"The correct call is not 'Dude'... the correct call is 'Reject'." Excellent distillation of the cause of this accident, Juan!

I will lay odds that like with the Challenger disaster, there is a Cessna engineer that said, “I told you to include that PB alert.”

Pilot sets parking brake; promptly forgets and doesn't release. Ignores first officers concerns about reluctance to move. Continues with takeoff beyond point of no return. Nice job

@Cwra1smith

2 жыл бұрын

Yea, this guy is a nitwit.

Always remembered items from initial training. 45 years ago, I was told. NEVER APPLY PARK BRAKE ON THE RUNWAY, JUST HOLD IT ON TOE BRAKES. I did that for 45 years without incident. R

@Banshee365

2 жыл бұрын

He didn’t set the brake on the runway…

@etops8086

2 жыл бұрын

I wonder if the same wise man that told you that told it to me too. Never set the brake on the runway, easy as - especially at an uncontrolled airport where you should spend minimal time on the departure runway. Though in this case did they set it on the runway or while they were holding short?

@chuckschillingvideos

Жыл бұрын

@@Banshee365 Sure he did. He wouldn't have been able to taxi onto the runway with the parking brake set.

@Banshee365

Жыл бұрын

@@chuckschillingvideos Incorrect. I have over 1,000 hours in the model 560XL. The parking brake traps the pressure you applied to the toe brakes. If you apply just enough brake pressure to stop the airplane, hold that and pull the brake handle it will set the brake at that light pressure. Then you can apply just a little power and it will start rolling. I’ve showed this to many copilots to see how dangerous setting the brake with low toe brake pressure can be.

@bayouflier6641

2 ай бұрын

I applied the brakes on every “position and hold” without incident for 46 years.

The Term "Dude" tells the story ... thanks Juan this helps us all

Experience is Invaluable. When you know the aircraft you are flying well, you can sense when something is not right. The pilot not flying knew something wasn't right and verbalized it to the flying pilot because his experience told him and he followed procedure. The flying pilot should have sensed the same and if he didn't, when he heard the other pilot alert, he should have sensed the same. The pilot flying should be even more aware because he has the controls and additionally, he is getting feedback from the controls. When he was aware of the abnormal slow takeoff roll, should have done a scan and that should have included the parking brake setting. The pilot knew his takeoff weight, runway slope, and the meteorological conditions so he had no reason to have a slow takeoff roll. Having dragging brakes is not some ultra rare event, any experienced pilot knows what dragging brakes feels like and looks like. The experience of the non flying pilot almost prevented this accident, but the flying pilot's failure to access and react to the situation allowed this to happen. Not realizing there is a problem is one thing, but being advised there is a problem and disregarding the advisory is another. Seems like the flying pilot just really wanted there to not be a problem instead of acknowledging there may be a problem.

@steveholton4130

2 жыл бұрын

Flying pilot was rehearsing landing before ever taking off.

@NicolaW72

2 жыл бұрын

Yes, exactly.

@barrydysert2974

2 жыл бұрын

"I Think I Can! I Think I Can!" Some men never grow up. Thank God no one died due to his childish behavior !:-) 💜🙏⚡️

@sevenravens

2 жыл бұрын

Ego

@marlinweekley51

2 жыл бұрын

I know you must know who “has got the plane” BUT when things are going south fast the life you save might be your own - screw protocol it’s an emergency. A buddy of mine a few years ago was in the back of a 180. The 2 guys up front were both cfis. Roll down the grass strip the fence row was coming up fast and the two flyers up front did nothing - without a word he reached up a feet hundred feet before the fence and pulled the flap handle. Nuff said about that.

Every car I have ever driven gives me a big red light on the dash warning me when the parking brake is on. Yet this jet didn't? That is madness.

@miguelsuarez8010

2 жыл бұрын

Pilots have to take care of so much data and read so many gauges, compared to a car, that events like this can occur sometimes.

@jimamizzi1

2 жыл бұрын

The thing is the co pilot knew straight away something wasn’t right, yet the pilot flying did nothing

@lwilton

2 жыл бұрын

I drove lots of cars that didn't have parking brake (or any brake) warning lights. Those were added due to Federal legislation in the 1970s. Before that you were just supposed to know. It appears to be the same thing here. Before 2002, it wasn't required.

@stone8597

2 жыл бұрын

I was going to say the same thing, but you beat me to it.

@larrybe2900

2 жыл бұрын

It is not like it was a lot of time that passed from when he engaged the brake to when they attempted to take off. It is almost like ..... duh.

I’ve got over 1,000 hours in the 560XL. Here is a couple of extra points. In the AFM checklist, rudder bias is to be tested before taxi, not before takeoff. Most XL pilots don’t do it this way because of jet blast on FBO ramps and the noise associated with it. Also, the parking brake traps whatever pressure you’re holding the brakes with. We all like to stop smoothly. If you pull the parking brake while holding that light pressure it will hold the airplane at idle but a little amount of thrust will get it rolling again. When I set the brake , I stop the airplane, push the brakes hard and set it that way. The lightly set parking brake is the real threat. I’ve demonstrated this to some of my FO’s and it’s a pretty scary possible scenario.

@alanmorrison3598

2 жыл бұрын

Again the marks on the runway indicate wheels were locked up! Not rotating!

@Banshee365

2 жыл бұрын

@@alanmorrison3598 With speed the initial light braking pressure is compounded by heat and thermal expansion.

@alanmorrison3598

2 жыл бұрын

@@Banshee365 Nope..Ever heard of fade? The wheels were locked from the get go..

