to keep recording for a short while after a high G event. In many aviation accidents, a 5G upset in the air would be followed by other events which would be good to catch on the recorder. Also, there's no way that any real crash is going to cause only 5G acceleration.

[@MatthijsvanDuin]

any chance this FDR was recording onto a medium that involves moving parts (e.g. tape or HDD) hence stops at 5g to prevent damage?

[@porkrind]

The switch is there to stop recording after a catastrophic event that doesn't kill power to the FDR. It's assumed that an aircraft of that type will only face that level of G loads in an impact.

[@cathyl2338]

Thank you Juan

[@bkailua1224]

How does one person in an aircraft have a fatal injury and no other are injured? I imagine lack of seatbelt use or improper seat belt use. 100 hours of experience in type is just a little more than what I flew as an airline pilot in one month of flying. Most stab trim systems use a worm drive. In this type of system air loads will not drive a worm drive the system backwards.

[@j_taylor]

I wonder too. Injuries could come from bouncing off something, or from something bouncing off her. Such intense forces would not have been nice no matter now tight the seatbelts were.

[@gkbrown2443]

When the first Max Jet crashed and they mentioned Runaway Trim,I remember every line of the check list and I’d been retired for 15 years!

[@Ryanboy2020]

I worked with Dana during the Obama Administration at the White House. I had no idea and did not hear that it was Dana who was the victim in this accident. Although, we worked in different areas at the White House, I have great memories of her infectious smile and wicked sense of humor. My thoughts are with her family, friends and the rest of the Obama Alumni as we all process the loss. Hold your family tight. 🙏🇺🇸

[@Heike--]

Do political elites such as yourselves typically obey rules for commoners? Like "fasten your seat belt"? Or, as we see demonstrated in DC daily, are the rules only for little people? I think this explains what happened here.

[@Jules-6022]

Dana’s family is in our thoughts and prayers. Rest in peace, Dana 🙏🙏

[@MattyEngland]

Did you get to meet Big Mike? 🍆🍆

[@BlackMan614]

It was certainly a tragedy but it allows us peons a window of visibility into how ex-politicos use their influence once out of public service. Premium private jet, owned by a rural broadband company who gets most of their revenue from the federal government in the form of subsidies, flying - a non-revenue flight - a lobbyist allowing her son to visit various universities. You can't make this stuff up. Corrupt to the core.

[@mikedineen7857]

She will be missed. I think he had the best staff in history.

[@larrysmith1851]

Retired Challenger 350 guy here. In my experience with [PRI STAB TRIM FAIL] on the Challenger 350, the procedures called for setting the STAB TRIM switch on the pedestal from 'PRI' position to 'SEC'; not 'OFF'. There is only one mechanical actuator that can be driven by either the primary or secondary motor. There in no 'manual' trim on the CL350; only electric control via the trim switches on the control wheels. When 'SEC' is selected, the autopilot, Mach trim, and automatic configuration trim are inoperative, but the airplane remains trimmable at a constant rate of 2º per second, whereas primary trim rate varies between 4º and 1º per second with airspeed. Additionally, if this happens in flight, airspeed is limited to .75M/250 KIAS max. I experienced an actual [PRI STAB TRIM] fail on a hand flown climb out just a few weeks into flying the 350. It was not a trim 'runaway', but a failure of the primary channel to respond to trim switch input. Without trim control it felt like a jammed pitch control. Switched to 'SEC' and trim control was restored, albeit with the previously listed system limitations. Not familiar with 300 vs 350 specificities, but I expect the trim systems operate the same. On a side note, as an ATP rated pilot who spent his professional flying career in Part 91, I'm a tad bit offended by your subtle suggestions that Part 91 pilots lack the knowledge, experience, and professionalism of Part 135 or 121 pilots. I think we can all agree that skill and safety has less to do with the FAA rules under which an aircraft is operated, and more to do with the abilities and judgment of the pilot at the controls.

