Pilot Decision-Making in a Fatal Six-Person Crash

The Bombardier Challenger 605 was approaching Truckee, California, on a warm July afternoon.

The aircraft had two pilots and four passengers.

The flight had been routine.

But as the crew prepared for landing, they discovered a problem.

The runway ATC assigned for the expected approach was too short for the airplane's landing requirements at its expected weight.

The correct solution was simple:

Request the longer runway.

Instead, the crew decided to accept a circling approach.

That decision began a chain of increasingly serious errors.

The approach was not properly re-briefed.

The aircraft entered the pattern too fast.

The crew failed to stabilize the approach.

The airplane descended into a turn at low altitude.

The wings stalled asymmetrically.

The Challenger rolled sharply.

It crashed near the airport.

All six people aboard were killed.

The NTSB concluded that the accident resulted from the flight crew's poor decision-making and crew resource management during the circling approach, which culminated in an aerodynamic stall and loss of control. (NTSB Data)

The Flight to Truckee

The aircraft was Bombardier CL-600-2B16 Challenger 605, registration N605TR.

It was operating a non-revenue Part 91 flight.

There were two pilots and four passengers.

The destination was Truckee-Tahoe Airport in northern California.

Truckee is a challenging airport because of its high elevation, surrounding mountainous terrain and runway limitations.

Runway 20 is relatively short for a heavy business jet.

Runway 11 is longer.

That distinction became central to the accident.

The Runway Problem

During descent, ATC told the crew to expect the RNAV GPS approach to Runway 20.

The captain, who was the pilot flying, reviewed the landing requirements.

That should have ended the discussion.

The crew could have requested the straight-in approach to Runway 11.

Instead, the captain proposed taking the Runway 20 approach and then circling to Runway 11.

The first officer communicated that plan to ATC.

ATC approved the circle-to-land maneuver.

The crew accepted it.

But the approach had now changed.

The original straight-in approach briefing was no longer sufficient.

The crew needed to conduct a new briefing for the circling maneuver.

They did not.

The NTSB specifically identified the failure to brief the new approach as an important factor. (NTSB Data)

What a Circling Approach Requires

A circle-to-land approach is different from a straight-in instrument approach.

The pilot flies the published approach toward the airport.

Once the runway environment becomes visible, the aircraft must maneuver visually to align with another runway.

That means the pilot must maintain visual contact with the airport while flying a safe traffic pattern at a prescribed altitude and airspeed.

There is little room for improvisation.

The crew must know:

the required pattern,

the wind,

the maneuvering area,

the descent profile,

N605TR's crew did not properly re-brief the changed approach.

That meant the pilots were effectively entering a complex maneuver without having established a shared mental model.

The Hold

ATC subsequently instructed the aircraft to hold.

The captain was slow to comply.

The first officer initiated the turn into the holding pattern and then advised ATC that they were established.

About 20 seconds later, ATC cleared the aircraft for the approach.

The first officer asked the captain whether he was ready.

The captain said he was.

The aircraft then began the approach.

Almost immediately, the first officer noticed that the airplane had too much airspeed.

He suggested a 360-degree turn to lose energy.

The captain did not accept the suggestion.

The airplane continued.

This was another opportunity to stop the chain.

The aircraft was fast.

The crew knew it was fast.

There was time to go around or reposition.

Instead, the approach continued.

Seeing the Airport

The first officer eventually saw the airport.

He directed the captain to turn right and establish a heading approximately parallel to Runway 11.

The maneuver was supposed to place the aircraft on the downwind leg of the circling approach.

But the turn was not executed correctly.

The aircraft rolled out early.

The approach geometry deteriorated.

The airplane was too close to the runway environment and still carrying excessive energy.

The crew was now attempting to salvage an approach that had become unstable.

The Final Turn

The Challenger continued around the airport.

The aircraft was still moving too fast.

The first officer issued additional guidance.

But their communication became increasingly ineffective.

Its speed decreased.

