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Autopilot trim fail blamed for Challenger 300 death, not turbulence, in NTSB prelim

The crew of a Bombardier Challenger 300 did not experience turbulence during a March 3 flight in which a passenger died. Just prior to the deadly incident, the Engine Indicating and Crew Alerting System (EICAS) in the aircraft displayed a series of alerts relating to trim failure. That's according to the NTSB preliminary report released on Friday. The aircraft, registration N300ER, departed Dillant/Hopkins Airport (EEN) in Keene, New Hampshire en route to Leesburg Executive Airport (JYO), Leesburg, Virginia. On initial takeoff after a routine preflight inspection, the second-in-command reported that, despite the aircraft accelerating normally, the airspeed indicator on the left and right sides did not match and takeoff was aborted. The pilot in command slowed the plane without issue and exited onto a taxiway. The left engine was shut down and it was discovered that the red pitot probe cover on the right-side pitot probe had not been removed. The second in command took off the cover, observed no damage, and the flight resumed. After the left engine was restarted, the EICAS reported a message of rudder limiter fault. The pilot in command attempted two ground avionics stall tests to clear the message but did not succeed. The flight was continued given that the message was an advisory, and not a caution or warning, according to the NTSB report. Acceleration was normal during the second takeoff, according to the crew, but the second in command SIC noticed that the V-speeds were not set. "The SIC called V1 and rotate at 116 knots from memory and the PIC entered the climb without issue," the report states. The pilot in command engaged the autopilot as the Challenger 300 continued to 6,000 feet and was cleared for flight level 2240. At this point, the crew received "multiple" EICAS caution messages, including ‘AP STAB TRIM FAIL' [autopilot stabilizer trim failure] ‘MACH TRIM FAIL' and ‘AP HOLDING NOSE DOWN'. "Neither crewmember could recall exactly what order the EICAS messages were presented," the report states. "They also reported that additional EICAS messages may have been annunciated." The crew turned to the quick reference handbook via an electronic flight bag on an iPad. They then began to execute the checklist for the ‘PRI STAB TRIM FAIL.' The crew performed the first action, to turn off the stabilizer trim switch (‘STAB TRIM'). As soon as the switch position was moved, the jet "abruptly pitched up." "The (pilot in command) reported that his left hand was on the flight controls and his right hand was guarding the right side of the flight controls," the report states. "He immediately with both hands regained control of the airplane in what he estimated to be a few seconds after the airplane's pitch oscillated up and down. "During the oscillations, the PIC instructed the (second in command) to move the stabilizer trim switch back to the primary position, which the SIC accomplished. The PIC reported that preceding the rapid pitch event, the autopilot was on, and he expected that once the stabilizer trim switch was turned off, the autopilot would disconnect, which it did." There was no issue for the pilot in command manually flying the plane afterward, and there were no abnormalities trimming the airplane using the manual pitch trim switch at any point during the flight. The autopilot was not engaged at any other point during the flight, according to the report. The crew was alerted shortly afterward of an injured passenger. The second in command exited the cockpit and provided medical attention before informing the pilot in command that they needed to land. The flight diverted to Bradley International Airport (BDL) in Windsor Locks, Connecticut. The passenger, 55-year-old Dana Hyde, a prominent attorney who served in the Clinton and Obama administrations as well as on the 9/11 Commission, died later at a hospital. Findings from the Flight Data Recorder Here is what the NTSB observed from the Flight Data Recorder of the Challenger 300, as written in the preliminary report: Throughout the initial climb, (there were) multiple pilot-commanded manual pitch trim inputs and corresponding movements from the horizontal stabilizer were observed. During the climb, the preliminary FDR data showed that the autopilot had been engaged and disengaged (in) three separate instances. With each autopilot engagement, an immediate master caution was annunciated (Note, the FDR does not record specific EICAS caution messages). The autopilot disconnected in the first two instances after the manual pilot pitch trim was activated and small pitch oscillations were observed after the disengagement. The autopilot was re-engaged for the final time at 6,230 ft msl and remained on until reaching 22,780 ft msl. The airplane's airspeed had increased from 238 knots to 274 knots in this segment of the climb. Immediately preceding the in-flight upset event, the autopilot abnormal disconnect parameter was activated, and no manual pitch trim inputs were recorded. This data was consistent with (the) flight crew's report that the stabilizer trim switch was moved from ‘PRI' (Primary) to ‘OFF', which resulted in the autopilot disengaging. The airplane immediately pitched up to about 11° and reached a vertical acceleration of about +3.8g. The airplane subsequently entered a negative vertical acceleration to about -2.3g. The airplane pitched up again to about 20° and a vertical acceleration of +4.2g was recorded. The stall protection stick pusher activated during this pitch-up; subsequently, vertical acceleration lowered to about +2.2g which was followed by a cutout of FDR data. The FDR and cockpit voice recorder (CVR) were equipped with an impact switch g switch. The CVR continued to record for an additional 10 minutes as it was equipped with a backup power supply, however, the CVR also stop recording data prior to landing at BDL. About the aircraft's ownership and flight crew Executive Flight Services (EFS) LLC managed the aircraft and employed the flight crew, according to the NTSB. The flight was operated as a non-revenue Part 91 flight operated by the owner of the airplane, Conexon LLC, a Kansas City-based company that provides high-speed internet access to rural areas, according to NBC News. Hyde was married to Conexon partner Jonathan Chambers, who was also on the flight along with his son. Neither was injured nor was any member of the flight crew. FAA records show the pilot in command holds an airline transport pilot certificate and a type rating for the Challenger, in addition to other type ratings, with 5,061 total flight hours, including 88 hours in the Challenger 300. The second in command also holds an airline transport pilot certificate and held a pilot-in-command type rating for the Challenger, among other type ratings, with 8,025 total flight hours, including 78 hours in the Challenger 300. Both pilots completed initial ground and simulator training and earned their PIC-type rating in the Challenger 300 in October 2022. The Challenger was not damaged in the incident, according to the NTSB. Initial reports of turbulence The incident occurred while a severe storm system swept across the Eastern United States. Initial reports from the NTSB the following morning indicated that it could have been due to turbulence. However, the agency later reported that a trim issue was being investigated as a potential cause. PREVIOUS STORY: Challenger 300 passenger dies in turbulence; storms damage airports, cancel flightsPreliminary reports from the NTSB are subject to change. Final reports can often take a year or longer to complete. The NTSB is holding the aircraft and the CVR for further examination.
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