[@markairman8041]

Please don’t take the part 91 comment personally. You probably ARE a professional and safe pt91 pilot. But having flown in both arenas, i have a strong opinion that the pt 91 pilot is more susceptible to pilot error than in a 135/121 environment where operations are more thoroughly reviewed/scrutinized. One reason has to do with the number of pilots. For example, in the 135 world, there is usually (not always) a two pilot crew. With another pilot observing as crew, it’s less likely a pilot will cut corners, do things from memory, or abbreviate checklists. Also, in a single pilot environment, I’ve seen pilots plateau in their skills. Complacency is easy to happen. I recently gave a flight review to a professional pt91 pilot. It was disappointing. He lost the basics of hand flying and minimally used checklists. Scary that he has been taking passengers who trust his skills. Then there are the FAA rules that place higher restrictions on pt135. Take landing distance requirements. Under pt91 pilots may land on whatever runway is length the aircraft POH allows. Under pt135, pilots must factor an additional 60% for safety. I fly both pt91 and 135. Its My opinion that It’s the operation as two pilot crew and the stricter 135 rules that fosters a safer flight. Not necessarily the professionalism of the pt91 pilot.

[@larrysmith1851]

​@@markairman8041 Hey Mark - I have flown both Part 135 and 91 under the same certificated carrier. I think we can agree that the rule differences are actually minor - even when it comes to conducting an IAP - predominantly in that Part 91 allows me to at least attempt an approach in lower weather minimums where it would be prohibited under Part 135. I feel most of the rules have been written to prevent unscrupulous 135 operators from putting income over safety, and question how often those rules are consistently followed. Even during Part 91 ops we operated as an airline crew through cockpit discipline, religious checklist usage and detailed briefings. We computed takeoff, 2nd segment climb (airport analysis), and landing performance, weight & balance for every leg regardless of field elevation or obstacles. Even under Part 91 we operated under the carrier's 80% LDA Eligible On Demand approval. Plus, when we went for sim training it was 4 to 5 days which allowed more opportunities to practice real-world normal and emergency procedures (in flight TR deployment, dual engine flameout, complex interconnected systems failures, etc) rather than the standard 2 day Part 135 COT event and check ride. Not saying one is better than the other, because in the end it's the human/machine interface that determines flight safety; not necessarily the rules.

[@ProblemsNeverEnd]

Thank you for your insight. My apologies if you've already done this one, but will you provide your insight into the final report of Accident Report ERA21FA234? The Smryna TN private jet crash in May 2021.

[@blancolirio]

Spacial Disorientation.

[@Paul1958R]

Juan, Great report - thank you! A really terrible tragedy. Keene NH is about 50 mi NW of me in SW NH. Paul (in MA)

[@Brooke95482]

Prior to turning the stabilization switch off does the check list say to turn on the "fasten seat belts sign"?

[@MatthijsvanDuin]

No, but the correct checklist for the AP STAB TRIM FAIL (which isn't a runaway stab and doesn't involve the stab switch) apparently does contain exactly that warning: (from another comment) "There is a specific checklist for this and it contains a warning directing the crew to have all passengers seated and belted prior to any action as there can be abrupt changes in control force once the autopilot is disengaged."

[@jcarne1015]

I have to admit that I was guilty of overlooking the pitot tube cover a few times in the past, on my modified S1-S, even though the pitot tube is clearly visible from the cockpit if you look. Fortunately, I was capable enough to land that airplane in near darkness, with no visible instruments, after an unanticipated takeoff with a sick engine. Don’t ask how I know. 😊 Condolences to the family and friends of Ms Hyde. 🙏

[@jamescole1786]

3/27/23..very impressive analysis of NTSB report on that Challenger pito tube, v1 & auto pilot issues resulting in hand flying & safe landing at alternate to off load medical injury resulting from auto pilot gyrations & roller coaster activities. Great explanations, as always Juan. Another 1st class education on details of flying executive twin jet. Fundamentals make flying safe. Stay safe Juan, & carry on!👍👏✅️

[@paulsherman51]

Good you put up the Swiss cheese at the end, Juan-- maybe edit the video and make verbal mention of this highly important topic.