National Transportation Safety Board Printed on : 1/21/2011 7:02:47 PM

Washington, DC 20594

Brief of Incident

Adopted 10/29/2010

DCA10IA022
File No. 0 01/19/2010 Charleston, WV Aircraft Reg No. N246PS Time (Local): 16:00 EST

Make/Model: Bombardier / CL600 Fatal Serious Minor/None

Engine Make/Model: Ge / CF34-3B1 Crew 0 0 3
Aircraft Damage: Minor Pass 0 0 31
Number of Engines: 2
Operating Certificate(s): Flag Carrier/Domestic; Supplemental
Name of Carrier: PSA AIRLINES INC
Type of Flight Operation: Scheduled; Domestic; Passenger Only
Reg. Flight Conducted Under: Part 121: Air Carrier

Last Depart. Point: Same as Accident/Incident Location Condition of Light: Day

Destination: Charlotte, NC Weather Info Src: Unknown
Airport Proximity: On Airport/Airstrip Basic Weather: Visual Conditions
Airport Name: Yeager Airport Lowest Ceiling: 2600 Ft. AGL, Overcast
Runway Identification: 23 Visibility: 10.00 SM
Runway Length/Width (Ft): 6300 / 150 Wind Dir/Speed: 290 / 003 Kts
Runway Surface: Asphalt Temperature (°C): 9
Runway Surface Condition: Dry Precip/Obscuration:

Pilot-in-Command Age: 38 Flight Time (Hours)

Certificate(s)/Rating(s) Total All Aircraft: 9525

Airline Transport; Commercial; Multi-engine Land; Single-engine Land Last 90 Days: 169
Total Make/Model: 4608
Instrument Ratings Total Instrument Time: UnK/Nr
Airplane

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
 Brief of Incident (Continued)

DCA10IA022
File No. 0 01/19/2010 Charleston, WV Aircraft Reg No. N246PS Time (Local): 16:00 EST

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.
Updated at Oct 29 2010 1:57PM
 Brief of Incident (Continued)

DCA10IA022
File No. 0 01/19/2010 Charleston, WV Aircraft Reg No. N246PS Time (Local): 16:00 EST

OCCURRENCES

Takeoff-rejected takeoff - Miscellaneous/other

FINDINGS

Aircraft-Aircraft systems-Flight control system-TE flap control system-Incorrect use/operation - C

Personnel issues-Task performance-Communication (personnel)-CRM/MRM techniques-Flight crew - C
Personnel issues-Task performance-Use of equip/info-Use of checklist-Flight crew - C
Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot - C

Findings Legend: (C) = Cause, (F) = Factor

__________________________________________________________________________________________________________________________________________

The National Transportation Safety Board determines the probable cause(s) of this incident as follows.
(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.