@Banshee365

2 жыл бұрын

@@alanmorrison3598 With all due respect, you don’t know what you’re talking about.

@alanmorrison3598

2 жыл бұрын

@@Banshee365 please explain..

You would think that a multi million dollar citation would have the parking brake in the config warning for takeoff. Wow. That’s sad.

I watched this video when it came out. Then last weekend I was going on a flight. During my taxi to the run up area I noticed the airplane was very resistant to rolling. I thought it was just because my nose wheel was stuck in a little Divet in the pavement. I had already “glanced” at my parking brake a few times during my check list. In the run up area I took a good look at it and discovered it was partially engaged. I never use it, so in my mind it “should” be off. But I must have bumped it somehow since my last flight. I turned it fully off and the plane rolled normally as i taxied down to the runway for takeoff. I credit this video for putting this parking brake issue in the front of my mind and helping me discover that mine was partially engaged. Had I tried to do a takeoff run like this it may have caused some serious problems. Thanks Juan! You are really helping the pilot community.

Mr. Brown your coverage of these accidents and explanation of them is top notch.

@NicolaW72

2 жыл бұрын

@Buckwheat Hikes The Captain makes the final decision - therefore he´s the Captain. And in this case the First Officer unfortunately didn´t commmunicate plain and clear to his "dude" - he said: "somethin´ ain´t right" instead of "reject" or "abort" - but the Captain thought everything would be allright and so he made the decision to continue the take-off-roll. That was the repeating of a very old problem in aviation history: the use of a misunderstandable communication.

Yes the only words out of the FO should have been Abort. The PIC at that point should initiate it immediately no questions asked. I truly hope there are some lessons learned here for this crew and anyone else. If something doesn't feel ,smell, or look right stop and sort it out. It's much better to be able to say "Ah it was nothing" then the alternative. Thanks as always for putting these videos together Juan. You do such an incredible job with them brother.

@johndonaldson3619

2 жыл бұрын

"dude"...? how old is this kid?

@TheSoaringChannel

2 жыл бұрын

I know 135 is different (I worked there), but even in my environment the captain was who announced and performed a rejected takeoff.

@Airplane_Willy

2 жыл бұрын

LMFAO at people putting this on the FO. If you truly believe the FO was the cause of this accident, then you either have no experience in this arena or you are part of the problem to begin with.

@hawk_7000

2 жыл бұрын

​ @Craig Not the cause of the accident, the point is rather that the FO was very close to preventing this accident from happening but didn't because of what comes off as lacking crew communication/discipline. The FO clearly noticed and commented on pretty much immediately that something was causing the plane to struggle to move, so they had the chance to reject the takeoff right then and there, with plenty of runway and still low speed. The type of clear communication that could have fixed that is what the comment you responded to was pointing out, not that the FO directly caused the accident. How the parking brake is not considered for the "no takeoff" annunciation on that model Cessna Citation is another example of something that in hindsight seems kind of bad, and which could help prevent such an accident, while that is clearly also is not what directly caused the accident. The reason why these kinds of findings are interesting in the first place is so that we can learn from them in order to actually try to avoid repeating the same mistakes again.

@kevincollins8014

2 жыл бұрын

@@hawk_7000 You did an amazing job explaining exactly what I meant thank you.

After lining up and waiting, I transferred control to the FO, who set the parking brake. He then tried to takeoff with the parking brake still set. The bells and whistles were going off and he was totally confused. He brought the power back to idle and looked at me and said "what's going on here???" I looked at him, amazed at his confusion and said: "Parking brake bro". His face turned flush red. This was right after we watched your video on the CT parking brake accident. I now do not transfer control and allow the FO to set the brake. Thankfully that day, I noted it, the Airbus noted it, and we didn't end up on the Blancolirio channel. 👀

@NicolaW72

2 жыл бұрын

You had indeed Good luck!😀

@TheSoaringChannel

2 жыл бұрын

@@NicolaW72 good observation and awareness. Good design with the brake in the middle. Good design with the warning system.

@realulli

2 жыл бұрын

You only ended up in the comments. Good job. :-)

@NicolaW72

2 жыл бұрын

@@TheSoaringChannel Yes.👍

Outstanding analysis Juan. An old CIF and AF Academy and SAC instructor said in light aircraft he never he used, and did not recommend using the Parking Brake for anything other than "PARKING". And that once released it should never be applied after you start rolling for departure, as if it causes some partial application you might notice it during taxi but not during take-off. Also if you are using the toe brakes to hold during run-up and power-up you may be able to notice a soft pedal that you might not detect by using the Parking Brake. Being an aircraft dealer and flown well over 100 different aircraft, I've had several instances during takeoff and landing involving parking brakes, and one near takeoff disaster caused by a parking brake that did not fully release, and progressively bound during the take-off roll, on a high-density altitude strip with obstacles. The first part of the roll appeared normal but after about 1200ft just before reaching V1, and past a safe abort point (in an Cessna 310C), the old Bendx brakes bound enough to pretty much stop any further acceleration. As I rotated slightly a bit below V1 I heard the mains start skidding and was able to get airborne after a much delayed take-off roll, and then having thread between some trees. That was caused by an gummy Parking Brake cable/handle system and those grabby old Bendx Brakes. I've also seen occurrences where where parking brakes bled-off allowed an aircraft to roll during run-up, or when stopped in line when a pilot was head-down. I once just prevented a Cherokee from rear-ending a Turbo Commander by yelling on ground after the parking brake did not hold and it started creeping forward nearly striking the tail of the Commander. A partially applied (dragging) parking Brake on landing (especially in a tailwheel aircraft can also cause issues, I had that once and ended up off the runway and doing a ground loop in the grass. I didn't know what happened until I tried to taxi out and could only go in a left circle. Turns out the old Cessna parking brake was on a few clicks and as I rarely use a parking brake, even for parking I never checked it. Parking brakes are often not on Pre-take-off and Pre-landing checks, but perhaps that might be something some of us should consider adding.

