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A JetBlue Airways Airbus A320 incurred a tail strike on takeoff after trying to avoid an oncoming King Air. Ineffective radio communication, nonstandard use of phraseology, expectation bias and the exceedance of the plane's pitch limit resulted in a tail strike due to the surprise encounter with head-on landing traffic. The two planes were in communication prior, but the NTSB found the King Air's communications to be informal and ineffective, contributing to the event. Minutes before the tail strike occurred, the King Air crew replied to JetBlue, "I hope you don't hit us."
On Jan. 22, 2022 JetBlue Airways flight 1748 readying for departure at the Yampa Valley Airport (HDN). The A320 announced on the common traffic advisory frequency that the plane was leaving the ramp to taxi to runway 10 for departure. Within a few seconds, a Beechcraft King Air B300 (N350J) on an instrument flight rules flight plan reported to the CTAF that they were, "about nine minutes out, for 10, coming in from the east, descending out of 17,000 ft." The CTAF responded that there were "multiple aircraft inbound" and the winds were calm, then provided the altimeter setting. The JetBlue crew then began discussing the active runway and the multiple inbound planes using runway 10.
Two minutes later the JetBlue flight crew contacted the Denver air route traffic control center to report that they were at HDN and preparing for engine start, expecting to be ready for departure in about six or seven minutes. While the JetBlue crew was starting the second engine and conducting engine checks, the King Air flight crew began contacting Denver ARTCC to cancel their IFR flight plan as they had visually acquired HDN and intended to land on runway 28. Shortly after the King Air flight crew announced on CTAF that they were "going to go ahead and land two eight" and were "straight-in two eight right now" and about 10 seconds later the JetBlue crew announced on CTAF they were leaving the ramp area and taxiing to runway 10 for departure. The HDN UNICOM reported that there were multiple aircraft inbound and the winds were calm.
The JetBlue crew began its after-start checklist as the King Air announced on CTAF that they were on a 12-mile final two eight straight-in" and about 45 seconds later, the crew asked on CTAF if anyone was preparing to depart from runway 10. The JetBlue crew responded to the inquiry, stating that they intended to hold on to the taxiway near the end of runway 10 and wait for clearance from Denver ARTCC. The King Air responded, sharing that they were on a 10-mile final, two eight, straight-in." The JetBlue flight crew acknowledged this, responding that they would keep an eye out for them.
When the JetBlue was prepped and ready for departure, the crew contacted Denver ARTCC to report they were ready on runway 10 at HDN and the Denver center controller cleared them to Fort Lauderdale/Hollywood International Airport (FLL) as filed with a two-minute clearance void time. According to the Aeronautical Information Manual a pilot may receive a clearance when operating from an airport without a control tower, which contains a restriction for the clearance to be void if not airborne by a set time. About a minute later the JetBlue crew announced on CTAF that they received their clearance and would be departing on runway 10 and within five seconds, the King Air crew responded that they "had a King Air on final two eight" and they "had been calling."
The JetBlue crew responded on CTAF, sharing that they thought the King Air was eight or nine miles out, but the King Air replied that they were less than four miles out. The JetBlue first officer said they looked for the plane visually and on the onboard traffic alert and collision avoidance system and did not see any air traffic. The crew acknowledged the King Air and looked for traffic approaching runway 10, announcing on the CTAF that they were beginning their takeoff from runway 10. The King Air flight crew responded that they were on a short final and said, "I hope you don't hit us."
ADS-B data revealed that when JetBlue began the taxi onto the runway, the King Air was on a reciprocal course 4.91 nautical miles from the A320. The crew increased thrust for takeoff and 11 seconds later, before the 80 knots call out, the first officer (pilot monitoring) asked the captain (pilot flying) if the King Air was on runway 28 and the PF asked, "Is he?" The PM reported seeing the King Air on the runway and the PF responded that they did not. After the incident, the pm shared that he observed the traffic directly ahead on the TCAS during the takeoff run and pointed it out on the display for the captain.
The JetBlue crew began the takeoff on runway 10 and the King Air flight crew asked if they were doing a quick turn-out, to which they responded yes. The captain pitched the plane up, 24 knots before rotation speed, to try and avoid the approaching King Air. The A320's tail struck the runway and the crew continued to enter into a climbing right turn away from traffic. Both the captain and first officer on board the A320 said they never visually saw the approaching King Air. The ADS-B data showed the JetBlue plane beginning a right turn after departure as the King Air was on a reciprocal course with 2.27 nautical miles of separation between the planes.
