Near Mid-Air Collision – Runway
Pilot
Departed FBO for a flight to ALS to COS. At ALS Runway 02 on roll out I noticed a small aircraft at the end of 02 looking like they were taking off. I applied brakes in hopes to make it off taxi way A3 but was unable so I went to the left side of runway (west side) and stopped with the mind set if I have to, I will taxi off the runway between the edge lights if needed. I made 25 miles west call, 10 miles west call, and an extended left base call. Also, a 5-mile final call. When I checked the AWOS about 35/40 miles out it was calling 290 at 7. Direct crosswind so I opted to land 02. On final I check again and the AWOS said 270 at 5 which did favor 20. The departing aircraft on 20 noticed me on the runway and aborted takeoff. I didn’t get a TCAS ALERT. He went to the left side east side and taxied by me slowly. I followed him off the runway at A3 to the ramp. I shut down and walked over to him and we had a civil conversation. I was going to get his information, and the ambulance came rolling in at the same time. I told him I was going to be over at my plane helping the med crew. He then fired up and took off. I powered up my plane to get the radios on to make sure mine and his radios were working. He answered and we both had communication via our radios.
Chief Pilot
After this event, I requested that pilot send me the data card. I reviewed the footage on 06/05/2024 and I was able to determine that while the pilot was making the proper radio calls for operations at non-towered/uncontrolled airports the appropriate CTAF frequency was not used. The COM 1 frequency was set to 122.70 which is the CTAF frequency for the departure airport (KPSO), the frequency was not changed to 122.80 (CTAF for KALS) until after the incident occurred. Once the correct frequency was entered, the pilot was able to make contact with the Cherokee pilot. After reviewing the footage, I called to discuss the findings with the pilot. I let him know that it was confirmed that he never swapped the frequencies or even tuned the appropriate CTAF. The pilot accepted his mistake. Through that discussion, I was able to express our expectations and GOM requirements. I believe that this pilot has learned from his mistake and this (ensuring appropriate CTAF frequency is being used) will be something that we will stress in ground/flight training.
KEY ERC TAKEAWAYS
- FDM data was pulled – CTAF at uncontrolled airport was not used.
- Company plans to add emphasis in ground/ flight training.
- Company to put a notice to pilot group as a lessons learned.
- Captain was sent for re-training. Safety bulletin sent out to the pilot group. The aircraft returned to service.
Communications: Crew Communications
Pilot
On the climb out from VNY to CNO, the captain’s FMS screen darkened, but was still functioning with data displayed on his PFD. He freaked out and missed several radio calls. The copilot (pilot flying) took over the radio calls and checklists since he couldn’t get the captain (pilot monitoring) to response for the next 8-10 minutes. The captain then spent those 8-10 minutes punching his FMS and messing with his and my radio screens, while the copilot flew, answered the radio calls, made sure he was on the right frequency, and flew headings, leveled off, and then proceeded direct POM and PDZ VORs on FMS 2, descended, spotted the destination airport, and then got his captain to chill out, stop being a hot mess of a distraction, refocus on monitoring and not creating potential safety issues.
Approximately 3 miles from Chino, I got my captain back in the game enough to answer SoCal that I had the airport in sight to do a visual with amazing conditions. I tasked him with the spoilers after that radio call, so he wouldn’t mess anything up on me or violate us as he’s historically done in similar situations. I turned downwind for runway 26L (7000′ long). He wanted me to do an ILS to the short runway 26R (less than 5000′), and proceed on the ILS 26R on autopilot. I strongly declined since:
- That would further distract his extreme limited capacity at this time.
- We already briefed I would do a visual on the ground in Van Nuys.
- Anything else would distract me as essentially a single pilot.
