Yeager Airport
Aircraft Accident/Incident Report

Charleston, West Virginia
Tuesady, January 19, 2010 16:00 EST

NTSB Narrative Summary Released at Completion of Accident

Cockpit voice recorder (CVR) information revealed that the flight crew began a personal conversation (that is, a conversation not pertinent to the operation of the airplane) during departure delay. The flight crewmembers continued the nonpertinent conversation throughout the entire taxi, which was not in accordance with company procedures and Federal regulations regarding sterile cockpit. CVR information also revealed that, although the flight crew completed all of the required checklist items during the taxi, each item was read and responded to in a very quick and routine manner. About 1609, the captain called for flaps 20 and then for the Taxi checklist. Flight data recorder (FDR) data indicated that, 1 second later, the flaps moved from the flaps 0 to the flaps 8 position. Further, while conducting the checklist, the first officer stated, “flaps 8” and “eight degrees,” indicating that he had selected the flap handle to the flaps 8 position, not to the flaps 20 position as called for by the captain. However, the captain responded, “set” and “eight,” respectively, indicating that he did not notice the incorrect flap setting. The rapid and perfunctory manner in which the flight crew conducted the Taxi checklist resulted in the captain not visually comparing the airplane’s flap position with the aircraft communications addressing and reporting system data, which was his normal practice. After rapidly completing the Taxi checklist, the flight crew continued the nonpertinent conversation until the captain called for the Before Takeoff checklist. After the flight crew rapidly conducted this checklist, without including a proper takeoff briefing, the flight was cleared for takeoff. The takeoff was normal until the airplane reached an airspeed of about 120 knots. At this time, FDR data showed the flaps beginning to move from the flaps 8 to the flaps 20 position. Shortly thereafter, the first officer stated, “V one [the takeoff decision speed],” which was 127 knots. The CVR then recorded the sound of the airplane master caution and flaps and spoilers configuration aural alerts. The captain initiated a rejected takeoff (RTO) about 5 seconds after he started moving the flaps and when the airplane was at an airspeed of about 140 knots, which was 13 knots above V1. Bombardier computed the total distance required for the incident airplane to accelerate stop using data from the FAA-approved Airplane Flight Manual and the planned takeoff performance data (including configuration, weight, altitude, and reduced thrust takeoff). The calculations indicated that the airplane would have stopped about 5,730 feet from the beginning of the takeoff roll if the deceleration had been initiated at the planned V1 (127 knots). Given that the runway was 6,300 feet long and that FDR data indicated a normal deceleration during the RTO, sufficient runway distance would have existed for the airplane to stop on the runway surface if the captain had initiated the RTO immediately after he identified the misconfigured flap setting instead of reconfiguring the flaps. The captain should have called for an RTO as soon as he recognized the flaps were in the wrong position. As a result of the captain’s decision to attempt to reconfigure the flaps and delay the RTO, the airplane overran the runway end and entered the engineered materials arresting system (EMAS) at an airspeed of about 50 knots. The airplane stopped 128 feet into the EMAS arrestor bed with about 277 feet of arrestor bed remaining. Before the installation of the EMAS in September 2007, the runway end safety area for runway 23 was only 120 feet long. If this incident had occurred before the installation of the EMAS, the airplane most likely would have traveled beyond the length of the original safety area and off the steep slope immediately beyond its end.

NTSB Probable Cause Narrative

(1) The flight crewmembers’ unprofessional behavior, including their nonadherence to sterile cockpit procedures by engaging in nonpertinent conversation, which distracted them from their primary flight-related duties and led to their failure to correctly set and verify the flaps; (2) the captain’s decision to reconfigure the flaps during the takeoff roll instead of rejecting the takeoff when he first identified the misconfiguration, which resulted in the rejected takeoff beginning when the airplane was about 13 knots above the takeoff decision speed and the subsequent runway overrun; and (3) the flight crewmembers’ lack of checklist discipline, which contributed to their failure to detect the incorrect flap setting before initiating the takeoff roll. Contributing to the survivability of this incident was the presence of an engineered materials arresting system beyond the runway end.

Event Information

Type of Event Incident
Event Date 1/19/2010
Event Day of the Week Tuesday
Time of Event 1600
Event Time Zone Eastern Standard Time
Event City Charleston
Event State WEST VIRGINIA
Event Country --
Zipcode of the event site --
Event Date Year 2010
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport Yeager Airport
Event Location Nearest Airport ID CRW
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Unknown
Time of the weather observation 1400 Eastern Standard Time
Direction of event from weather observation facility (degrees) 230
Weather Observation Facility ID KCRW
Elevation of weather observation facility --
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation EST
Lighting Conditions Day
Lowest Ceiling Height 2600
Lowest Non-Ceiling Height 2600
Sky/Lowest/Cloud Conditions Thin Overcast
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 9
Dew Point at event time (in degress fahrenheit) 4
Wind Direction (degrees magnetic) 290
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 3
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.98
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 34
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) --
NTSB Notification Source --
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Oct 29 2010 1:56PM
User who most recently changed record schd
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N246PS
NTSB Number DCA10IA022
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Minor
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name BOMBARDIER
Aircraft Model CL600
Aircraft Series Identifier 200LR
Aircraft Serial Number 7920
Certified Max Gross Weight 53000
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 3
Cabin Crew Seats 1
Passenger Seats 50
Total number of seats on the aircraft 54
Number of Engines 2
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Aug 16 2010 12:00AM
Airframe hours since last inspection --
Airframe Hours 13723
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name AFS Investments 71 LLC
Aircraft Owner Street Address --
Aircraft Owner City Stamford
Aircraft Owner State CT
Aircraft Owner Country USA
Aircraft Owner Zipcode 06927
Operator is an individual? No
Operator Name PSA AIRLINES INC
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Vandalia
Operator State OH
Operator Country USA
Operator Zip code 45377
Operator Code VNAA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number VNAA111A
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code CRW
Departure City Charleston
Departure State WV
Departure Country USA
Departure Time 1600
Departure Time Zone EST
Destination Same as Local Flt --
Destination Airport Code CLT
Destination City Charlotte
Destination State NC
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Oct 27 2010 1:48PM
User who most recently changed record sedj
Since inspection or accident Time of Accident
Event Location Runway Number and Location 23
Runway Length 6300
Runway Width 150
Sight Seeing flight No
Air Medical Flight No
Medical Flight --