@sevenravens

2 жыл бұрын

Never used my parking brake in 35 yrs of flying. Never. Wheel chocks and tie downs. Toe brakes in operation.

@jackoneil3933

2 жыл бұрын

@@sevenravens Thanks. Pretty much me too. I've also noticed that leaving brakes pressurized all the time tends to contribute to leaks and seal damage. Often they simply bleed of pressure after a few hours or days anyway. I've heard from Factory Cessna A.I. and test pilot that the Parking Brakes were only intended to keep the aircraft from rolling during loading or until it can be tied down. During high speed winds however I've seen tie-downs pull out of the wing and ground and jump chocks, but seen un-tied aircraft stay put in high winds with just the parking brake engaged.

Communication, Communication, Communication! Don’t be intimidated by anyone! Speak clearly, make sure all involved has understood all activities involved in any situation! This works in all walks of life!

Just put a little red parking brake light on the dash. I can't believe a pilot left the parking brake on, tried to take off and left a skid mark all the way until he ran off the end of the runway. Geeze man, these guys are streaking over our houses at 400 miles an hour.

I fly the Ce-560. The parking brake knob is an accident waiting to happen AGAIN. There is no warning light, no sensor for the No Takeoff system, it is hard to see (black knob buried in the lower left corner of the panel) from the left seat and impossible to see from the right seat for the same reasons. Cessna is grossly negligent in this design, although they did offer design corrections as an OPTION to a few airplanes for sale overseas. The FAA is also derelict in its duties in that it has not issued an AD against this lousy design. The Excel takes a good pull to rotate anyway, even with the Rube Goldberg takeoff trim system, so the parking brake will definitely make it difficult to impossible to rotate.

@cspruitt3190

2 жыл бұрын

Thank you Dave. This is excellent information and sheds a ton of light on this failure.

@houseofsolomon2440

2 жыл бұрын

I wonder how common parking brake indicator lights are in jets(?) Seems intuitive that it would be a good idea.

@grafhilgenhurst9717

2 жыл бұрын

It would seem as though you would have to set the parking brake in order to test the rudder bias. I can't imaging that you could do it standing on the toe brakes. So the checklist should address this, at a minimum. And I would think an annunciator would be nice. Even my car tells me if I am driving with the E-brake on!

@systemloc

2 жыл бұрын

No trainer, such as a 172 or cherokee, has a light or warning, and in the ones I have flown, are under the dash or in some other inconspicuous position. I agree that a safety warning is excellent design, but to say the design is negligent, when it's consistent with pretty much every GA plane one starts on, is moronic. Don't set your brake once the plane is started and taxiing. It's what you should be taught in PPL, and its what you should practice in a everything from a 172 to a 747

@NicolaW72

2 жыл бұрын

@@cspruitt3190 Indeed.

My parking brake has a green/red indicator and chime. Always interesting and informative, thanks!

Physics in action. Absolutely incredible.

Juan, i remember you talking about the brakes and runway marks back in '19. As i recall it, this report confirms your thoughts at the time. Few of us would ever dig through these reports. i appreciate the work you put in condensing them into the salient bits thereby making them accessible and understandable to the wider world. Thank you and God bless !:-) 💜🙏⚡️

@NicolaW72

2 жыл бұрын

👍

Reminds me of the Air Florida incident in DC where the FO pointed out that the thrust readings weren't correct during roll out, and the captain insisted they were (they had neglected to turn on the thrust sensor de-icers). As I recall, the crew came to an agreement when the FO exclaimed: "we're going down" and the captain responded: "I know!". They ended up in the Potomac during a blizzard!

@NicolaW72

2 жыл бұрын

Yes, a very sad event.

@tomriley5790

2 жыл бұрын

Yes I was recalling this too, lots of paralells.

@rael5469

2 жыл бұрын

"(they had neglected to turn on the thrust sensor de-icers)." It is the "Engine Anti-Ice" push button which directs hot air to the inlet cowl leading edges. There is also a switch for "Probe Heat" which keeps the temperature and air data probes anti-iced. Either one of these could have caused the erroneous reading on the engine "EPR" gauges that the First Officer was commenting on in the recording when he said "Larry it doesn't look right". They set takeoff power by EPR (Engine Pressure Ratio) setting and the FO knew it didn't look right. Plus in that incident there was ice on the wings.

As a background to your analysis I can hear Pete Seeger singing "We were, waist deep in the Big Muddy And the big fool said to push on."

I don't know the reasoning behind the rudder bias check with parking brake, but it makes sense that holding the aircraft in place with the foot brakes might affect how much the pedals will move from the bias system. The parking brake would isolate the meat in the seat from the system. The failure is not having a no takeoff warning for the parking brake.

Great breakdown of the accident. I fly a 2017 XLS+ and they still don't have a light for the parking brake. We've added it to our checklist as part of the takeoff check.

@dfeuer

2 жыл бұрын

Is this something that should be mentioned to the FAA so they can require a checklist item or even retrofit?

