Poor crew resource management and failure to heed an advisory message that should have triggered a no-go call contributed to a passenger’s fatal injuries on a March 3, 2023 flight onboard a Bombardier Challenger 300, according to probable causes and findings published in a final NTSB report about the accident. One passenger sustained fatal injuries during an in-flight upset caused by “pilot-induced oscillations following the autopilot disconnecting from [an] out-of-trim condition,” the report says.
The flight originated at Dillant–Hopkins Airport (KEEN) in Keene, New Hampshire, and was bound for Leesburg Executive Airport (KJYO) in Virginia. The accident occurred about eight minutes into the Part 91 flight, which included two crew members and three passengers.
According to the report, the pre-flight walkaround done by the second-in-command (SIC) was interrupted by an FBO employee delivering ice to the aircraft. The SIC then forgot to remove the cover on the right pitot probe, which led to a first takeoff attempt being aborted.
Despite the crew alerting system (CAS) displaying a rudder limiter fault advisory on the taxiway after the aborted takeoff, and a flight director stuck in pitch mode, the crew proceeded with the flight rather than calling maintenance control.
“The flight crew did not consult the airplane’s ‘Go/No-Go’ guide, but if they had, they would have found that the Rudder Limiter Fault advisory message was a ‘No-Go’ item, and that the Minimum Equipment List provided no relief to depart with that message displayed,” the report stated.
Both the pilot in command and the SIC continued troubleshooting multiple advisory messages on the CAS, which included engaging and disengaging the autopilot several times during climb. The seatbelt light remained lit throughout the climb, but the crew did not notify passengers of a potential hazard, and the injured passenger did not have her seatbelt fastened at the time of the accident, according to the report.
The accident occurred near Windsor Locks, Connecticut. After being notified of a medical emergency onboard following pilot-induced oscillations, the crew landed the airplane 17 minutes after takeoff at its diversion airport, and the injured passenger was pronounced dead later that day.
Some of the CAS alerts were the result of the right pitot tube being covered during the first aborted takeoff, according to the report, and the crew failed to follow documentation and procedures, continuing with the flight in spite of the messages.