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I thought the canicule of ailing accomplished captains and seat-warming copilots were connected gone in agent operations — at atomic those conducted in the U.S. But it would assume there are still operators who are not abnormally accurate about who’s in the cockpit, or their akin of adequacy in the face of abrupt situations.

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This ages we’ll booty a quick attending at the blow of a Learjet 35A (XA-USD) baleful to all four occupants on Nov. 19, 2013, aback it comatose into the sea off the Fort Lauderdale, Florida, bank aloof 3 min. or so afterwards takeoff.

The NTSB bent the apparent account of the blow was “the pilot’s abortion to advance ascendancy of the aeroplane afterward an inflight deployment of the larboard agent advance reverser.” Further accidental to the accident, it said, “was the flight crew’s abortion to accomplish the adapted emergency procedures, the copilot’s abridgement of accomplishment and adequacy to act as a adapted flight crewmember for the flight, and the inflight deployment of the larboard agent advance reverser for affidavit that could not be bent through post-accident investigation.”

The aeroplane had aloof completed an air ambulance flight for Air Evac International from San Jose, Costa Rica, to Fort Lauderdale-Hollywood International Airport (FLL) and was repositioning aback to its abject in Cozumel, Mexico. Weather at FLL included few clouds at 2,500 ft. and a broadcast band at 6,500 ft. The wind was calm and afterimage was 9 mi. The temperature was 23C, the dew point was 22C, and the altimeter ambience was 29.93 in. of mercury.

The Flight

Investigators acclimated FAA ATC articulation and alarm recordings to actuate the Learjet’s clue and timeline. The aeroplane ancient Aerodrome 10 at FLL at about 1950 and climbed beeline ahead. Aback it accomplished an distance of about 2,200 ft. and a groundspeed of 200 kt., the copilot requested alarm vectors to acknowledgment to the aerodrome due to an “engine failure.” The ambassador directed the flight to advance 4,000 ft. and about-face to a branch of 340 deg. The copilot replied, “Not possible” and requested a 180-deg. about-face aback to the airport. The ambassador acknowledged, but the aeroplane connected a bit-by-bit about-face to the arctic as it slowed and descended.

Two account later, the copilot declared a “Mayday!” and afresh requested vectors aback to FLL. During the abutting 3 min., the copilot requested vectors to the airport assorted times. While the copilot requested, accustomed and accustomed added bluff and tighter turns to the southwest from ATC to acknowledgment to the airport, the aeroplane connected its apathetic about-face and coast to the north. During the 2 min. afterward the copilot’s declared ambition to acknowledgment to FLL, the aeroplane descended to 900 ft. and slowed to 140 kt. as it flew northbound, alongside to the bank and abroad from FLL.

At 1955:15, the copilot appear the aeroplane was “. . . 200 ft. over the sea.” Afterwards that, there were no apprehensible transmissions accustomed from the airplane, and communications with the aeroplane were lost.

A chase began immediately, but there was no affirmation of survivors. Some amphibian blow was recovered by the U.S. Bank Guard. It showed appulse blow but no affirmation of fire. The capital blow was amid on the ocean attic on Dec. 3, 2014.

The wings were afar from the fuselage, and the outboard area of the larboard addition was missing. The larboard and adapted wingtip tanks were alone from the wings. Both ailerons were identified, and one addition accessory was begin at the abandoned position. Both capital landing accessory were retracted.

On the burke quadrant, the larboard ability batten was begin accomplished the best position and blow to the advanced stop was constant with over-travel. The adapted batten was begin one-half inch from its best travel. There was no arresting blow to either the abandoned or blow stops.

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The advance reverser ascendancy console and console anatomy were askew by appulse forces. The centralized cyberbanking apparatus were breakable and/or coated with broiled abstracts apocalyptic of captivation in alkali water. The UNLOCK, DEPLOY and BLEED VALVE annunciator ablaze accumulation for both larboard and adapted engines appeared intact. The NORMAL/EMERGENCY STOW about-face on the advance reverser ascendancy console was begin complete in the ascendancy console and in the NORMAL position.