@CaptainCory

2 жыл бұрын

@@dfeuer you would think? They’ve amended less critical things in the checklist I hope they add this asap. Citation is notoriously bad at updating checklists. I also wonder if by adding this to the checklist at this point, do they accept some sort of fault? Like Juan said though, the checklist never calls to set the parking brake either so maybe their mindset is once the plane starts moving, the parking brake should not be set.

@getyoursupervisor8519

2 жыл бұрын

@@CaptainCory Well, Cessna is traditionally saving on "lights" (just think about the refuel door which has no light - dude I know had the tank cap going through the R/H engine during takeoff on a 560) - I currently fly the 680 and it has the no takeoff warning rigged to the PB. Since the pedestal and lever are the same, I only can imagine the urgent need to save on the switch and 2 cables itself to why Cessna omitted that in the 560. As good as Cessnas generally are, in some respects they lack and has been the case since the C500 IMHO (I am/was typed in the 500/550/560, 525, 650 & 680) e.g. the wing & engine anti ice "light" logic (light goes on when switched on, once surfaces are heated they go out and you have to look at the switch to see wether they are on or not. (thats the non EICAS models)

@CaptainCory

2 жыл бұрын

@@getyoursupervisor8519 yep totally agree. Some of it just doesn’t make sense. Can’t tell you how many times we exit icing conditions and forget to turn the ice off. No light, poor switch placement, and I hear you on the fuel door. Have to double and triple check that thing.

Modern diesel locomotives have a warning horn and will not load if the 'parking' brake is applied. I've tried...fortunately my employer's fleet was older (pre-1975) locomotives and you could get away with a lot of stuff as long as the event recorder didn't show it. For that matter, locomotives will overcome fully applied engine brakes although it takes about 1/3 to 1/2 throttle to get them to roll. We tried that in engineer's class a long time ago.

The remarkable thing about these Citation overruns due to the park brake remaining on is that the aircraft attains flying speed, but just cannot be rotated to the takeoff attitude. So many fail to appreciate the intriguing reason for this, but Juan has done so, at the 5:45 mark. To repeat and amplify his comments about this: The reason is that the braking action is exerting a significant nose-down moment. This moment is too powerful for the smaller nose-up moment that is exerted by the elevators when the control column is pulled aft. Even with the control column pulled fully aft, the nosewheel remains stubbornly on the runway. This comes as an enormous shock to the pilot, given that the aircraft is now well past V1 speed and the end of the runway is fast approaching. There was a similar accident to a Citation Bravo in Australia a few years ago. The investigation body there did an analysis of the relevant pitching moments and found that the nose-down moment, caused by the braking, had an effect equivalent to the centre-of-gravity being many feet forward of the limit. In such a situation the elevators just do not have the power to rotate the aircraft.

Juan. At NetJets (we had some 130 560XL/XLS's), we had an SOP to call "parking brake st or parking brake off" whenever the brake handle was moved. Further, my right knee always bumped up against the brake handle wen the brake was set. The point to avoid the mishap was when the F/O said he was not comfortable with the acceleration!

Thank goodness they got everyone out -- that must have been a harrowing few seconds!

The F-16 has a parking brake set electronically by a toggle switch. Above a certain throttle angle the switch is released and the brake disengages.

I fly a 560, there is no panel indication that the brake is on. The pilot on a normal scan should see the p brake knob in the out position. Also, my airplane, along with the XL model are fast accelerating airplanes so to just cast off the lack of speed is just unforgivable

@raybankes7668

2 жыл бұрын

the parking brake on issue should be an AD retro-fit. My 86 Subaru tells me when my parking brake is on... its not hard folks.

@wayneroyal3137

2 жыл бұрын

I doubt your Subaru has multiple check lists to go by before you get on the road. After the most recent crash I added “Parking Brake-OFF” to my before TO and my “FATS” check list. How about the pilots follow procedures and when “somethin ain’t right “ is noticed on the roll, abort abort abort….

@raoulcruz4404

2 жыл бұрын

Someone commented on here that the parking brake selector is not visible to the pilot from a normal scan in that aircraft. The TBM700 has a red warning BRAKE on the central advisory panel whenever the parking brake knob is turned. If the brake knob is turned without applying the pedal brakes, the brakes become useless. Another reason to have an indicator. However, I agree there are other cues that should have alerted the pilot such as a marked decrease in acceleration.

@wayneroyal3137

2 жыл бұрын

@@raoulcruz4404 yeah, so I’m sure the TBM has a great system. The comment that I saw was that the p brake handle was not visible from the co pilot side. It is in fact just above the pilots left knee. Point is, left seat guy should see its position. I flew today. Set the brake to wait for landing traffic and complete check list, to prove my theory I advanced powers to 50%, no forward movement. However, after releasing said p brake, it only took a little power to start rolling. Lights, no lights, buzzing noise, sexy female computer voice, whatever. All it took is look down, and run check list and or flow.

@raoulcruz4404

2 жыл бұрын

@@wayneroyal3137 Sure, there is enough bells, dings, female voices, etc going off that probably desensitizes a pilot to warnings anyway. Relying on built in warnings is not the answer all. I agree there are other cues the pilot should be aware of. I think people in general get a particular mindset to do something and it's difficult to alter or reverse that mindset quickly. (tired, repetitive tasks, conceited, etc) Incidentally, the TBM park brake knob is directly below the control yoke shaft and can't be seen unless you lean sideways a bit, Probably why they put a light.

Love the detail in these videos !

