NTSB Factual Report

HISTORY OF FLIGHT

On February 11, 1998, at 1216 central standard time, an Embraer EMB-145ER regional jet airplane, N14931, was substantially damaged when it impacted the ground following a loss of control during takeoff from runway 30 at the Jefferson County Regional Airport in Beaumont, Texas. The aircraft was registered to First Security Bank, Salt Lake City, Utah, and operated by Continental Express of Houston, Texas. Flight number 910 was being conducted as an aircrew training and proficiency check flight under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot-in-command (PIC) was not injured; the first officer (FO) received serious injuries; the check airman who was seated in the cockpit jump seat received minor injuries; and another FO seated in the cabin received minor injuries. Visual meteorological conditions prevailed and an instrument flight plan was filed.

The check airman who occupied the jump seat was the Continental Express program manager for the EMB-145. He was observing the PIC seated in the left seat who was administering a proficiency check to the FO in the right seat. The check airman was planning to recommend the PIC for observation by the FAA to approve him as a check airman in the EMB-145. The FO who was seated in the cabin had completed his flight earlier with the PIC, and during his flight, there were no reported mechanical problems with the aircraft.

The following information was derived from flight crew interviews and cockpit voice recorder (CVR) transcripts:

The proficiency check flight began with "high work" which included stall recognition, steep turns, holding patterns and other required air work, before the flight progressed to approach and landing maneuvers. The PIC stated that the FO was initially "a little nervous", but was getting comfortable. The check airman who was observing stated that the FO's "high work was very good, very acceptable, a good solid ride." After the air work, the FO completed a coupled ILS approach to runway 12 with a missed approach. He then performed a VOR-A approach and made a full stop landing. The PIC stated that the approach and landing were both satisfactory. The check airman stated that the landing was on centerline and in the touchdown zone.

After the landing, the airplane was taxied to runway 30 for takeoff. When the control tower cleared the flight into "position and hold," the PIC transferred control of the airplane to the FO and said, "your aircraft." The check airman suspected a "V1 cut was coming" so he checked that both crewmembers' feet were positioned correctly on the rudder pedals. The FO then set the throttle levers to the takeoff detent and called, "set thrust." The PIC saw that both engines had the proper thrust and responded, "thrust set." The airplane accelerated normally and the PIC called, "eighty knots," which the FO acknowledged. When the PIC called "V1," the FO removed his hand from the throttles and the PIC placed his hands on the throttles. The PIC then pulled the left, (number one engine) throttle to idle. The check airman noticed that the throttle was retarded smoothly.

The FO called, "check max thrust," and then called, "positive rate gear up." The PIC reached for the gear lever and noticed the airplane roll to the left at a rate which he felt was "excessive and dangerous." He then reached for the flight controls and felt the left rudder "go all the way to the floor." The PIC "got his hands on the controls when it felt like the left wing quit flying." He felt like the airplane was going to roll on its back and that all he could do "to save our lives was to level the wings." He felt the stick shaker and thinks he may have felt the stick pusher. The PIC stated that the FO initially put in the wrong rudder and then tried to correct his mistake by putting in more "wrong rudder." The PIC applied full right aileron and full right rudder as "fast" as he could and felt that the bank angle had exceeded "sixty degrees" but did not recall hearing the "bank and angle" warning. The PIC stated that the airplane began recovering from the bank and may have been nearly wings level when it impacted the ground. He stated that the airplane impacted first on the left wing, then the right wing, then slid to a stop.

The FO stated that as soon as he felt the airplane yaw to the left, due to the reduction of the left throttle, he applied "a little right rudder and a little right aileron." He stated that the yoke "felt a little soft and didn't feel right in roll and pitch." He also stated that when the left wing started dipping, he "added" right aileron and rudder. The FO stated that he heard the PIC say "my airplane," and "let go" of the controls and the PIC took control. The FO stated that the first bank "was not that steep," but after the PIC took control "the airplane banked a second time worse than the first." The FO stated that to his best recollection his hands and feet were off the controls during the second bank.

The check airman stated that the airplane rotated for takeoff "normally," but when the left throttle was retarded, the airplane began to roll and yaw to the left. He stated that the airplane began to correct toward wings level and may have been slightly right wing low prior to impact. He stated that the airplane hit the ground, bounced airborne, then impacted and slid to a stop.

