Bombardier CL600 incident near Charleston, West Virginia, January 19, 2010

The NTSB's narrative final · quoted from the NTSB record

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 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.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.