The crew continued the departure procedures, discussing whether they had experienced a tail strike and ultimately deciding to continue to FLL. A few minutes later the crew asked flight attendants what they felt in the back of the plane and they shared they felt a tail strike. At this time, the plane was about 16,000 feet in altitude. Within two minutes of the flight attendant's feedback and about 20,000 feet altitude, the JetBlue crew contacted the airline's maintenance controller for guidance. The plane did not show any warnings regarding a pressurization issue, but within five minutes, while climbing through 26,000 feet, the maintenance controller recommended landing immediately for an inspection of the damage. The crew leveled at FL310 and chose to divert to DEN, making a safe landing.RELATED STORIES:Roger that - 5 tips for pilots to improve radio communication skills5 ways for a pilot to improve ATC radio calls
HDN is an uncontrolled airport, where pilots will self-announce procedures. Pilots will broadcast their position, altitude, call sign and intended activity on the designated CTAF. The King Air made several calls on the CTAF with the original intent to land on runway 10, then the decision to switch to runway 28. The NTSB reported that the composition of these calls could have been clearer. According to FAA Advisory Circular 90-66b, the correct airport name must be spoken at the beginning and end of each self-announce transmission. Using the airport name at the beginning and end of the transmission will reinforce the airport the transmission relates to others on the frequency call in case the first annunciation was missed or unclear. All of the King Air calls omitted identifying the airport at the beginning and end of the transmission and some completely omitted the airport name.
"This nonstandard phraseology reduced the effectiveness of their radio calls by providing an opportunity for their call to be dismissed as relating to a different airport, or not relevant for the airport at hand," the NTSB final report shared.
Another informality in King Air's calls came down to the use of the word runway. Many pilots may refer to the runways by the number and omit the word runway, but standard ATC phraseology uses the word followed by the separate digits of the runway destination, like "runway one zero" and "runway two eight." All of the King Air calls omitted runway when indicating the choice to land on "two eight." The NTSBs said including the word runway would provide a cue to listen and would be more difficult to look at when presented with expectation bias.
HDN uses a Universal Communications Frequency, which is a nongovernment air/ground radio communication station that will provide airport information. UNICOM operators are not required to communicate with pilots and there are no standards for how the information is conveyed if they do. During the incident, the UNICOM operator spoke with both the JetBlue and King Air crew, letting them know that multiple airplanes were inbound. The UNICOM operator could have improved situational awareness by including the runway in the brief, or letting the JetBlue crew know when they left the gate that the aircraft was inbound for runway 28, rather than just stating "multiple aircraft inbound."
The NTSB speaks about JetBlue's case of expectation bias. During the pushback from the gate, taxi and beginning of the takeoff roll the crew thought the King Air was approaching runway 10. After hearing the King Air crew was on the four-mile final the JetBlue crew expedited their departure so as to not interfere with the King Air's landing. The A320 crew believed the King Air was preparing to land behind them after they departed runway 10. The assumption also led the crew to only scan for traffic on the approach end of the runway before entering.
Expectation bias is the psychological concept that causes an incorrect belief that persists despite available contradictory evidence. The crew expected the King Air to arrive on runway 10 and were biased in their perception of incoming information, like the radio calls that stated the King Air was landing on runway 28. This belief led to the calls being ignored or manipulated by the brain to remain consistent with the individual's current expectations. This bias can occur as part of basic information processing and someone may not be actively aware of these biases at a perceptual level, the NTSB says.
The crew was correct in the initial assessment of the situation, in which the King Air was inbound to runway 10. Despite multiple communications from the King Air crew announcing the change, it was not actualized by the JetBlue crew until the takeoff roll. The NTSB reports that this was a result of expectation bias. The crew typically flew seasonally out of HDN and would depart and land on runway 10. The crew also had limited experience flying out of a non-towered airport and the time-sensitive nature of the clearance may have contributed to the expectation bias.
The company Flight Crew Operating Manual says that in case of a tail strike, land as soon as possible and that a pilot should climb at a maximum of 500 feet per minute and descend at a maximum rate of 1000 fpm to reduce pressure changes, while not exceeding 10,000 ft msl or minimum safe altitude. The NTSB report states that the JetBlue crew took about six minutes to establish that they had a tail strike. At this point, the crew was climbing through to 16,000 feet. Due to the terrain near HDN along the flight path, the minimum safe altitude was established at 16,600 feet. Based on the QRH procedure, the NTSB said this would have been an appropriate time to perform the procedure, since the guidance refers to actions when a tail strike has been experienced, not suspected.
However, the crew did not discuss the QRH and continued about 16,600, suggesting they did not reference the QRH. The NTSB said the higher-than-normal workload in the cockpit from discussing the event, talking with the company maintenance and the resulting diversion may have led the crew to omit the checklist after confirming the tail strike. After the incident, JetBlue's safety team worked with instructors to develop a training curriculum for flight crew on non-towered operations, unannunciated failures and QRH procedures.Photo from airport security video
The NTSB reports the probable cause of the tail strike as the captain's rotation of the plane pitch before the rotation speed on takeoff due to the surprise of encountering head-on landing traffic, resulting in the exceedance of the plane's pitch and a tail strike. The report noted that the flight crew's expectation bias that the King Air was landing on the same runway they were landing from and the conflicting traffic's nonstandard use of phraseology when communicating position calls on the CTAF contributed.