Failure to Go Around Leads to Runway Excursion

A 2016 Flight Safety Foundation (FSF) study of 16 years of runway excursions determined that “83 percent could have been avoided with a decision to go around. In other words, 54 percent of all accidents could potentially be prevented by going around.” Failure to conduct a go-around is the number one risk factor in approach and landing accidents and a primary cause of runway excursions, the FSF added. The foundation also believes that while unstable approaches are a primary cause of landing excursions, “the global aviation industry’s rate of compliance with go-around policies is extremely poor with just 3 percent of unstable approaches resulting in a go-around.” Executing a go-around carries its own set of risks, such as exceeding flap and gear extended speeds and a failure to achieve a positive climb during the maneuver, because go-arounds are seldom practiced in the locations where they often occur.

The FSF also said, “Many aborted landing attempts have been investigated thoroughly over time, and much is known about contributing factors. What is lacking, however, is an understanding of the psychology of [pilot] noncompliance.” The foundation said the collective industry norm is to accept the non-compliance of go-around policies despite research indicating this contributes to abortive landing attempts. They added that the industry tends to focus on eliminating unstable approaches, mainly because pilots—management included—seem to have so little understanding of the risks involved in aborted landing attempts. Additionally, many pilots don’t see current go-around policies as realistic. The lessons learned in planning for an approach in turbine-powered aircraft can correlate closely to those necessary for the pilots of smaller GA airplanes.

On August 15, 2019, a Cessna Citation Latitude—a midsize business jet—crashed off the departure end of Runway 24 at Elizabethton, Tennessee (0A9), following an unstable VFR approach, a poorly executed landing, and a botched go-around attempt. The go-around decision by the pilot was made beyond the commit to stop point (CTS), a spot on the runway when a successful return to flight is not possible. The weather was good VFR with calm winds and the runway was dry. Neither pilot was injured, but all three passengers received minor injuries as they attempted to exit the aircraft after it burst into flames.

Upon arrival in the Elizabethton area, the flying pilot (FP) never completely configured the airplane for a stable approach despite a number of nudges from the non-flying pilot (NFP) in the right seat. The Latitude touched down 18 knots above its calculated reference speed for the 5,001-foot Runway 24 that included a 902-foot displaced threshold . That left just 4,099 feet of usable runway remaining. Because of its excessive speed and a poorly executed flare, the Citation bounced the first time it touched down about 240 feet past the displaced threshold. It bounced two more times before finally touching down firmly on the fourth try. At that point there was just 1,120 feet of hard surface remaining.

According to the NTSB report ERA19FA248, during the first touchdown, “All three landing gear registered ‘on-ground’ simultaneously with a vertical acceleration of 1.4 Gs. Thrust reverser deployment was commanded 0.4 seconds after the landing gear first touched, however, the airplane bounced after being down for 0.6 second and became airborne again before the thrust reverser command could be executed.” The airplane touched down a second time on the nose gear first with a force of 1.2 Gs, followed immediately by the right main landing gear. The left main landing gear never registered on-ground this time as the airplane again became airborne 0.4 seconds later.

"On the third touchdown, the Latitude struck the runway with a force of 1.7 Gs. This time, the thrust reversers unlocked after all three landing gear registered on-ground because the reverser deployment command from the first touchdown was still active. Almost immediately after the thrust reversers unlocked, the pilot advanced the throttles to idle—perhaps to initiate a go around?—now sending a thrust reverser stow command. However, the landing gear status changed to ‘in-air’ that triggered a cut in hydraulic power to the reverser actuators to prevent their airborne deployment. The cut in hydraulic power to the reversers allowed the unlocked thrust reversers to be pulled open by aerodynamic forces.

“Moments later, an amber ‘T/R UNLOCK’ CAS message illuminated and the thrust reverser emergency stow switches began flashing. The pilot then advanced the throttles to maximum takeoff power in an attempt to go around just as the thrust reversers reached full deployment. The airplane’s full authority digital engine controls (FADEC), by design, prevented an increase in engine power while the reversers were deployed. The NTSB said the red ‘T/R DEPLOY’ CAS message was displayed in the cockpit, indicating that the thrust reversers were deployed, and the thrust reverser emergency stow switches continued flashing.” The pilots later confirmed they attempted a go-around, but because the engines did not respond as expected, they elected to land straight ahead on the runway.

But in just a few seconds while the airplane was airborne, the crew partially retracted the flaps as the airspeed decreased from 119 knots to 91 knots. The pilot retarded the throttles partially but not fully to idle, but then pushed them forward again with no effect because the FADEC prevented the action. The FP never did extend the speed brakes after touchdown, which would have significantly helped slow the airplane. The stick shaker activated half a second before the airplane touched down for the fourth time, warning of an imminent stall. During the touchdowns, the aircraft reported a peak G load of 3.2. Once all three landing gear touched down on the runway, the thrust reverser system was again reenergized and the reversers stowed 0.9 seconds later because the throttles were now at idle.

During the final hard landing, the Latitude’s landing gear began to collapse and the airplane departed the 97-ft-long paved surface beyond the end of the runway, passed through a 400-ft-long open area of grass, down an embankment, through a creek, through a chain-link fence, and up an embankment before coming to rest on the edge of a four-lane highway. In post-accident interviews with the flight crew, they reported they quickly secured the engines and assisted the passengers with the evacuation through the main entry door as a post-accident fire erupted, which eventually destroyed the airplane.