The angle of attack increased.

The airplane entered an asymmetric aerodynamic stall.

One wing stalled before the other.

The aircraft rolled sharply.

The crew attempted to recover.

There was not enough altitude.

The Challenger crashed into terrain near the airport.

All six occupants died.

The CVR

The cockpit voice recorder captured the crew's interactions during the final minutes.

The recording was approximately two hours long and provided investigators with a detailed chronology of the crew's decision-making. (NTSB Data)

The recording showed that the first officer recognized several problems.

He identified the excessive airspeed.

He suggested a 360-degree turn.

He provided directional guidance during the circling maneuver.

But the captain retained control of the aircraft.

The problem was therefore not that the first officer said nothing.

The problem was that the crew did not effectively resolve their disagreements and did not establish a stabilized approach.

Crew Resource Management

This accident is an important CRM case.

Crew resource management does not mean that the captain must surrender authority.

It means that both pilots must communicate clearly and respond appropriately to safety-critical information.

A first officer saying "we are too fast" is not a casual comment.

It is a safety warning.

A suggestion to go around or perform a 360-degree turn should trigger a deliberate evaluation.

The captain should either accept the recommendation or clearly explain why another action is safer.

In N605TR, the cockpit did not reach that level of coordinated decision-making.

The Aerodynamic Stall

The final loss of control was not simply caused by excessive speed.

The problem was the transition from excessive speed to aggressive maneuvering at low altitude.

The aircraft had energy that needed to be managed.

Instead of abandoning the approach, the crew continued maneuvering.

As the aircraft banked and slowed, its stall margin decreased.

An aircraft stalls when the wing exceeds its critical angle of attack.

The stall does not require the airplane to be at a particular airspeed.

A heavily banked aircraft can reach the critical angle of attack at a much higher indicated airspeed than it would in level flight.

That is particularly important during a circling approach.

The bank angle increased.

The available recovery altitude disappeared.

No Mechanical Failure

The NTSB's investigation did not identify a mechanical failure that would have caused the loss of control.

The engines were capable of producing power.

The flight controls were examined.

The aircraft's systems did not provide an explanation for the crash.

The accident therefore remained fundamentally a flight-crew decision-making and aircraft-control event. (NTSB Data)

NTSB Probable Cause

The NTSB determined that the probable cause involved:

The investigation also identified the crew's failure to brief the circling approach, excessive airspeed, inadequate monitoring and ineffective coordination as important links in the accident sequence.

Accident Facts

The NTSB investigation included the cockpit voice recorder, aircraft performance study, ATC information and wreckage examination. (NTSB Data)

Why the Runway Decision Matters

The accident could have been prevented before the airplane ever began the circling approach.

They had identified the problem.

There was a simple alternative: request Runway 11 directly.

Instead, the crew chose a more complicated procedure.

That decision introduced additional maneuvering.

It introduced visual circling.

It introduced a new approach briefing requirement.

It increased workload.

And it placed the aircraft in a configuration in which speed management became critical.

This is a classic example of risk multiplication.

One decision creates another problem.

That problem requires another maneuver.

The maneuver increases workload.

The workload reduces monitoring.

The monitoring failure allows the aircraft to become unstable.

Eventually, there is no longer enough altitude to recover.

The Broader Safety Lesson

The Challenger 605 accident is a powerful lesson in the danger of trying to salvage a bad approach.

Request the longer runway.

If the approach became unstable, go around.

If the airplane was too fast, stop the approach.

If the circling maneuver was not properly briefed, do not continue until the crew is ready.

Aviation does not reward pilots for completing approaches at all costs.

It rewards pilots for recognizing when an approach has become unsafe.

The N605TR crew had several opportunities to stop the chain.

They did not.

The final result was an aerodynamic stall at low altitude.

Six people died.

The lasting lesson is not that circling approaches are inherently unsafe.

It is that a complex approach should never be allowed to become an improvised approach.

Sources

• Original ATC recording