On late downwind, I turned the autopilot off since my captain was in no shape to follow any instructions concerning that. He stated he wanted the autopilot on, but I said “NO” because if he touched anything up there, I was 99% certain it would have led to a go around or a traffic conflict with the Cessna on 26R final. I turned base and final 26L, and did a text book approach and flare. As the mains touched down and the nose settled, the captain violently grabbed the yoke and greatly oscillated the elevator bouncing the nose wheel creating a potential safety issue. I didn’t hear him say “my controls”. He just slammed, thrashed, and pumped the controls making my correct and slight input 4-5 times worse in the opposite direction until I said “your controls” a moment later and let him pump the elevator 2/3-3/4s deflection until he calmed down and the tail couldn’t fly anymore. He taxied down to the end of the runway clearly not even half way mentally there while trying to get a hold of [name] to find out where to park instead of getting the plane off an active runway and taxiing to a safe location to make that communication, deferring it to the flight attendant, or a myriad of other safer options. I made sure he kept the jet on the runway and taxiway, while completing the checklists. As taxiing into Threshold Aviation was fairly tight, we stopped and discussed getting marshallers out due to this, but my main concern was he still wasn’t there mentally, and I wanted a second set of eyes on his side to greatly reduce the risk of him hitting the wingtip on the other jet, a large metal box that appeared to be an electrical transformer, and several light poles. After a delay and him taking a few minutes to collect himself, we continued taxiing and shut down. I post-flighted the plane, unloaded all the baggage and the 200lb windshield box with some assistance from the mechanics, and got everything squared away minus the cockpit since the captain didn’t have the mood or mental wherewithal to do a debrief more than him saying “good job” and me saying “well, we survived” in a very calm, but concerned tone. He then immediately ran off to monitor the mechanics as I helped the flight attendant load the car.
I tried to talk to him over the next 30 minutes in the hangar, but he avoided me by either talking with dispatch, his friends and family, or walking to the other side of the hangar when I approached him. He disappeared for 20-25 minutes as we waited for him to surface from avoiding us in the hanger. He then said he was looking for us when I was walking in front of the FBO with the car within his view most of that time or sitting in the FBO with the flight attendant less than 50′ away. I drove to the hotel, and then the same thing happened as he ran off before the rest of us checked in, which is extremely unusual for him. He said he was extremely busy with school for the next few days, and he said he’d get a hold of us if anything popped up.
As previously stated in past safety reports, I will bring my concerns up at the end of his rotation in person. Otherwise, he will become short, impulsive, and angry with the flight attendant and me. This compounds him going into this quasi-single pilot mode where he is greatly impulsive, agitated, resigned, and several other negative safety attitudes rather than him being an intricate part of the safety team and flight crew. This has continued for more than a year now. There is some improvement, but there’s a lot of relapsing when he is slightly or more fatigued if something simple like a screen darkens, a dispatcher says something to make him mad, he can’t get his particular approach, another plane didn’t taxi up to the hold short line close enough, or his hotel is a Hilton instead of a Marriott, exc….
Suggestions:
Captain gets remedial training on emergencies such as Aviating, then Navigating, and then Communicating, CRM, communication, and remaining somewhat composed under stress and fatigue. This has been a large issue over the last year with these issues numerously discussed between him, me, him and other pilots, the safety officers, chief pilot, and director of operations. He’s also not getting enough rest with his schooling piling up, so it’s starting to become concerning that he’s not mentally there especially during slight hiccups like an FMS screen going dark. As previously stated in the last 8-10 safety reports I’ve submitted with him not mentally being there, it’s very concerning that this trend is continuing which greatly increases the risk of something extremely negative happening. Since I’m a cruise captain now, it would be greatly in the interest of safety to allow me to exercise being in the left seat when the other pilot is greatly fatigued. Also, this would build my experience as well, which benefits the company down the road.
KEY ERC TAKEAWAYS
- CRM issues identified as root cause.
- Crew debriefed and counseled.
- No issues between pilots since.
Wrong Airport Landing
Pilot
This event occurred on October 20 around 15:15 local time on the way from KJZI to KSSI. During this short leg a number of factors contributed to the unintentional landing at the wrong airport. I was the pilot flying while the captain was pilot monitoring. While about 20-15 miles out from the airport ATC asked if we had the airport in sight. The captain confirmed that we had it in sight while pointing out the airport to me. I agreed that I also had it in sight. At this time, we canceled our IFR and I proceeded to hand fly and enter a left downwind. At this time traffic called departing SSI towards our position. Between traffic, hand flying, and keeping the airport in sight we were very busy. On my side (SIC) the MFD was zoomed out, so it appeared that we were on the approach course into SSI. However, we were in fact now lined up for runway 7 at BQK without realizing. Similar runway directions and both airports being close together also help contribute to what happened. Even after landing we suspected nothing due to it clearly being an uncontrolled field like SSI and other jets being on the ramp. It was not until we started taxiing when things started to not make sense. Our taxi diagrams obviously made no sense. We taxied to the ramp shut down and realized what had happened. The captain immediately called the chief pilot to explain and to acquire a new release. Besides being incredibly embarrassed, the Captain and I thoroughly debriefed the incident and took away many lessons.
KEY ERC TAKEAWAYS
- Crew debriefed. Understand their mistakes.
- Uncontrolled airport, no airspace violations.
