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Operational Factors

This report delves into the operational factors contributing to the crash of a Cessna 550. Examines pilot deficiencies, crew resource management issues, and autopilot interface challenges. Critical insights provided for aviation safety improvements.

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Operational Factors

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  1. Operational Factors Crash of Cessna 550 Tim Sorensen Operations Group Chairman

  2. Captain • Hired by Marlin Air February 2005 • Properly certificated and rated to act as pilot-in-command • Flight time: • 300 hours Citation • 14,000 hours total • Served as company chief pilot and check airman

  3. Captain’s Deficiencies • Prior certificate revocation • Three checkride failures • Irregularities in recent checkride reports • Failure to comply with procedures and regulations

  4. First Officer • Hired 3 days before the accident • Previously employed by operator • Properly certificated to act as second-in-command • Flight time: • 420 hours Citation • 9,200 hours total • Expressed investment interest in the company

  5. First Officer’s Deficiencies • Left Marlin Air in 2002 after failing to upgrade to captain • Pilot’s comments about deficiencies • Unable to fly stabilized approaches • Selected wrong switches • Confusion regarding radios • Prior accident • Pilot induced electrical failure • Improper emergency gear extension

  6. Crew Resource Management / Decisionmaking • Casual, undisciplined environment • Haphazard, confused troubleshooting • Improper actions and lack of crew coordination • Uncommanded trim input (first officer) • Airspeed control (captain) • Relinquished control of airplane (captain)

  7. Autopilot Interface • Autopilot / yaw damper systems • Identical push-button switches • Out of pilot’s direct line of sight • Prone to inadvertent activation

  8. Human/Airplane Systems Interactions • Human factors issues observed • Circuit breaker identification • Trim control sensitivity • Trim motion salience • Need to monitor safety critical systems throughout life cycle of airplane

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