Once is an accident, but twice means there's a design flaw because people are missing noticing the problem. Unfortunately, the second incident caused fatalities. So, Cessna will likely have to do something now to address this issue if it wasn't addressed already. True, it was pilot error both times, but would training fix this issue, or better checklists? A warning light on the dash might be the best fix.

@av8tor261

2 жыл бұрын

I agree.

@bearlemley

2 жыл бұрын

When aircraft are fist certified and production starts, the QRH, the AFM and the checklist are smaller than they will eventually become.

As a result of this and the other very similar accident, I am now in the habit of hitting the stopwatch when I apply takeoff thrust and timing how long it takes to get to 100kts. As a result, I now have a reasonable idea of how long that should take at different weights and conditions. In future, if we pass the expected time and we aren’t anywhere near 100kts yet, I’ll know we probably have an acceleration issue and reject.

@TheSoaringChannel

2 жыл бұрын

I reference runway remaining. 80kts and the runway touchdown zone should be going by. 100kts and less than midfield. 15 prior to V1 should occur prior to 3000' remaining. For the big airports - it's really easy to do with the runway markers. What's nice is utilizing flex takeoffs and this method works like a charm no matter the weight, because about the same distance remaining we will be at flying speed. The faster the Vr, the further back these checkpoints are for my checks. I have selected TOGA before. I have my hands on the thrust levers ready to hit TOGA if I feel something is off, and thankfully have done so twice. One time - the numbers were loaded for the crossing but far longer runway with flex. That shorter runway was TOGA, packs off, static thrust set, Flaps 20 (not 8). On smaller non-instrument runways these checkpoints wouldn't work, so I like your time method. Just not sure how I could uniformly apply them on a 5000' runway vs a 15000' runway at varying weights (we have a 105,000lb gap from light load to fully loaded).

@jpoconnor5744

2 жыл бұрын

As an airline passenger, I have no access to gauges, but can time the TO roll and sense the acceleration (and see it out the window). When we hit the 30 second mark we had better be moving right along at a good clip and rotating soon! The PIC ignored that and the FO on this one. Yikes!

@davestarr7112

2 жыл бұрын

@@jpoconnor5744 Exactly! ht even have a FO if you are going to ignore him or her?

@FlyingDoctor60

2 жыл бұрын

@@jpoconnor5744 I thought I was the only geeky passenger who does that! I also always try to time the rotation call in my mind so that I call it without looking at my watch and before I can actually feel rotation beginning. I generally fly 2 trips a month with 10-12 segments, so I'm getting pretty good at it. Occasionally I forget and start mumbling "V1...rotate" to myself, and my seatmates think I'm daft. 🤪

@lbowsk

2 жыл бұрын

@@davestarr7112 Sometimes, yes. Not all FOs are created the same. And at some airlines, they're even...... ;) A nervous and new pilot might call out for an abort for no good reason. Not to mention that a high-speed abort is a very dangerous proposition.

Thank you, Juan. Appreciate your videos.

I remember your first report on this accident, Juan. Thank you for all you do!

@keithhoss4990

2 жыл бұрын

Juan is one of the World’s top aviators. He’s an absolute force multiplier for everyone who watches his videos and heeds his advice. Countless lives are saved because he teaches so well in his outstanding videos.

@catherinenelson4162

2 жыл бұрын

@@keithhoss4990 Are you just Hossing around? Juan's good, no doubt about it, but how do we know there aren't 50 or 100 in other places that are also at a high level of skill?

Much appreciated Juan 👍

Excellent and thorough analysis, Juan.

It's really not an emergency brake. It's an emergency "make the car smell funny" lever. Mitch Hedburg

There is always a chain of events, and a deviation from the norm in these incidents. I appreciate hearing about your process.

Brilliant analysis. Thanks for your effort Juan.

I'm a big fan of your many years! thank you for videos

If the bias check was completed while holding short of the runway, how did they not notice how much throttle it took to taxi into position. Surely it would have been abnormally high!?!? Great analysis, as usual, Juan!

Thank you, Juan. Great report.

Thank you for covering this!

Excellent report! Thank you!

Why is it that so many Part 135 crews seem to think it's ok to be less professional and precise than their Part 121 peers? I would think that they would want to be just as good, if not better than, the airline folks. After all, they're flying very expensive aircraft with precious lives in the back relying on their skill, judgment, and professionalism to get the job done safely. What's the advantage to trying to "cowboy" it?

I really appreciate your efforts on this channel. It's very easy to understand what happened when you explain it.

Thanks for the information.

Thank you very much for picking this story up again when the Final Report came out and there´s now really something to learn - and this especially after three years had gone since the accident happened.

Juan, your explanation of the parking brake / rotation was enlightening💡thx! The front seaters at my airline have their ipads in suction cup mounts on the side windows...

Great video as always sounds crazy no red light or flashing light when the plane is moving and parking brake is engaged

Great video, as always

What is the psychology of a pilot who hears his co-pilot say the words "something ain't right" and doesn't abort the T/O immediately? Ego? Hubris? Arrogance? "If I don't think it, it can't be true?" This entire incident is avoided if the pilot trusts his colleague.

@biscuitag97

2 жыл бұрын

Same psychology that led to the disaster in Tenerife where the captain took off below minimums and without takeoff clearance.

@NicolaW72

2 жыл бұрын

@@biscuitag97 At Tenerife the time pressure played a huge role, too, a radio interference and also a mistunderstanding due to the language barrier between the Dutch Pilots and the Spanish ATC. This Cessna accident was much easier to avoid! Very much easier!

