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Fatal "Joy Ride" in RJ


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A Case Of Fatal Joyriding?

Crew Aboard Pinnacle Flight Wanted To Join The 4-1-0 Club How high is too high?

In the case of a Pinnacle Airlines Canadair CRJ-2, the answer is 41,000 feet. Finding that out cost two Pinnacle pilots their lives. That's what NTSB investigators derived from the cockpit voice recorder aboard the CRJ.

It was the end of a flight full of pilot hijinks, according to the NTSB, which is holding three days of hearings into the October 14 mishap in Jefferson City, MO.

Flying deadhead from Little Rock, AR, to Minneapolis, MN, the crew was positioning the aircraft for the next morning's flight, according to investigators. The flight data recorder shows the pilot, 31-year old Jesse Rhodes and the copilot, 23-year old Richard Cesarz, starting having fun shortly after take-off. While still on ascent, they pulled 1.8 G's in a pitch-up maneuver that activated an automatic system designed to keep the engines from stalling.

They pulled up again shortly after that, as the data recorder registered 2.3 positive G's.

Then, according to the NTSB, they decided to join the "4-1-0" Club by taking the aircraft to its maximum altitude.

"There's my four one oh oh my man," said Cesarz, according to the transcript. "Yeah. . . . [sound of laughing] this is [unintelligible] great."

"You'll get the, you'll do the next one to say four one oh," Rhodes said.

"[unintelligible] Yeah baby."

"[sound of laughing] Four one oh [expletive] Four one oh."

An air traffic controller then asked what in the world Rhodes and Diaz were doing at 41,000 feet.

"We don't, we don't have any passengers on board so we decided to have a little fun and come on up here," Rhodes said, according to the transcript.

But the laughter was suddenly quiet as the engines died. The following is an abridged transcript of what followed:

9:48:44 p.m.

Cesarz: "Man we can do it. Forty-one it.''

9:48:46

Rhodes: "(Unintelligible) baby.''

9:48:57

Cesarz: "Hundred and eighty knots, still cruising at Mach point six four.''

9:51:51

Cesarz: "There's four-one-oh, my man.''

9:51:53

Cesarz: "Made it, man.''

At that point, the engines apparently spooled down in a double-flameout.

9:54:19

Rhodes: "Yeah, that's funny, we got up here, it won't stay up here.''

9:54:22

Cesarz: "Dude, it's (expletive) losing it.'' (Sound of laughing)

10:14:36

Cesarz: "We're not gonna make it, man, we're not gonna make it.''

10:14:38

Rhodes: "Is there a road? Tell her we're not gonna make this runway.''

10:14:46

Rhodes: "Let's keep the gear up. (Expletive) I don't want to go into houses

here.''

10:14:51

Cesarz: (Expletive) "road right there.''

10:14:52

Rhodes: "Where?''

10:14:52

Cesarz: "Turn, turn...''

10:14:53

Rhodes: "Turn where?''

10:14:53

Cesarz: "Turn to your left, turn to your left.''

10:14:56

Rhodes: Either: "I see it'' or ``I can't.''

10:14:58

Warning signal in cockpit: "Too low, terrain, terrain.''

10:14:59

Rhodes: "Can't make it.''

10:15:03

Rhodes: "Aw (expletive). We're gonna hit houses, dude.''

FMI: www.ntsb.gov

aero-news.net

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Mayday, I'd guess it's how and why they got there, more than that they were there, that earned that label.

Worth mentioning is that it has been reported on another web site by a man who claims to have been involved with the investigation, that they did not hit those houses at all... they intentionally hit the dirt to avoid hurting anyone else.

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9:51:53

Cesarz: "Made it, man.''

At that point, the engines apparently spooled down in a double-flameout.

10:15:03

Rhodes: "Aw (expletive). We're gonna hit houses, dude.''