Both pilots were experienced. The captain had logged about 5,800 hours total time, with 765 hours in make and model, while the NFP in the right seat had logged about 11,000 hours total time with 1,165 hours in make and model. The NFP also served as the flight department’s director of operations, making him the left-seat pilot’s immediate supervisor. The flying pilot said he did not believe flying with his boss caused him to make any decisions he wouldn’t also have made if he’d been flying with anyone else.

The NTSB’s docket on this accident includes both a transcript of the cockpit voice recorder (CVR), as well as copies of the individual post-accident interviews with the crew. One item that stood out was the crew’s apparent lack of preflight planning for the short 70-nm flight conducted at 12,500 feet between Statesville, North Carolina (KSVH), and Elizabethton. Within the world of flying, even jet flying, it’s not that unusual for pilots to fall into the potential trap of believing they can cope with most anything they encounter during such a short flight. In interviews, both pilots said they encountered nothing at all unusual during the approach, except the flying pilot’s admission that he failed to slow the aircraft, and also that he could have descended earlier.

About 10 minutes out from 0A9, the crew can be heard on the cockpit voice recorder discussing what sounds like the pair trying to find a hole in order to get below the bases of some scattered to broken clouds to prepare for the visual approach. Nine minutes before the accident the NP asks the other whether any sort of approach aid was available to the runway, which it is not. Both pilots were however, well aware of the nearby terrain as they began their descent. Elizabethton airport is located at the southwest end of a valley with ridgelines that rise between 1,000 and 2,000 feet above 0A9′s field elevation.

During the flight, the CVR conversation between the two crewmembers seemed to indicate the FP was not entirely sure of his abilities as the flight approached OA9. Five minutes before touchdown, the NFP suggested, “It wouldn’t hurt to slow down.” Certainly, the flying pilot could be given the benefit of the doubt in that he interpreted the conversations more as gentle nudges from the right seater, such as when to start the descent, when to slow and a heading to find a hole in the clouds. The flying pilot did ask for confirmation of the location of a nearby ridgeline as he descended through the hole they apparently managed to locate. Both pilots mentioned some inbound traffic flying above them as they approached the airport. Two minutes prior to touchdown, the FP apparently had not yet sighted the airport as the NFP suggested, “Well, I wouldn’t turn. I wouldn’t turn to the right anymore. I would just climb right where you are.”

About 30 seconds later while on a seven-mile final for Runway 24, the crew received a Terrain Awareness and Warning System (TAWS) alert, “Terrain, Terrain,” followed shortly after by another warning, “Whoop, Whoop, Pull Up, Pull Up.” Less than a minute from touchdown, the aircraft was still flying beyond reference speed as the FP called for the landing gear. The NFP said he’d comply as soon as the airplane slowed below extension speed. Twenty five seconds before touchdown, the crew again received a TAWS, as well as another pull-up command. Fifteen seconds from touchdown, the NFP said, “And I don’t need to tell ya, we’re really fast.” About two seconds before touchdown, the FP asked his boss if he needed to go around, to which his boss replied, “No.” The FP then extended the speed brakes in an attempt to slow the Latitude, a violation of the aircraft’s limitations when the wheels are down. A few seconds after an apparently hard landing, the FP said, “sorry,” and “damn.” Seventeen seconds later, the flying pilot could only say, “hold *, hold *. hang on. hang on.” The NTSB deleted the expletives.

The final seconds of the flight were marked by decisions on the part of the flying pilot that seemed to indicate either a lack of understanding of how certain aircraft systems would function or a more adrenalin-charged series of near instantaneous, almost panicked reactions as nothing he tried seemed to slow the airplane before it left the runway.

Adding to the chaos, this accident nearly became fatal to all aboard as the aircraft slid to a stop. All landing gear eventually separated from the fuselage as the aircraft slid along on its right side The Latitude was equipped with an emergency exit at the right rear of the aircraft. Once the crew secured the engines, they tried to help one of the passengers who was unable to open the entrance door. Unfortunately the pilots were also unsuccessful in their attempts. Another passenger tried unsuccessfully to open the emergency escape door. The pilots were also unable to open that door as they saw heavy smoke and flames beginning to emerge from the rear of the airplane. The two pilots returned to the front door and this time were able to push it open just enough to allow for everyone to scurry to safety before the fire destroyed what was left of the airplane.

Investigators later found the entrance door handle was pushing against the ground on the outside making it difficult to open. Investigators found a fence post had impaled itself into the emergency escape hatch. The NTSB said, “Although there was extensive post-accident fire damage to the hatch, the latching pin was found in the closed and latched position. After investigators removed the hatch from its frame and the pole pinning it in place, the handle operated in a normal manner with full range of motion.”

The NTSB reported the probable cause of this accident as “the pilot’s continuation of an unstabilized approach despite recognizing associated cues and the flight crew’s decision not to initiate a go-around before touchdown, which resulted in a bounced landing, a loss of airplane control, landing gear collapse, and a runway excursion. Contributing to the accident was the pilot’s failure to deploy the speed brakes during the initial touchdown, which may have prevented the runway excursion, and the pilot’s attempt to go around after deployment of the thrust reversers.”