@realulli

2 жыл бұрын

Exactly. As evidenced in the conversation: "Something ain't right" - "She's moving, call out speeds!". PF really was full of it.

@michaelhansen7516

2 жыл бұрын

@@NicolaW72 True, but the captain should have taken extraordinary steps given they knew the PanAm flight was taxiing on the runway, just as they had, and he could not see his path as the runway was in a fog bank, and he knew there was no ground radar and no help from the tower. He wasn't thinking. Hundreds dead due to incompetence.

@davestarr7112

2 жыл бұрын

@@biscuitag97 aAnd lso the flight engineer telling the captain that he believed the runway was not clear. Sad case of over-inflated ego, and 582 others paid the price along with him.

I am a aircraft mechanic at AA and I was messing around in 737 simulator years ago. I taxied out and held short of the runway. while holding the brakes with my feet i was head down punching number into the box, I felt a couple large bumps, looked up and had run off the taxiway into the salt river wash. The lesson I learned was an time I am taxing an airplane and I stop to always set the brakes so if distracted I don't inadvertently roll off into something. I always set the parking brake!

Sorry for the loss of the aircraft and very thankful there were no deaths or injuries. When you showed the co-pilots comment "somethings not right dude" I lost it and still chuckling at the end!!

I got my PPL in the olden days and I can still remember most of my checklist after runup. TMPFGHIE. Trim, Mixture, Pitch, Fuel, Gyros (yep, that old), Hatches/Harnesses, Instruments, Electrics. We weren't taught to check the brakes, but pre-takeoff check was after take off clearance or announcement when we were about to roll onto the runway. The crappy aircraft I learned on were incapable of rolling with the parking brake on. PS we definitely used the parking brake for runups.

Physics always applies... Thanks again for the cool video...I learn something every time. Much appreciated...

Thank you, RB, Nova Scotia.

Great analysis!

So, it's a case of the parking brake was left on. Not that complicated! So good that no one was injured in this senseless incident. When you compare to cars, that have a light warning that the parking brake is on, you can't help but wonder why an idiot light as a minimum can't be provided on a FOURTEEN MILLION $ aircraft. "Something ain't right dude..." and the captain presses onward. Way to go, dude!

@RK-kn1ud

2 жыл бұрын

I agree that the plane probably should have had a parking brake warning light/system, but at some point you have to realize that you can't install a light/system for everything. Space constraints, distractions, possible false alerts...all complications of airplanes probably. In the end, it was a pilot error. People could probably drive their car for 30 years and probably never use the parking/emergency brake, so it's not really in their nature to worry about it. I imagine the pilot of this plane uses the parking at least twice every time the plane takes a trip

Thank you.

Good presentation and analysis as usual

Need to brief this at every takeoff - anything not right, chop throttle, apply brakes, and stay on the runway.

Above everything else, this was a CRM failure. The captain ignored the copilot's not-very-well-expressed concerns with regard to the readiness of the aircraft for flight. Excellent CRM is based on respecting the other pilot's concerns. Dude! WRT getting the clearance, I don't know what the correct procedure is but it seems that interrupting multiple pre-flight checklists to deal with ATC by phone is a dangerous practice. Negative kudos to Cessna for a glaring omission in the documentation. With other parking brake incidents recently, what does it take to get the FAA to issue an AD?

@systemloc

2 жыл бұрын

Terrible CRM

@NicolaW72

2 жыл бұрын

A very good question.

@daviddubbin3451

2 жыл бұрын

I fully agree. This aircraft is not certified for single pilot flight yet the Captain failed to recognize that the the FO is a valuable and required resource. As an old hockey coach of mine used to remind me, "there is no I in TEAM". CRM mandates that both crew members use the individual skills to the benefit of the team. There were a bucket load of errors committed on this flight but the most aggreges is the Captain's failure to listen to the FO when the aircrafts performance was suspected to be substandard. The person in the right seat is not a trained parrot. They are there a valuable part of the team at the pointy end. This company needs to change how flight crew members communicate during the two most critical events of the flight. Those being takeoff and landing. Clear concise and plainly identifiable words need to be used. Take off power, engines are nominal, speed is alive, V speeds, VR, Rotate, positive rate and for heavens sake the most important , "ABORT". Cessna holds a great deal of responsability from a design stupidity standpoint but where is are the flight ops trainers and or CFI with this company. Why is this parking brake issue not part of the take off check list? Best thing that happened here was that no one was injured.

@NicolaW72

2 жыл бұрын

@@daviddubbin3451 Indeed, exactly.

@dualinfortyfives

2 жыл бұрын

@@daviddubbin3451 I agree with you! For example it’s been said “…if we have a fire, failure or serious malfunction, prior to V1 the PILOT noticing it will call ABORT twice and WE will bring the aircraft to a complete stop on the runway.” “At or after V1 we will continue…” CRM

I remember sitting right hand in a C182 on t/o roll when some engine roughness occurred. The pilot flying did not react so I retarded the throttle and called aborting over the mic to both the pilot and tower. This was a private flight but CRM training took over apparently. Funny how the pic seemed to freeze in continuing the roll…

@av8bvma513

2 жыл бұрын

The actions of a True Hero! Bravo!

@maesc2001

2 жыл бұрын

@@av8bvma513 don’t be ironical, I was just recalling an anecdote.

@maesc2001

2 жыл бұрын

@@SusanKay- Absolutely! Just: many GA (private) pilots will tend not to respond when the pic not; out of deference and/or lack of experience.