Not to play armchair quarterback although I guess I am, I find it odd that in the 23 minutes from flameout to impact that they couldn't have gotten at least one of them relit. Perhaps these engines don't do inflight starts well but I do know from maintenance tests flights that the venerable old Pratts fire up in a heartbeat.

Additionally, while I don't have any idea of the glide ratio of the Skidoo, in the '37 a glide from 410 at best glide speed should take you in the neighbourhood of 150 miles or so. (Not that we could likely drag our loveable old -9 powered bird up there even if we had a mind to.)

It's always difficult to read these reports without doing the 'Woulda/Coulda/Shoulda'. Tough stuff. sad.gif

Kev

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Somebody who's RJ qualified may be able to explain it better, but the "Story" I heard is the reason the engines couldn't be restarted had something to do with bleed air selection?????? having never had anything to do with them I couldn't say if this is plausible but it's what I heard

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Guest Starman

A few questions come to mind:

If the RJ is certified for FL410, why did the engines flame out?

Considering that they had 23 minutes to obtain a successful re-light; why were they not successful? (...the bleed status should be covered within the QRH if it is pertinent)

Why is the FAA releasing confidential CVR tapes to the public which are highly embarassing to two pilots who are now dead?

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Guest directlaw

"Hundred and eighty knots, still cruising at Mach point six four"

If you have ever flown at an RJ you would never want to be that slow that high

My guess is they got behind the power curve. Continued to decelerate. Stalled, no warning but this aircraft has a rep for that, then flame out.

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The Bae-146 had multiple occasions of 1,2,3,and even 4 engine flame-outs. Usually associated with atmosperhic/weather conditions.

It seems the little fan engines don't like living at their maximums.

Maybe lack of oxygen in this case in regards to decision making. They were way up, and when things quit, pressurization may have had something to do with it. You would think 23 minutes to get a re-start would be sufficient. Wonder if they discussed a re-lite.

Kind of makes you wish you were there to see what was going on, but glad you weren't.

Whats the old saying, learn from others.......

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9:54:22

Cesarz: "Dude, it's (expletive) losing it.'' (Sound of laughing)

10:14:36

Cesarz: "We're not gonna make it, man, we're not gonna make it.''

Upon further reading, there appears to be 20 minutes missing from the tape transcription. This obviously wasn't a full release of the tape.

I have to agree that I'm not comfortable with any release of CVR recordings to the general public/media, particularly after a fatal accident. That said, the only tapes that are considered newsworthy seem to be those that involve a total or at least partial loss of all souls.

Who knows what went on. Maybe there were valiant but unsuccessful attempts at a re-light and an intense search for a viable place to land...or maybe just...?

Kev

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...I'm not comfortable with any release of CVR recordings to the general public/media, particularly after a fatal accident. That said, the only tapes that are considered newsworthy seem to be those that involve a total or at least partial loss of all souls.

I agree. Most of the time my impression is that the readership in the public press is comprised simply of goulish lookie-loos. In this instance, however, I get an uncomfortable feeling that the NTSB has erected a pillory ...if indeed it used words like "hijinks" and "joy-ride" in its presentation.

Then again, a public inquiry is just that: public. But it is sobering to realize how what we may perceive at the time to be a private indescretion, can quickly become a public spectacle, and how the words in our personal conversations can become our epitaph.

ccairspace

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The Bae-146 had multiple occasions of 1,2,3,and even 4 engine flame-outs. Usually associated with atmosperhic/weather conditions.

The 146 engines never actually flamed out, they spooled down to sub idle, this was caused by icing of the inlet probe

No. CF-2000-12R1

Issue Date: 22 May 2002

AIRWORTHINESS DIRECTIVE

The following airworthiness directive (AD) may be applicable to an aircraft which our records indicate is registered in your name. ADs are issued pursuant to Canadian Aviation Regulation (CAR) 593. Pursuant to CAR 605.84 and the further details of CAR Standard 625, Appendix H, the continuing airworthiness of a Canadian registered aircraft is contingent upon compliance with all applicable Ads. Failure to comply with the requirements of an AD may invalidate the flight authorization of the aircraft. Alternative means of compliance shall be applied for in accordance with CAR 605.84 and the above- referenced Standard.

