This article is based on the NTSB report of this accident, and is intended to bring the issues raised to our readers’ attention. It is neither intended to judge nor to reach any
definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.Ocean Reef is more than a club, it’s family; a family that holds tradition, privacy and belonging at
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medical center to name a few. Most importantly, Ocean Reef is about its Members and their
core belief in family and tradition.
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AFTERMATH
procedures, the crew should have
begun a missed approach some time
earlier—and certainly should have
started one now—but neither pilot
mentioned that possibility.
While the airplane was in the right
turn, the second pilot, sounding
stressed, turned over control to the
captain, who now initiated a left turn,
saying, “Watch my airspeed.”
“Lookin’ good,” the second pilot
said. Then, “Add airspeed. Airspeed,
airspeed...airspeed!”
“Stall,” the pilot said.
“Airspeed! Airspeed!”
The pilot pressed the mic button.
“Ah, —,” he yelled.
The Learjet, whose stalling speed
in a 35-degree banked turn should
have been 102 knots, stalled at 111. The
discrepancy could have been caused
by a sudden control movement by thepilot or a lull in the north wind. The
NTSB’s analysis of the pilot’s mental
state during the turn is persuasive:
“Despite the SIC’s airspeed callouts,
the PIC continued the left turn with-
out adding power or lowering the
airplane’s nose to reduce AOA. The
PIC might not have processed the
SIC’s callouts warning him that
airspeed was decreasing due to a phe-
nomenon known as inattentional
deafness, in which pilots tune out
critical auditory alerts in the cockpit
during times of stress. ... As a result,
the PIC’s announcement of “stall”
might have been a response to the
stall warning system’s stick-shaker
activation rather than any of the SIC’s
callouts. Although the AOA indicator
would have depicted the decreas-
ing stall margin, the PIC likely did
not scan the AOA indicator becausehe was focused on the visual task of
aligning the airplane with the land-
ing runway. Thus, the NTSB concludes
that the PIC’s focus on the visual
maneuver of aligning the airplane
with the landing runway distracted
him from multiple indications of
decreasing stall margin, resulting in
an aerodynamic stall at low altitude.”
The NTSB’s 145-page report on
the accident uncovers the wide gulf
that sometimes exists between
official operating procedures and
actual conduct in the field—and the
inability of FA A oversight to do much
about it. It also highlights, as reports
on accidents involving egregious
pilot errors often do, the culture of
omertà among professional pilots
that keeps them from blowing the
whistle on colleagues whom they
consider incompetent or unsafe.Unstabilized Approach