Another outstanding video JB, thanks! The correct CALIFORNIA protocol for the co-pilot to address comments to the aircraft command pilot is “Captain Dude”. Carry on!

"Jet Card" is the callsign for DPJ (Delta Private Jets).

👍 Thanks Juan

The beginning of the modern checklist occurred after the crash of a bullying model 299 I believe in 1939. They hadn't unlocked the controls. The trim tabs had enough effect on flight to get the plane off the ground and actually climb it out into a stall. Plane crashed. I'm pretty sure that's when they started coming out with checklist for planes. Or maybe it was just for the model 299. For those that don't know the model 299 ultimately became the Boeing B-17.

I bet all your videos and lessons learned that come from them could be turned into a great book of do's and dont's for pilots.

It is also clear that the crew was already 'behind the aircraft' before they were even off the blocks. Steps missed on the AP/FD tests, incomplete FMS setup, improper takeoff configuration, etc., etc.. Add to that the distraction of the PNF having to 'disengage' from normal cockpit flows to call for clearance and the risk of overlooking critical items multiplies - especially during takeoff. No aircraft should roll even an inch forward for taxi unless every checklist item that can be performed when parked is complete. I just retired from flying this past March in a Challenger 350. This aircraft was significantly more complex than the Excel, yet we could completely perform the entire after engine start and before taxi checklist in around 2 minutes at a relaxed pace. The only items performed during taxi were brakes, steering, TRs, and departure briefing. No fumbling around with heads down in the cockpit and all runway lineup checks completed when holding short. If aviation has one historical constant, it is that rushing always has consequences.

Thanks for keeping us pilots sharp.

Thanks

Another excellent analysis. I haven't flown a 560XL since 2016, but logged around 2500 hours in type. The crew coordination and communication (or lack thereof) in this accident was as significant a factor as the parking brake being set. The rudder bias can be easily checked on the taxi roll by applying light pressure to the opposite brake pedal to overcome the thrust differential during the procedure. There is no need to set the parking brake, but if it is set for any reason during taxi it should be called out by the PIC and acknowledged by the SIC: 'brakes set', 'brakes released'. Without having the entire CVR transcript to review, I think it's safe to say based on what was presented here that the crew lacked a disciplined and methodical approach to checklist usage and abort/continue contingency briefings. So many accidents and incidents are so easily avoidable. Thank goodness everyone got out without injury this time.

This looks to be all on the Captain/Pilot. He set the brake and failed to release it, then ignored multiple warnings that something was wrong. Plus, even my 2016 4runner screams at me if I try to drive away with the brake on.

@DoubleMonoLR

2 жыл бұрын

Almost, the co-pilot really should have called abort though.

@steveegbert7429

2 жыл бұрын

@@DoubleMonoLR Have to agree with that.

I used to fly our 172 Hawk XP with my grandfather as a kid. We spoke professionally every single time we were flying. Yeah, once we were in the air sightseeing we’d have some fun but takeoff, landing and everything else was all business.

“Dude”…, awesome report Mr. Brown…. Crazy that no fatalities… Sometimes their is a higher being present…

14:31 FO knew something was up just 2 seconds in. Crazy that this wasn't stopped.

Good video, I learned a lot.

Yes sounds like duplicate of the Conn accident Thank you for your excellent analysis

The Captain sets the parking brake and forgets? duh Even when the FO says its not moving. Good grief. Captain's a ding dong.

@YodpilotID

27 күн бұрын

The situational awareness that you're basically at sea level. This citation XL should be taking off like a rocket, as opposed to taking off in Denver.

Do not ever rush and communicate also bouble check . Five killers - flaps, slats, trims (3), spoilers last parking brake. always

Well explained... Us A&P's understand the physical stuff, but the checklist and interactions between jockeys we don't. Ah now most checklist are used by us too,, but only to the extent of is something (physically) happening, not why so much... You do a great job in helping me understand your view. Swear they should take us into a sim at work!!! The taxi stuff sure we get most of that in training. But the once airborne side of the equation, not so much... Thanks Juan

This is a good case study. Should parking break warning lights be mediatory for certain category aircraft under the Type Certificate. I say yes. This might trigger a AWD by the FAA or at least a service letter by Cessna for liability issues. It's amazing no one was hurt or killed.

@lwilton

2 жыл бұрын

While I won't disagree that they should be in all recently built airplanes, modifying the safety systems in a plane is a major heart-rending event requiring years of paperwork and testing, even for something this obvious and simple. Just adding it to the takeoff checklist requires no hardware modifications, and would probably take two or three years less approval time.

@charlestoast4051

2 жыл бұрын

People did die in the similar accident a couple of years later, I suspect this will cost Cessna a bunch of money.

@etops8086

2 жыл бұрын

Most aircraft have it associated with the takeoff warning and in a very *very* obvious spot and part of the pre-takeoff flow/checklist.

Human element, human element, human element. How many times do we hear it.

Glad everyone is okay. Odd that a brake check isn’t addressed on checklist after bias test and get the feeling that the pilot was in a hurry.

@DoubleMonoLR

2 жыл бұрын

The checklist didn't call for using the parking brake, if he was using his feet for the brakes as per the checklist, it would presumably be all but impossible to miss. That there was no warning prior to 2002 manufacture, even with full thrust, seems incredibly strange though.

@camsmeltzer9388

2 жыл бұрын

Terrible news again out of Oroville. Small Beechcraft with two aboard went down off runway!! Two dead as result. Condolences to the family and friends.