This AD has been issued by the Continuing Airworthiness Division (AARDG), Aircraft Certification Branch, Transport Canada, Ottawa, telephone (613) 952-4357.

Number:

CF-2000-12R1

Subject:

British Aerospace BAE 146 - Engine Power Rollback

Effective:

28 June 2002

Revision:

Supersedes Airworthiness Directive (AD) CF-2000-12, dated 11 May 2000, and UK CAA AD 003-06-96R1.

Applicability:

All models of Canadian registered British Aerospace BAe 146 aircraft fitted with Honeywell (formerly AlliedSignal) ALF-502R series engines.

Compliance:

Is required within 24 hours after receipt of this directive or before further flight, whichever occurs later, unless already accomplished.

Background:

A Canadian registered BAe 146 aircraft experienced a power rollback on three engines during descent from 29,000 ft to 26,000 ft in icing conditions. Transport Canada AD

CF-2000-12 was issued to restrict the operation of Canadian registered BAe 146 aircraft to a maximum altitude of 26,000 feet in known or forecast icing conditions. This revision has been issued to introduce terminating action for the operating limitations mandated by AD CF-2000-12.

Corrective Actions:

To prevent engine power rollback during flight in icing conditions above 26,000 ft, accomplish the following:

I. Amend the BAe 146 Aircraft Flight Manual by adding the following Limitation:

“In order to prevent uncommanded thrust reduction, flight in known or forecast icing conditions above 26,000 ft is prohibited.In the event of inadvertent encounters with icing conditions above 26,000 ft:

(1) Observe LIMITATIONS, POWER PLANT, ENGINE OPERATING LIMITATIONS.

(2) Confirm all engine anti-ice ON. Disconnect TMS and set all engines to 87% N2 and 80% N1 minimums. Descend to 26,000 ft or below using airbrake.

(3) Prior to selection of airframe outer wing and tail anti-ice in descent, set all engines to 90% N2 and 80% N1 minimums. Select CABIN AIR to RECIRC (if fitted). Thereafter maintain 87% N2 and 80% N1 minimums.

For definitions of Icing Conditions see LIMITATIONS, ICE AND RAIN PROTECTION, ICING CONDITIONS.”

This amendment requirement can be accomplished by inserting a copy of this Directive in the BAe 146 Aircraft Flight Manual, opposite Section 2.01.1, page 5.

II. Modification of all four engines with improved engine fan core inlet anti-ice system in accordance with Honeywell (formerly AlliedSignal) Service Bulletin (SB) ALF/LF 72-1020 Revision 3 dated 19 January 2001 and British Aerospace (BAe) SB 71-72-30473A Revision 1 dated 2 November 1998 constitutes terminating action for the operating limitations defined in paragraph I of this Airworthiness Directive.

Note: Installation of engine modifications in accordance with earlier versions of Honeywell SB 72-1020 and BAe SB 71-72-30473A meet the requirements of paragraph II of this Directive.

Authorization:

For Minister of Transport

B. Goyaniuk

Chief, Continuing Airworthiness

Contact:

Mr. Robin Lau, Continuing Airworthiness, Ottawa, telephone (613) 952-4461, facsimile (613) 996-9178 or e-mail laur@tc.gc.ca or any Transport Canada Centre.

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Comments elsewhere indicate that the engines on this RJ were "core locked"

- for those not familiar, that would be a condition where the turbine rotors had siezed with their tips against the inner case. That can happen when the case gets cool and the rotor is flippin' hot, and stretched while the case shrunk. The clearance is kept to a minimum for efficiency, often by cooling the case intentionally... but it ain't supposed to get to that point!

