Safety Pilot Landmark Accidents: Jet Transition Troubles

Thurman Munson tried to play the game his way

August 1, 2008

The delivery of very light jets (VLJs) has begun. As you read Tom Haines’ training experience in the Eclipse 500 (see “ Typed and Tried,” page 62), it’s obvious that the manufacturers are making a real effort to prep new jet pilots to fly safely. However, some in the corporate community fear that VLJs will fall from the sky in sufficient numbers to ruin an excellent jet safety record. The initial projected delivery numbers were optimistic but safety concerns about how low-time turbine pilots might fare are legitimate, as the following Landmark Accident illustrates.

Few who were flying at the time will forget the media attention devoted to the loss of New York Yankees star catcher Thurman Munson. Munson might be considered by some as a stereotypical VLJ purchaser, even though the term hadn’t been invented yet. At this writing we don’t know who the VLJ purchasers will be over time, nor their flight experience and there are so few accidents that it’s impossible to determine a pilot profile—yet. Munson was professionally successful, new to aviation, and fast tracking through the hardware. The brand-new Cessna Citation 501 he bought was technically not a VLJ by weight, but by performance and single-pilot designation, it was one of the first of a genre. This accident happened some time ago but its lessons may be timeless especially as the industry moves toward this new breed of aircraft.

On the afternoon of August 2, 1979, Munson invited two fellow pilots to join him on a local flight at Akron Canton Airport in Ohio. The right-seat passenger was Munson’s instrument and multiengine flight instructor, but was neither rated nor familiar with the Citation. The second passenger, seated in an aft-facing seat behind the copilot’s seat, was a private pilot who also had no experience in the Citation.

Munson secured the door but did not brief on shoulder harnesses, location, and operation of emergency exits or emergency procedures. It was an unfortunate omission. After startup he asked the tower if he could remain in the pattern for takeoff and landing practice. The two passengers provided a sequence of events that illustrated exactly what happened.

Touch and goes

Three touch and goes were flown on Runway 23. The first landing was normal except that Munson pulled the right throttle back on the “go” to demonstrate single-engine climb capability. On downwind of the second landing, Munson pushed the power up to demonstrate the aircraft’s acceleration. Speed brakes were needed to slow down but the landing was uneventful.

On the third pattern, Munson invited the right-seat passenger to fly as he continued his aircraft demonstration. He suggested a zero-flap approach, which is an abnormal procedure in a jet, and perhaps not the best thing for a pilot’s first landing in a new aircraft. Munson predicted that the aircraft would float significantly and he was right. The right-seat pilot flew “considerably faster than the reference speed (bug) on the airspeed indicator,” and touched down about midfield. During the ensuing takeoff roll, the Citation suddenly floated “about five to 10 feet” into the air, startling the right-seat pilot. Munson had lowered takeoff flaps causing the aircraft to balloon as he took control. It was not exactly an orderly transfer of command.

The tower then requested the Citation to enter a right pattern for Runway 19 because of other traffic. The downwind leg was flown at 3,500 feet msl and 200 knots. Things were about to unravel farther. The recommended pattern altitude for turbine aircraft is around 1,500 agl (2,700 msl at Akron) and 150 knots in the CE-501, so they were high and fast. The landing gear warning horn sounded, as power was reduced to near idle. Munson silenced it with the horn override. Neither passenger recalled speed brakes, landing gear, or flaps being deployed to slow the aircraft. The tower controller asked for an extended downwind and later advised that the jet could turn base at any time.

That sinking feeling

The right-seat passenger confirmed the jet was on the glidepath, according to the visual approach slope indicator (VASI), as they rolled out on final and but had to remind Munson to lower the gear. The passenger then commented about being low and perceived that the aircraft was “settling in” and told the pilot, “We’re sinking.” Munson gradually applied power.

The passenger in the cabin recalled that the power application was relatively slow as the pilot “sort of inched them [throttles] forward. I sensed the airplane sinking and I could sense through the expression in Thurman’s face that the aircraft was out of control.”

No one remembered the vertical speed on final approach but the right-seat passenger verified the airspeed was “nailed right on the bug” (93 knots) during the final approach. Neither passenger felt any acceleration from the power application during the last portion of the approach. The cabin passenger felt the left wing drop slightly and saw Munson suddenly push the throttles “to the firewall.” He reported a slight shudder before impact and faced rearward in his seat, expecting to crash.

