Friday, December 7, 2007

2006 jet crash points to pilot error

4 deaths included Ketchum councilman?s wife


By PAT MURPHY

The 2006 fatal landing crash of a Hailey-based private jet seems to have resulted from a series of faulty decisions by the aircraft's captain in the final minutes before touchdown at the airport in Carlsbad, Calif., according to a second-phase investigative report issued Thursday by the National Transportation Safety Board.

A final "probable cause" finding still must be issued by the board.

But the newest, 7,165-word report 22 months after the accident points to pilot error. The 1994 model Cessna Citation 560 twinjet aircraft, once owned by Coca Cola, was cleared by the National Transportation Safety Board of any mechanical malfunctions. The weather at Carlsbad was ideal, and proper airways and tower procedures were followed by Federal Aviation Administration controllers in clearing the aircraft for descent and landing at McClellan-Palomar Airport north of San Diego.

The accident at 6:40 a.m. Pacific time Jan, 24, 2006, which followed a 1-hour 40-minute flight at 38,000 feet from Friedman Memorial Airport, took the lives of Janet Shafran, wife of Ketchum City Councilman and international financier Steven Shafran; retired Sun Valley health food executive Frank Jellinek, and the crew, Jack Francis, the captain-pilot, and Andy Garrett, the first officer-co-pilot.

Radar recordings, witnesses on the ground, airport video security camera tapes and the doomed aircraft's cockpit voice recorder indicate the pilot changed his mind about the direction he wanted to land, was approaching the field too fast and too high, landed too fast and too far down the 4,897-foot runway and then decided too late to take off for a go-around.

Moreover, the National Transportation Safety Board also found that pilot Francis apparently had not reported suffering from Type 2 diabetes, which was not indicated on his second-class medical certificate and which friends told safety board investigators he treated with medications from Mexico. Investigators also were told by a relative of co-pilot Garrett that he "had become concerned with the captains (sic) health because he thought the Captain often appeared fatigued, slept often during their flights together and would eat large quantities of certain foods while in flight (i.e. 'two large cans of nuts in one sitting.')"

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A post-mortem found the captain's hemoglobin A1C blood sugar level was 7.7 percent, whereas 4 to 6 percent is considered normal.

In the final seconds on approach, the National Transportation Safety Board reported that the cockpit voice recorder picked up intermittent electronic voice "sink rate" alerts (warnings about the aircraft's feet-per-minute descent) then new emergency warnings—"pull up, pull up, pull up, pull up, pull up, pull up, sink rate, sink rate, minimums, minimums, one hundred, sink rate, forty, thirty, sink rate."

The jet touched down 1,500 feet from the end of the runway, the safety board found, but the pilot attempted to take off less than 200 feet from the end of the runway, was briefly airborne, but then struck a wooden platform used for a navigation aid antenna. The aircraft quickly erupted into flames and was gutted by the blaze.

During those few moments, pilot Francis was heard on the cockpit voice recorder exclaiming, "Yeah, let's get (unintelligible word) out of here." Two seconds later, co-pilot Garrett uttered several expletives before the cockpit voice recorder picked up "a sound similar to a clunk and a sound similar to two thumps."

The recording ended with a final electronic voice warning, "Bank angle."

The National Transportation Safety Board asked Cessna Aircraft to calibrate what speed the jet should have been flying when it approached and touched down at that airport, at its estimated weight, with a slight tail wind.

Cessna calculated that the jet actually landed at about 130 knots (150 miles per hour) but should have touched down at 101 knots (116 miles per hour). At the jet's speed, it would have needed virtually the entire 4,897 feet of the runway to land and stop.

Pilot Francis was said to have 17,000 hours flying time and co-pilot Garrett, 7,500 hours.




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