Anyway, again, I obviously have no way to substantiate that, but it would sure explain the inability to restart.

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There was some indication shortly after the accident (I believe in the AEF) that the pilots tried several times to relight but were to slow to schieve the appropriate N@ rotation to be successful.

This would seem to be the "self preservation" thing. It would be in human nature to try to keep the thing as far from the ground as possible for as long as possible. Altitude must be traded for airspeed in order to relight the engines. If they were scared out of their pants (which I am sure they were) they would not want to see the altimeter dropping like a rock.

I also think that if they were pulling 2+g maneuvres on the way up then they werent really thinking about what they were getting into.

B

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Guest Starman

Pulling 2 G's is obviously contributing to the perception of a "joyride" but plus 2 G's is well within the design criteria for the aircraft.

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Guest directlaw

Comments elsewhere indicate that the engines on this RJ were "core locked"

- for those not familiar, that would be a condition where the turbine rotors had siezed with their tips against the inner case. That can happen when the case gets cool and the rotor is flippin' hot, and stretched while the case shrunk. The clearance is kept to a minimum for efficiency, often by cooling the case intentionally... but it ain't supposed to get to that point!

Anyway, again, I obviously have no way to substantiate that, but it would sure explain the inability to restart.

Mitch,

Could this situation be caused if airflow was suddenly interrupted at high altitude and high thrust settings...IE wing stalling with a rear mounted engine?

I don't have any graphs but flown the aircraft. 180kts at FL410 sounds like it is behind the power curve to me. For those that don't know what that means. At high altitude it is possible, due to attitude/drag of the aircraft and reduced eng performance, that there is not enough thrust left to overcome said drag ( back side of the power curve). The result is slow air speed decay. One of the ways this can happen is a repeated trading of airspeed for altitude during the climb and getting the aircraft to an altitude that it just does not have enough performance to maintain.

Edited by directlaw
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Hi Directlaw,

I'd hate to speculate... For one thing, I'll feel like a fool if I turn out to be wrong cool.gif , and for another, I'm sure there are some who find it unfair, or otherwise wrong to do so... and it probably is.

...and I'm not familiar with that specific engine at all...

I can imagine though... And yes, I'd imagine that could happen as you described... and I can tell you what I think I know...

Here's what I can come up with at this point in my (lack of) sleep cycle:

If FL410 is the limit for an engine, that means it's close to suffering for air at that altitude... and I'd imagine a turbine suffering for air would be running pretty hot, and turning pretty fast - rotational forces don't change with altitude, but the actual rpm will... Turbine engines are limited in the thrust they can develop by the heat they can take and the speed they can turn at that temperature (centrifugal forces), before the turbine blades (or entire rotor assembly's I suppose) begin to stretch ... beyond their limits, they could either stretch to their breaking point, or until they begin to rub the case...

Turbine basics - air flow through the engine is all a magic happening of static and dynamic pressures, and temperature... all governed by "laws" written by guys with names like Bernoulli and Newton...

The compressor up's the static pressure to it's highest point just at the inlet to the combustion chamber - add fuel and ignite, and the compressed air rapidly expands due to the added heat... the higher static pressure in front means it escapes rearward at high velocity, that velocity increases as it moves back through the turbine section due to the convergent area of the passage ... and it's continued expansion... the dynamic pressure of the rapidly expanding gasses does the spin thing on the turbine. The highest velocity reached will be at the exit of the tailpipe where it'll be at the speed of sound for the temperature of the gas, and a shock wave will form, thus limiting (by static pressure) the acceleration ...need more thrust? - add more fuel to produce more heat, which increases the speed at which that shock wave forms (speed of sound increases with temp), and increasing the volume of rapidly expanding gasses to push the turbine, and thence the compressor/fan assembly's faster, accelerating more mass rearward, as well as more mass blasting out the tailpipe (or in the case of a pure jet, scratch the bit about the fan)

To improve thrust, you either have to find better materials that can take the heat and rotational forces better without stretching too much; improve the efficiency of the turbine by controlling the tip clearance better; or make a bigger engine.