Despite having much more flight experience, the right-seat passenger deferred to the type-rated novice: “I was trying to convey to him [the pilot] my discomfort with the fact that we were getting a little bit low and that I was uncomfortable with the sink rate. I didn’t want to come out and say, ‘I don't like this approach; please add power.’”

Neither passenger saw Munson use a checklist at any point, nor did he lower the flaps during the last approach.

Aftermath—the crash

According to the NTSB, the aircraft touched down about 870 feet short of the runway and sheared the nose gear. It passed through a clump of small trees, struck a large stump, and spun around about 270 feet from the initial touchdown point and 600 feet from the runway threshold. A fire erupted immediately.

Bob Hoover’s very good advice to “fly the thing as far into the crash as possible” is a reminder that the crash isn’t what’s bad, it’s the sudden stop. If the G-forces can be spread out and the structure absorbs the energy, then there is a reasonable chance of getting out without too much injury. But luck plays a part in many accidents.

The NTSB reported that, “The cockpit interior showed little evidence of impact damage, except for the left side. The pilot’s control yoke was broken in half just above the mid-column. About two feet of the floor structure, including the pilot’s left seat floor track, was buckled by impact from below.... The seat had become detached from the floor track and was found loose in the cockpit.”

Back in the cabin, the right emergency exit door was open but the main cabin door on the left side was jammed closed.

Neither front-seat pilot was wearing a shoulder harness. This may have played a significant part in Munson’s death as the autopsy revealed severe impact injury to his head and neck. The two passengers were essentially uninjured by the crash. They made several attempts to free Munson, who was pinned between his seat and the instrument panel. Both fuel tanks ruptured and fire spread rapidly. The passengers were forced to leave through the emergency exit and suffered severe burns on face, neck, and hands. No malfunction of the aircraft or engines was noted.

Jet performance

Flying jets by the numbers is essential, much more so than in smaller prop aircraft. Stall speed and landing performance can vary significantly based on weight. Based on the density altitude and aircraft weight, the flight manual showed a full flap stall speed of 74 knots with aerodynamic buffet at 79 knots. The reference speed (V REF) for this configuration was about 95 KIAS. The no-flap stall speed, aerodynamic buffet, and V REF was 82 knots, 92 knots, and 107 knots respectively. The flight manual specifies a no-flap approach be flown at 117 knots so the Citation was 20 knots too slow and operating in the area of reverse command (behind the power curve). More power is needed to fly more slowly, and it’s a bad place to be at low altitude.

Power management in jets is different than piston or even turboprop aircraft. Jet engines respond more slowly to power application, hence the term “spool up.” The technique described as “inching the throttles forward” is typical of prop aircraft technique, but jet power requirements must be anticipated with early throttle application, and much thrust occurs at the top of the rpm range compared to the linear response of piston engines. Additional airflow over the wings and control surfaces from the prop improves performance quickly as power is advanced. Jets may be fast, but they’re slow to get going.

The pilot

Munson began flight training in February 1978 in a Cessna 150. Later that spring he also began flying a Beech Duke and completed his private pilot training that June in a Cessna 172. Several days later, with a total flight time of 97 hours, he added a multiengine rating. In February 1979, at 330 hours, Munson purchased a Beech E-90 King Air. In early July 1979, he had logged about 480 hours with 428 hours of multiengine time when he purchased the Citation. At this point he had 165 hours dual and 315 hours pilot-in-command.

Munson trained at FlightSafety International (FSI) in Wichita, in a modified program. The standard curriculum typically consisted of two weeks of ground school including 12 to 14 hours of simulator training. This was usually followed by several hours of actual flight followed by the checkride. Because of an active baseball schedule, where it would be impossible for him to be away from the team for two weeks, FSI provided a pilot/flight instructor. According to the instructor, Munson completed the entire ground school in a week.

He flew with the instructor for 10 flights before receiving a type rating in the CE-501 in July 1979. The flight training was conducted during cross-country flights to Oakland, Seattle, Kansas City, and Wichita. Local training flights were also made at Oakland and Seattle. Munson logged 21.7 hours and 24 landings in the aircraft but only completed four hours in FSI’s Citation simulator. In the 16 days following the check flight, he flew 10.6 hours dual with 4.1 hours as single pilot. At the time of the accident he had 516 total hours and 34 hours in the Citation.

Munson’s knowledge and performance in the simulator were described as “above average.” The instructor reported, “From the onset to completion of training, Mr. Munson displayed well above average skills and judgment as a pilot. He was very knowledgeable of the flight manual.” Munson received his type rating from an FAA-designated pilot examiner employed by FSI and reportedly had no difficulty during the checkride. Other flight instructors who had flown with Munson for his various certificates and ratings considered him above average in operation and knowledge.