PERSONNEL INFORMATION

The PIC, who occupied the left cockpit seat, was employed by Continental Express on May 22, 1994. While at Continental, he flew as an FO on the ATR-42 and Brasilia and as PIC on the Beechcraft BE-1900 and the Embraer EMB-145. He estimated that he accumulated approximately 350 hours on the ATR-42, 1,200 hours on the Brasilia, 800 hours on the BE-1900, and 500 hours on the EMB-145. He was type rated on the EMB-145 on July 31, 1997 and was selected as a check-airman while he was in EMB-145 training. Continental had asked him to be a check-airman on the BE-1900, but he declined in order to upgrade to the EMB-145 as soon as possible. He was qualified as an "off-line aircraft instructor" authorized to conduct flight training in the EMB-145. He had about 8 previous students who had all successfully completed flight training in the EMB-145.

The FO, who occupied the right cockpit seat, was the pilot at the controls at the onset of the accident. He was employed by Continental Express on October 7,1996. Prior to training on the EMB-145, he flew as an FO on the ATR-42/72 for Continental Express. He estimated that his total flight time was approximately 1,900 hours with about 800-860 hours on the ATR 42/72. His total flight time in the EMB-145 was 15 hours. His total flight time in the last 90 days was 15 hours, all of which were in the actual aircraft. He had completed EMB-145 ground school.

The check airman, who occupied the jump seat, was employed by Continental Express on March 12, 1990. At the time of the accident he was the EMB-145 Program Manager. He described the position as being the "lead check-airman." The FAA had approved him as a check airman on February 15, 1997. He estimated his total flying time as approximately 10,800 hours, with about 700-800 hours in the EMB-145. The FAA appointed him as a designated examiner on the EMB-145, which authorized him to give type ratings. He estimated that he had given approximately 20-25 type rating check rides on the EMB-145 and had disapproved at least 5 of these candidates for type ratings.

In an interview with the check airman in his capacity as EMB-145 Program Manager for Continental Express, he stated that he had experienced two situations similar to the accident in previous training sessions on the EMB-145. Both occasions had occurred during "V1 cuts." He stated that he was not certain of what caused the first situation, but that the second was caused when the student pilot applied the wrong rudder. He stated that in both instances he was able to prevent an accident by taking control of the airplane and reducing the angle of attack. He reiterated that "the key thing was to reduce the angle of attack even though it may be difficult to do close to the ground." The program manager stated that he had discussed these previous events with the PIC.

AIRCRAFT INFORMATION

The EMB-145 is a low wing, T-tail, pressurized airplane powered by two rear fuselage mounted turbofan engines. The airplane has retractable tricycle landing gear with two tires mounted on each landing gear strut. The EMB-145 was certified by the FAA in January 1997, and Continental Express completed proving runs in April 1997.

Airplane maintenance records were reviewed dating back to the airplane's original delivery date of April 30, 1997. The records revealed that the required inspections had been performed in compliance within the established times. Total airframe hours and cycles at the time of the accident were 1,844.6 and 1,472, respectively. The airplane was equipped with two Allison model AE3007 engines, serial numbers CAE310022 (left engine) and CAE310050 (right engine). The left engine was original on the airframe and had accumulated 1,844.6 hours and 1,472 cycles at the time of the accident. The right engine was installed in October 1997 and had accumulated 905.6 hours and 754 cycles at the time of the accident.

The following records were reviewed, with a specific focus on any flight control difficulties: airplane logbooks, non-routine work cards, and a list of airplane modifications and applicable service bulletins. No open write-ups or trends were found. A review of the airplane logbooks revealed two flight control discrepancies. On January 21, 1998, a write-up indicated that the spoilers deployed on the take off roll. An operational test of the spoilers was conducted, and no defects were discovered. On February 2, 1998, a write-up indicated that both control yokes were offset to the right of neutral (with greater offset on the left yoke). As corrective action, the neutral position between the control yokes and the ailerons was verified.

The maintenance records review also included an examination of Engineering Authorizations (EM) on the airplane, cross-referenced with the original service bulletins (SB) prompting the work, showing those effective on the EMB-145 and those listed or performed on the accident airplane. The records indicated that all SBs related to flight controls had been performed except SB 145-27-0011, which provides for a modification to the rudder PCU input arm to preclude interference of the input arm with the PCU manifold. However, review of records from Parker Aerospace and subsequent examination of the rudder PCU during its testing revealed that the modification had been incorporated.

AIRDROME INFORMATION

Runway 30's surface condition at the time of the accident was classified as "Good." There were no NOTAMS in effect for the runway or the airport facility.

FLIGHT RECORDERS

The airplane was equipped with an Allied Signal two-hour solid state digital cockpit voice recorder (CVR), serial number 0354. After the accident, the unit was removed from the airplane and delivered to the NTSB Audio Laboratory in Washington, DC. The exterior case of the CVR showed no evidence of structural damage and the interior of the recorder and the memory module sustained no apparent heat or impact damage. On February 18, 1998, a CVR group convened in Washington, DC. A transcript was prepared of the final 6:52 minutes of the recording.