Back to imagining... I can also imagine at 41,000 ft. the exterior of the case could get relatively cool, relatively quick, once the fire goes out.

*** but I have no idea what, if anything, any of that had to do with what happened to that RJ. ph34r.gif

If none of that makes any sense at all, please disregard and try not to hold it against me. huh.gifbiggrin.gif

Cheers,

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There was some indication shortly after the accident (I believe in the AEF) that the pilots tried several times to relight but were to slow to schieve the appropriate N@ rotation to be successful.

This would seem to be the "self preservation" thing. It would be in human nature to try to keep the thing as far from the ground as possible for as long as possible. Altitude must be traded for airspeed in order to relight the engines. If they were scared out of their pants (which I am sure they were) they would not want to see the altimeter dropping like a rock.

I, too, recall reading this after the accident. It seems to me that at no time during the descent did they achieve sufficient airspeed to re-light the engines.

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Guest directlaw

High Altitude Climbs- Factual report

A review of FDR data indicated that the airplane climbed from FL370 to FL410 at an airspeed that decreased from 203 / .63M at the start of the climb to 163 / .57M as the airplane leveled at FL410. The vertical speed during the climb was 500 FPM. When the airplane was level at FL410, the airspeed gradually decayed to 150 knots just prior to the stick shaker.

Subsequent to the accident, the company added the following restriction to the Limitations Section of FCOM 2: Minimum climb profile speed above 10,000 feet MSL will be 250 / .70M whichever was lower. The company also revised the CRJ instructor guide12 to include more specific high altitude climb information and procedures. Additionally, Bombardier, Inc., issued an All Operator Message13 that stated in part: Climb profiles as detailed in the AFM must be strictly adhered to. Climbing below the recommended profile speed may place the airplane behind the energy curve when it arrives at the desired altitude and it may not be capable of remaining at that altitude. This may be evident by an aircraft nose-high attitude and its failure to accelerate.

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Guest woxof

Found links to these in the pprune forum concerning incidents on June 09 and 10.

NTSB Identification: DCA05IA072

Scheduled 14 CFR Part 129: Foreign operation of Air Canada Jazz

Incident occurred Thursday, June 09, 2005 in colorado spring, CO

Aircraft: Bombardier, Inc. CL-600-2D15, registration: CGJAZ

Injuries: 66 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

An Air Canada Jazz Bombardier CL-600-2D15, tail number C-GJAZ, operating as flight number JZA8501 from Houston, Texas to Calgary, Alberta Canada, experienced a stick shaker event while at flight level 410 and in the vicinity of Colorodo Springs, Colorado. The airplane was at Mach 0.070 when the flight encountered a downdraft and the stick shaker activated. Maximum thrust was set and a lower altitude was requested. The airplane descended at approximately 1000 feet per minute with a 3 degree nose down attitude. An attempt to recover at flight level 400 was made but the stick shaker activated briefly and the descent was continued. Recovery was made at flight level 380 and the airplane returned to a planned speed of Mach 0.77. There were 62 passengers on board and no injuries were reported. Transportation Safety Board Canada has secured the flight data recorder and has provided an accreditted representative to the investigation.

NTSB Identification: DCA05WA073

Scheduled 14 CFR Part 129: Foreign operation of Air Canada Jazz

Incident occurred Friday, June 10, 2005 in Canada/US borde

Aircraft: , registration:

Injuries: Unavailable

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

An Air Canada Jazz Bombardier CL-600-2D15, tail number C-FBJZ, was operating as flight JZA8501 from Houston, Texas to Calgary, Alberta Canada, experienced a stick shaker event while at flight level 400 and in the vicinity of the US/Canada border. The airplane experienced a loss of airspeed and the flight crew pitched the nose down to maintain airspeed. The stick shaker and an aural stall warning sounded. The descent was arrested at flight level 380. One passenger struck thier head on the overhead bins during the descent manueuver. The Transportation Safety Board Canada is investigating and the Safety Board has provided a US accreditted representative.