The agent N2 rpm gauges adumbrated 96.8% on the larboard agent and 96.5% on the right. The agent agent temperature gauges adumbrated 781C on the larboard agent and 780C on the right. The agent fan gauges adumbrated 89.2% on the larboard agent and 89.8% on the right. It would assume the engines had been operating at abreast best thrust.

Thrust Reverser System

Photographs taken of the abysmal blow afore its accretion from the ocean attic showed that the larboard engine’s advance reverser and acquaintance doors were not in the stowed position. Assay of apparatus from both advance reverser systems (left agent and adapted engine) afterwards accretion adumbrated that the apparatus abiding impact- and seawater-immersion damage. This blow precluded testing for electrical, aeriform and automated continuity.

Examination of the larboard engine’s advance reverser arrangement apparatus begin that the high acquaintance aperture was absorbed to the reverser and was in a partially deployed position. The lower acquaintance aperture was begin blind from one of its astriction links. The lower acquaintance door’s rod arm was missing a area of its anchor arm, and the pivoting pins were broken. The lower acquaintance aperture showed a gap amid the aperture bark and aperture pan with a angle at the advanced bend abreast the gap. Areas of acrylic and bark on the larboard agent bassinet bark and anatomy anatomy advanced and aft of the avalanche bankrupt showed birthmark and scorching, with some acrylic blistered or missing. The absolute ambit of the alien fan aqueduct abaft which the acquaintance doors bundle (when the advance reverser was stowed) was missing.

Examination of the adapted engine’s advance reverser arrangement apparatus begin that the high and lower acquaintance doors were in the stowed position. There was no arresting blow or arrest empiric amid the acquaintance doors and the surrounding structure. There was no affirmation of calefaction blow on the agent bassinet alien bark or paint.

The Pilots

The blow assay (and afterwards bank testing) adumbrated acutely that the larboard reverser had deployed in flight. The actuality that the aeroplane concluded up in the baptize adapted that commodity went actual amiss in the cockpit.

Both pilots were active by Vuela SA de CV, which was an absolute aggregation that “leased” the pilots to Aero JL SA de CV. Both companies were endemic and operated by the aforementioned individuals.

The pilot captivated a Mexican bartering pilot affidavit with ratings for aeroplane single-engine, aeroplane multiengine acreage and apparatus airplane, and an ATP and blazon ratings in Learjets and the Gulfstream GI. The abettor told board the pilot had accrued 10,091 absolute hours of flight experience, of which 1,400 hr. were in the 30-series Learjet.

On July 5, 2013, the abettor issued the pilot a affidavit of training for 8 hr. of aggregation ability management. On the aforementioned day, he was issued addition affidavit for an added 8 hr. of apprenticeship on controlled flight into terrain.

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The copilot captivated a bartering pilot affidavit issued by Mexico, with ratings for aeroplane single-engine, aeroplane multiengine acreage and apparatus airplane. The copilot’s absolute flight acquaintance could not be reconciled. Documents provided by the abettor adapted the copilot had accrued an estimated 1,243 absolute hours of flight experience, of which 29 hr. were in the Learjet 35.

According to aggregation annal and a resume, the copilot began aerial Learjets for the Vuela SA/Aero JL organizations on May 1, 2013. At that time, the copilot declared 1,206 absolute hours of flight experience, of which 82 hr. were “observer” time in Learjet 25s. From the day of appliance to the day of the accident, the copilot accrued 37.16 hr. of flight acquaintance in Lear 25/35 airplanes.

A affidavit formed “General Abstruse Department of Licenses,” which was forwarded by the abettor to the NTSB, adapted the copilot accrued 175 hr. in the Learjet 35A amid July 4, 2013, and Oct. 30, 2013; however, his absolute accurate flight acquaintance added alone 29 hr. over the aforementioned time period.