The airplane was equipped with an Allied Signal Solid State Flight Data Recorder (SSFDR), serial number 1975. After the accident, the unit was removed from the airplane and delivered to the NTSB Flight Recorder Laboratory in Washington, DC, for read out and evaluation. A SSFDR group was convened in Washington, DC, evaluated the data, and produced a Factual Report. The following is a summary of the pertinent evaluated data from the last 30 seconds of the accident flight:

At 1215:51, SSFDR data indicated that the aircraft was traveling down the runway on a magnetic heading of 298 and at an airspeed of 109 knots. Engine #1 (left engine) N1 and N2 values were 86% and 94%, respectively. Engine #2 (right engine) N1 and N2 values were 86.29% and 94.80%, respectively. The thrust lever angle (TLA) for the left engine was at 75 degrees. Pitch angle values indicate the start of a pitch up, going from a value of 0 degrees to 1 degree. Rudder pedal position (RPP) values indicate right rudder inputs, at values of 1 degree and 2 degrees.

At 1215:52, TLA for the left engine was reduced to 30 degrees, indicating the left throttle lever was being retarded to idle. The airspeed value was 115 knots, while pitch angle values reached 5 degrees. The RPP value was minus 1-degree, indicating left rudder inputs. Control wheel position (CWP) reached a value of 22 degrees, indicating right control wheel inputs.

At 1215:53, TLA for the left engine remained at 30 degrees, while left engine N1 and N2 values dropped to 70% and 84%, respectively. Left rudder inputs continued, indicated by a RPP value of minus 2 degrees. Pitch angle reached 8 degrees. At this time, roll angle values increased from 1 degree to 2 degrees (right roll). During this time, the air/ground switch value indicated "air."

At 1215:54, TLA for the left engine dropped further to 25 degrees. At the same time, left engine N1 and N2 values continued dropping to 47% and 70%, respectively. Left rudder inputs increased, indicated by RPP values reaching minus 7 degrees. The aircraft continued rolling to the right, reaching a 4 degree roll angle. Pitch angle continued to increase, reaching 11 degrees.

At 1215:55, RPP values increased to 6 degrees, indicating right rudder inputs. The airplane began to roll to the left, reaching a roll angle of minus 1 degree at a rate of minus 1 degree per second. Right control wheel inputs continued, with CWP reaching 40 degrees. Airspeed continued increasing, having reached 122 knots.

At 1215:56, the left roll continued, going from minus 9 degrees to minus 23 degrees. At the same time, pitch angle was 10 degrees. According to documentation from the aircraft manufacturer, in the EMB-145, when the main landing gear is on the ground and the pitch angle is 10 degrees, the wing touches the ground at a roll angle of 11 degrees 20 seconds.

From 1215:57 to 1216:01 (the last second for valid data on the SSFDR), the left roll continued, reaching a maximum left roll of minus 71 degrees at 1215:58 before decreasing to minus 23 degrees at 1216:01. Magnetic heading continued to decrease from 270 degrees to a final value of 237 degrees. The aircraft reached a maximum airspeed of 125 knots at 1215:58 before slowing to 120 knots at 1216:01. Left engine TLA increased to 82 degrees at 1215:58, indicating power being applied to the engine. Left engine N1 and N2 increased to final values of 60% and 87% at 1216:01.

WRECKAGE AND IMPACT INFORMATION

The first physical evidence of the airplane's ground track across the runway was a contact mark, consistent with the left wingtip, beginning at the left edge of runway 30 where it intersects the east edge of taxiway "F" (approximately 2,800 feet from threshold on runway 30). The mark was overall white in appearance and continued to the left and across the taxiway. The mark began thin, became thicker toward the middle of the taxiway, then thinner again toward the far edge of the taxiway. Three small composite pieces from the left wingtip were found adjacent to the mark on the taxiway. No impact scar was observed for the next 55 feet until the beginning of an arcing 117-foot gouge in the soil. Other wingtip composite pieces and a wingtip lens were found adjacent to the gouge. Additional ground scars consistent with the left main landing gear, nose landing gear, and right main landing gear were subsequently observed along the energy path. The airplane came to rest with a final heading of approximately 230 degrees (magnetic) and approximately 750 feet southwest of the left edge of runway 30 and 650 feet northwest of the edge of taxiway "F." All components of the airplane were found along the energy path and the final resting pl

NTSB Probable Cause

The first officer's improper use of the rudder when given a simulated engine failure on takeoff and the pilot-in-command's delayed remedial action which resulted in a loss of control. A factor was the first officer's lack of experience in the regional jet airplane.