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  • 4 weeks later...

Article on the Pinnacle accident in Flight International 28 June:

Pinnacle Airlines flame-out caused by stall turbulence

Crew’s decision to explore edges of aircraft’s flight envelope led to disaster

The hitherto mysterious double engine failure on a Pinnacle Airlines Bombardier CRJ200 has been revealed as a flame-out caused by a combination of high altitude and intake turbulence resulting from high angle of attack and wing stall.

According to a US National Transportation Safety Board (NTSB) initial factual report on the 14 October 2004 fatal accident, the aircraft arrived at the pilots’ requested altitude of 41,000ft (12,500m) behind the drag curve at Mach 0.57, with indicated airspeed reducing.

Flight level 330 was the height identified as best for fuel burn on the Little Rock-Minneapolis/St Paul positioning flight, but a verbal exchange with the controller revealed the pilots decided to try flying at the aircraft’s service ceiling for “a little fun” (Flight International, 8-14 March).

The NTSB says there is no evidence as to whether or not the crew consulted the aircraft operating manuals, but it has since been estimated that the maximum altitude for the weight and conditions was 40,000ft.

When they reached their planned level the pilots quickly realised the aircraft’s airspeed was falling and they asked for a lower level. The aircraft stalled fully, with the stick-pusher operating four times in 20s, and the engines flamed out. During this period the maximum recorded angle of attack was 27º. Finally the nose pitched down 32º, with 82º left wing low. Cockpit voice recorder (CVR) playback indicates the crew realised they had a double engine failure. They reported an emergency and the need for descent, but did not report for 17min that they had a double engine failure and needed vectors to the closest airport.

Meanwhile, they tried several times to relight the engines, but with no success. The continuing NTSB investigation is examining whether the engines suffered core lock, a phenomenon caused by differential cooling of static engine parts compared with the internal rotating core. The NTSB found the turbines had suffered overtemperature, which can exacerbate core lock. Absence of engine windmilling was recorded during much of the descent.

The aircraft crashed 2.5nm (4.6km) south of Jefferson City airport, Missouri, to which it was being vectored by air traffic control. Half of the left wing was torn off by the first impact with a tree. The aircraft rolled left and hit more trees before coming to a halt inverted. Both pilots died in the accident.

Flight descent progress

The cockpit voice recorder was active throughout. The flight data recorder (FDR) was briefly interrupted after the double engine failure, but restored when the auxiliary power unit (APU) was started. Timeline is local time.

21:52:08 crew notifies ATC on reaching FL 410 (41,000ft/12,500m);

21:54:31 crew reports unable to maintain level, requests lower;

21:54:38 stick-shaker activated, followed by stickpusher operating four times in next 20s;

21:54:58 FDR confirms attitude 32º nose down and 82º left wing low;

21:55:05 engines fail and crew declares emergency;

21:55:21 FDR stops;

21:59:17 FDR starts with the APU power;

21:59:51 crew requests descent to 13,000ft;

22:03:14 ATC asks what the emergency is. Captain gives confusing reply. Controller believes only one engine has failed;

22:09:06 crew tells ATC for first time that they have a double engine failure and requests vectors for nearest airfield. Controller provides vectors to runway 30 at Jefferson City airport;

22:09:15 crew reports descent rate 1,500ft/min (8m/s), passing 9,500ft;

22:13:19 crew reports on vector heading 360º, says airport is not in sight;

22:14:39 first officer says aircraft is not going to make it to the runway;

22:15:07 aircraft hits ground 2.5nm (4.6km) south of airport.

DAVID LEARMOUNT/LONDON

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