On Aug. 20, 2012, the copilot accustomed a authority for classroom apprenticeship accustomed for the Learjet 20 alternation airplanes from a abstruse training academy in Mexico that had neither airplanes nor flight simulators. There was no affirmation that the copilot completed any training or activated tests in a Learjet aeroplane or flight simulator.

On July 5, 2013, the abettor issued the copilot a affidavit of training for 8 hours of aggregation ability management. On the aforementioned day, he was issued addition affidavit for an added 8 hours of apprenticeship on controlled flight into terrain.

Pay annal for the pilot and copilot appearance identical hours, deductions, and pay over several afterwards pay periods. The pilot and copilot had aureate calm on three occasions afore the blow flight. The blow flight was their aboriginal flight calm in the United States.

The Safety Board said a chase of apprentice annal by “two arresting Learjet training vendors in the United States” appear no annal of actor flight training or appearance by either the pilot or copilot. Emergency action training for an inflight deployment of a advance reverser could be performed alone in an appropriately able flight simulator.

The Director General of Civil Aeronautics (DGAC) for the government of Mexico advised the pilot and flight training annal for both pilots and abbreviated their allegation for the NTSB report:

“Both the pilot and copilot annal showed inconsistencies on the verifications of training and certifications based on the way official government stamps and certifications were displayed over, and with, the entries. They were copies, and did not represent entries appropriately certified by the Government of Mexico.”

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Some of the captain’s acquaintance and certifications were based on logbooks never presented. The copilot’s annal showed the training for the Learjet 20/30 alternation airplanes provided and conducted alone by the operator, Aero JL. Further, there was no “original adopted authorization and logbook,” no “official authorization certificate” or DGAC book annal to abutment a affirmation that the copilot had 1,243 absolute hours of flight experience.

According to the DGAC, the copilot had absolutely accrued alone 206 absolute hours of flight experience. The copilot was evaluated by the DGAC in the aeroplane on May 2, 2013, and his achievement during the activated analysis was begin to be “unsatisfactory.”

The CVR

The archetype of the cockpit articulation recorder (CVR) absolutely reflected the training bearings aloof outlined.

No checklists were alleged for, offered or acclimated by either crewmember during accustomed operations (before or during agent start, taxi, takeoff) or afterward the appear inflight emergency. There were no challenge-and-response account callouts amid the pilot and copilot at any time during the flight, no elements of aggregation allocation and no identification of the emergency.

After the “engine failure” was declared to ATC, neither crewmember asked for or offered the “Engine Failure” checklist, nor was there any attack to complete an emergency action and again ask for a account analysis of accomplishments taken. The pilot asked the copilot for bearding “help” because he did not “know what’s activity on” and he could not analyze the emergency or absolute the copilot in any way with attention to managing or responding to the emergency. At no time did the copilot analyze or verify a specific emergency or malfunction, and he did not accommodate any advice or abetment to the pilot.

According to Learjet, in the blow of an inflight emergency, the archetypal assemblage was for the pilot aerial to fly the aeroplane and booty over communications with ATC. The pilot ecology should again complete the adapted checklist, while audibly announcement his accomplishments as they are completed. The pilot aerial was to verify these accomplishments above-mentioned to completion. Although altered flight departments may accept their own procedures, there was no affirmation that any aggregation allocation accomplishments took abode on the blow flight.

Specifically, the Safety Board said, “Based on the blow affirmation and abstracts recovered from the larboard engine’s agenda cyberbanking agent ascendancy [DEEC], the advance reverser rocker about-face was not placed in the “EMER STOW” position, and the larboard agent was not shut down.

“The DEEC abstracts showed a abridgement in N1 about 100 sec. afterwards ascent followed by a acceleration in N1 about 35 sec. later. The abstracts were constant with the advance reverser deploying in flight [resulting in the abridgement in N1] followed by the inflight break of the lower acquaintance aperture [resulting in the acceleration in N1 as some absolute bankrupt breeze was restored].

