RISK MANAGMENT

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021

 PSA Airlines Canadair CRJ-200 on
behalf of US Airways

Taking off from Charleston, WV

The Accident enroute to Charlotte, NC (USA)

30 passengers and 3 crew, overran

runway 23 after rejecting the
takeoff at high speed
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
 • The cockpit voice recorder
transcript shows, that the airplane
had been delayed by about 15
minutes due to traffic flow control
into Charlotte.
BACKGROUND • The airplane waited on the apron
and subsequently taxied out to
runway 23 with the crew still
engaged in casual conversation
that started during the wait.
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
COCKPIT VOICE RECORDER
• During the initial takeoff run no alerts can be heard.
• 6 seconds after the 80 knots call, a sound similar to a flap handle
movement is recorded.
• Another 5 seconds later, the first officer calls V1, another 2 seconds later
the master warning sounds followed by an exclamation of surprise by
the captain.
• 2 seconds after the master warning the automated aural alert "config
flaps!", master warning and "config spoilers!" were recorded.
• 11 seconds after V1 call the CVR records sounds of engines spooling
down, another 4 seconds later the crew announced the rejected takeoff
to tower.
• The captain starts swearing "why did I do that?"
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
 • Failure to follow the checklist and
set the flaps/slats for takeoff
• Failure to observe the flaps/slats
were not in the correct position
FACTORS for takeoff
LEADING TO • Failure to immediately reject the
THE CRASH takeoff when the master caution
sounded
• Failure to follow the sterile
cockpit rule
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
SOLUTIONS
• Better Training on Risk Management
• Better Procedures
• Additional checkpoints on the takeoff checklist
to ensure flaps/slats are set for takeoff
• Better engineering
• Electronic alerts and throttle engagement
locks that prevent the throttles from being
advanced if the flaps/slats are not set
appropriately for takeoff

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021

Risk Management

• Hazard
• Present event, object or
mechanism
• That could lead to an
unplanned or unintended
event

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021

 • Tools –
• Advisory Circulars
• Check lists
• Good habits
Recognizing • Defining Risks
the Hazard • Potential future impact of the
hazard
• Lack of oil v broken hobbs
meter

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021

 • Total Risk
• Identified
• Unidentified
• Acceptable
• Residual
Managing • Human Behavior
Risks • Disdain for rules
• Thrill seeking
• Impulsive
• Disregard for rules

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021

Identifying Risks and
Mitigation

• PAVE
• Pilot in command
• Aircraft
• EnVironment
• External Pressure
• IM SAFE
• Illness
• Medication
• Stress
• Alcohol
• Fatigue
• Emotion

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021

 • Identify personal attitudes
• Behavior modifications
• Recognize and cope with stress
Aeronautical • Using all available resources
Decision • Evaluating ADM skills

Making • Automatic Decision Making

• Operations Pitfalls
• Get there itis, scud running loss of situational
control, flying outside the envelope, VFR to IMC

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021
 AUTOMATION CAN VARY
WIDELY EVEN BETWEEN
THE SAME MAKE AND
MODEL

Civil Air Patrol - Internal Use Only - Version 1 - January 2, 2021