Excellent commentary Juan. What an eye opener. Procedures and sterile cockpit below 10,000 are definitely needed. That captain screwed up not aborting as soon as they noticed something off with the acceleration. Good point about the copilot not calling out “reject”. I wonder if he was a new copilot and didn’t have the confidence to stand behind a reject call. Might not have wanted to be embarrassed if it turned out to be nothing. In this case he would have been the hero if stuck by his gut feeling

@wiregold8930

2 жыл бұрын

I wonder if any passenger was a celebrity known for a lack of patience when being ferried about.

Juan, I’m not a pilot (yet?) and at 69 this bucket list item should have happened long ago. I really appreciate the meticulous and articulate way in which you present these events…fortunately no fatals this time. Thank you so much and take good care of that beautiful 310…my all time Dream Ship, since being addicted to that show with Penny and uncle what’s-his-name! The timeless beauty of that airplane is amazing to me.

I’d have to say calling the FO “distracted” on the phone makes it sound like he was talking to his girlfriend rather than talking with departure. Regardless of phone vs. radio he was obtaining his IFR clearance which is a critical step in flight, but is doing that task and not able to participate in the checklist. The failure there is calling a checklist “complete” when it wasn’t 2-person verified.

@NicolaW72

2 жыл бұрын

Yes.

Just an observation: I believe the paved chevroned area of RWY 20 "north" RWY 13/31 was removed several years ago at Oroville airport Now there is direct access from the ramp to RWY 13 without having to cross RWY 13/31 to get to the departure end of 13 via the south side of RWY 13 (or taxiing on the chevroned off section). The taxi ways used to be closed ("X'd") from the ramp to the north side of the departure end of RWY 13 . Now only the northern most "taxiways" paralleling Oroville Dam Rd are X'd off. Thanks for you excellent reports.

My car has audible and visual warnings that the parking brake is on....... Jeez, I know it's expensive to retrofit stuff but clearly it should be there!!

I depart my parking space often with the Parking Brake locked in my 2017 Subaru Crosstrek....I hear the rear brake drums squealing and correct my error...I think lawsuits against Cessna will be very successful! Great report and follow up Juan, where r u flying for work in June, some of your lay-overs are fabulous!

@TheNapalmFTW

2 жыл бұрын

Your Crosstrek should have a parking brake warning light. Why do you often try and drive with it on? You will definitely feel it dragging.

So the correct call should have been, "REJECT". That makes sense. At the rifle range, if anyone sees an unsafe situation, the correct call is "CEASEFIRE", not, "Hay, is that someone in the target area? Do you see them, or is that just a shadow?".

🛫📖🛬 Thanks Juan, Very excellent recap. On this one you can say the feds really got it right, except for the fo being distracted by being on the phone. 📖🛐✈️🐆

Great Job Juan!

@ Juan The parking brake has to be set for the rudder bias test …sometimes the rudder movement in the test is barely discernible much less if you were to have your feet pressing hard on both pedals at the same time. And unfortunately the most convenient place to conduct the rudder bias test is lined up in position.

Crazy how a simple parking brake cost someone the price of an aircraft. I bet someone is pissed at these pilots.

When the aircraft moved from the holding point ( rudder bias), the parking break didn't stop movement at reduced thrust, nor did the crew observe any reduced motion.

@christopherrobinson7541

2 жыл бұрын

Good point, maybe taxing at half throttle would have been a clue.

Habit patterns can be useful. I try and always tap my left hand on the parking brake at the beginning of the roll every time I move the plane. Just to verify that the brake is indeed off. It's tied to the start of the roll. The plane that I fly now won't accelerate from a full stop with idle thrust, so I don't always use it. But at my last job parking brake use was required any time the plane was stopped. While this might seem a bit much, it simply reinforced that the brake was set, and released every time the plane was stopped and then moved. On the fourth leg of a 13-hour day, little stuff like this reinforced muscle movement makes sense. And on some larger planes, the parking brake SET doesn't always mean that it is indeed SET. You can pull the PB on a 57 and it can appear set, but it's not. The light is on and the plane is rolling. At least, that was true when I flew it 20 years ago. IOW, PB awareness is a big thing. Also a great reason for a rolling takeoff. Just bump the throttles up a bit, verify two good engines spooling at the same rate with matched thrust, etc. Then shove. This will get the plane rolling, but not if the PB is set. Small planes do not have a takeoff warning horn. The Citation that I fly doesn't.

@rael5469

2 жыл бұрын

"Habit patterns can be useful. I try and always tap my left hand on the parking brake at the beginning of the roll every time I move the plane. " I've had the opportunity to ride along in the jump seat with test pilots at the controls. And believe me those guys are super busy with their test flight syllabus and could be easily distracted if they weren't so professional. So here is what all these test pilots did every time......they did just as you said. Even though they had completed their checklist, the pilot flying always took a last look around at what they called the "show stoppers." Brake pressure, stab trim, flaps. It only takes a few seconds to reach out and touch each of those things. Our taxi instructor for us mechanics asked us a test question, "What are the three most important things before you start engines?" We're all like....."Oil quantity, fuel onboard, bleeds"....or whatever. He said "NO.....the three most important things to remember are, Brake pressure, Brake pressure, Brake pressure." He said, it doesn't matter if you ever get moving......all that matters is whether you can stop." Then he showed a slide show of accidents where they simply started engines with no hydraulic pressure on the brake system.

Good morning to all from SE Louisiana 2 Jun 22.