“Further, the DEEC abstracts appear abounding agent ability appliance throughout the flight. Although neither flight crewmember accustomed that the botheration was an inflight deployment of the larboard advance reverser, acceptance flight analysis abstracts adumbrated that the aeroplane would accept been controllable as it was configured on the blow flight. If the aggregation had activated the “engine failure” emergency action [the perceived botheration that the copilot appear to the air cartage controller], the aeroplane would accept been added calmly controlled and could accept been auspiciously landed.”

Unwanted TR Deployment

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Manufactured in 1979, the blow aeroplane was powered by two Garrett (Honeywell) TFE731-2 turbofan engines. Its best contempo connected airworthiness analysis was completed Nov. 4, 2013, at 6,842 aircraft hours.

The Lear was able with an Aeronca Inc. 45-1000 advance reverser system. Aback about-face advance was allowable from the cockpit during a landing roll, the advance reversers operated to about-face the administration of the agent bankrupt gases to abetment with endlessly the aeroplane on the runway. The advance reversers were advised to arrange alone aback the broad switches were in the “weight on wheels” approach and the throttles were in the abandoned position. Aback activated, the advance reverser arrangement acclimated 28-volt ability for reverser ascendancy and agent drain air to arrange the advice structure. The electrical arrangement in the advance reverser congenital an automatically accomplished “stow” command if the aeriform latches became apart in flight.

A rocker about-face in the cockpit could be positioned to either “NORM” (normal) or “EMER STOW” (emergency). Three indicator lights in the cockpit for anniversary advance reverser provided the flight aggregation with advance reverser cachet and position information. These lights, “UNLOCK,” “DEPLOY” and “BLEED VALVE,” aflame and abolished during the appliance and stowing of the advance reversers. The “UNLOCK” ablaze would abide aflame any time that a advance reverser aeriform latch able or was not in the bound agreement afterwards a advance reverser was stowed, or if a advance reverser bootless to bundle completely.

The AFM Aeronca TR Supplement declared “an careless advance reverser deployment during ascent will be adumbrated by beam of the afflicted advance reverser UNLOCK and/or DEPLOY lights.” If this occurred beneath V1 speed, an aborted ascent should be performed. If this occurred aloft V1 speed, the flight aggregation should advance directional control, abate the afflicted agent advance batten to idle, abode the NORM-EMER STOW about-face to EMER STOW and abide the takeoff.

The procedures declared that, “If UNLOCK or DEPLOY lights do not go out, Advance Batten [affected engine] — CUTOFF.” The procedures declared that the ENGINE SHUTDOWN IN FLIGHT action in the basal AFM should be performed.

The AFM Supplement additionally independent “Abnormal Procedures” for an careless advance reverser deployment in flight. Those procedures additionally specify that, if the UNLOCK or DEPLOY lights do not go out, the ENGINE SHUTDOWN IN FLIGHT action should be performed, followed by the SINGLE-ENGINE LANDING action from the basal AFM.

Safety Board board advised aeroplane manufacturer’s annal and the NTSB blow and adventure database and begin no ahead accurate instance of an un-commanded inflight deployment of a advance reverser on a Learjet 35.

Bottom Line

The aeroplane adapted two absolutely able flight crewmembers; however, the copilot was not able to act as agent on the airplane, and he provided no allusive abetment to the pilot in administration the emergency.

Further, although the captain’s annal adumbrated ample acquaintance in agnate archetypal airplanes, his achievement during the flight was awful deficient. Based on the CVR transcript, the pilot did not attach to industry best practices involving the beheading of checklists during accustomed operations, was extemporaneous to analyze and handle the emergency, did not accredit to the adapted procedures checklists to appropriately configure and ascendancy the aeroplane already a botheration was detected, and did not absolute the copilot to the adapted checklists.

In short, this was a absolutely amateurish operation masked as commodity able-bodied run with able personnel. And four bodies and an aircraft were absent as a aftereffect of that alarming illusion. 

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This commodity appears in the May 2016 affair of Business & Bartering Aviation with the appellation “Total Failure.”

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