Probable cause and analysis

The NTSB determined that the probable cause of the accident was “the pilot’s failure to take action to maintain sufficient airspeed to prevent a stall during an attempted landing. The pilot also failed to apply sufficient power to prevent the stall during an inadvertent no-flaps landing approach. Contributing to the pilot’s inability to recognize the problem and to take proper action was his failure to use the appropriate checklist and his nonstandard pattern procedures which resulted in an abnormal approach profile.” The NTSB felt that Munson’s training was sufficient and was not considered to be a factor. A dissenting opinion by board member Francis McAdams will be discussed shortly.

The NTSB noted, “None of the patterns were flown at the ‘recommended’ airspeeds or altitudes. The pilot was certainly aware of standard pattern procedures from his previous flying experience, and during recent training in the CE-501 had demonstrated his ability to fly standard patterns during a checkride. The pilot failed to use a checklist. The routine of lowering landing gear and flaps on downwind leg was followed on the first three approaches even though he did not use a checklist. However, these ‘natural’ actions were not performed for the last approach because the habit pattern was broken by the changed landing pattern and a wider and higher than normal base leg entry. If the pilot had followed the landing checklist, the accident could have been prevented.”

Munson certainly fit the profile of an overachiever who steps through aircraft quickly, arriving in the high-performance environment with very little calendar or flight time compared to a more normal and measured progression. Many pilots, even those financially blessed, take years before they move into an entry-level jet, taking time to learn the nuances of aviation. Munson appears, by all accounts, to have been exceptional in physical flying skills and in memorizing procedures for multiple, complex aircraft. But rote memorization and learning are quite different.

Sharp, talented people are usually quite confident, and often with good reason. They’ve been successful at everything else they’ve tried, and when they suffer a setback, it’s only temporary. They study, persevere, and ultimately conquer problems. But aviation is different because gravity plays for keeps. Munson showed a superficial understanding of aviation safety culture and protocol, which is somewhat complex to describe, but often all too lacking in accident pilots. It’s not that jets are especially difficult—in many respects they’re easier—but they demand more precision than a prop aircraft. Too fast or too high in the pattern or in the terminal area is not so quickly fixed. Neither is too low and slow. When close to the ground, there may be no second chance.

In this scenario, Munson forgot to lower the gear and flaps, failed to compute the proper V REF, failed to recognize that he was in the region of reverse command, and attempted to conduct an aircraft demonstration in an aircraft that he only marginally understood. The fact that he gave no safety brief, did not use a checklist, and neglected to use the shoulder harness that may well have saved his life, shows casualness toward safety measures.

The NTSB did not find fault with his training, noting that Munson’s training record showed him as above average. They also noted that he could not have passed his checkride by flying the way he did on the day of the accident. But board member McAdams dissented, “The majority concludes that the cause of the accident was the failure of the pilot to recognize the need for, and to take action to maintain, sufficient airspeed to prevent a stall, and the reason for the pilot’s failure was the fact that he did not use the checklist and used nonstandard pattern procedures. This equates to 100 percent pilot error, but the majority has made no attempt to determine why the pilot failed to take adequate action.

“In my opinion, the board should have cited as a contributing factor the fact that the pilot lacked sufficient flight experience in the aircraft, and further he may have lacked adequate basic training. The Citation is a high-performance aircraft and, although the pilot had the minimum number of hours (approximately 30 hours), I believe that with more experience in the aircraft he would have arrested the high sink rate and approach to stall by immediately adding thrust.”

FlightSafety and Cessna settled the inevitable lawsuit out of court, likely recognizing that while they may have prevailed in law, they would lose far more in the court of public opinion. Unfortunately, reality is that someone is able to pass a checkride but it does not guarantee that they will have the skills, ability, and judgment that the test purports to measure. That’s not unique to aviation.

To effectively measure judgment it has to be watched over time, in a series of situations without the subject knowing that they are being evaluated, or, they have to know that they are being watched constantly and will suffer the consequences for misbehavior. Given the state of the art in human performance measurement, it will be some time before we understand the human mind well enough to predict future performance in all areas of possible exposure with a short-term testing instrument.

Is this accident a foreshadowing of the VLJ generation? Time will tell.

Bruce Landsberg is executive director of the AOPA Air Safety Foundation.