Aircraft and Flight Information
The aircraft, a Learjet 35A registered C‑GAJS (serial number 35‑380), was operated by Canadian Global Air Ambulance. It departed Brunswick, Georgia, United States, on a medical evacuation flight to Montréal/Pierre Elliott Trudeau International Airport, Quebec. On board were two pilots, two flight nurses, and two passengers.
History of the Flight
The flight was the second leg of a medevac originating at Toronto/Lester B. Pearson International Airport. The crew reported for duty at 2000 eastern standard time on 25 November 2006. The aircraft arrived from a previous mission at about 2145. The first leg from Toronto to Brunswick departed at 2254 and landed at 0045. During that approach, the left main gear down‑and‑locked light did not illuminate; the crew concluded the light was burnt out and landed without incident.
After embarking a patient and a passenger, the flight departed for Montréal at 0305. The captain was pilot flying, the co‑pilot pilot not flying. At 0500, the aircraft was cleared for an ILS approach to Runway 06R. Reference speed V ref was 124 knots. Weather included wind 120° at 2 knots, visibility 15 miles, and few clouds at 12 000 and 21 000 feet.
During the descent, about 6 nm from the runway, flaps were extended to 8° and then 20°. When the flap selector was moved to 40°, the indicator remained at 20°. The co‑pilot noted the discrepancy; hydraulic pressure appeared normal. At that time, the aircraft was abeam the final approach fix, 1000 feet above glidepath at 150 knots (26 knots above V ref). The crew continued the approach, planning to use spoilers, thrust reversers, and delay braking to exit at the end of the runway.
At about 200 feet above touchdown, the EGPWS alerted “TOO LOW FLAPS.” The captain requested flaps 40; the co‑pilot indicated the flaps were still at 20°. The aircraft touched down about 1000 feet past the threshold at approximately 130 knots. According to the AFM, landing distance for 20° flaps was 3300 feet. At about 3500 feet, the spoilers were selected to extend but did not deploy, which went unnoticed. Starting at about 4800 feet, the captain attempted three times unsuccessfully to move the thrust reverser levers beyond the idle/deploy stop. At about 8300 feet, the captain announced no brakes. At the runway end, he called for the brace position. The aircraft left the runway at about 53 knots.
It came to rest about 600 feet off the end in a grass field after striking multiple light posts and a manhole. The left wing leading edge and fuselage sustained damage. There were no injuries. The crew evacuated immediately.
Crew Information
The captain held an ATPL and joined the company in June 2006. He had 7300 total hours, 180 on Learjet 35 (100 as captain). Duty time was 7.2 hours after a 34‑hour rest. The co‑pilot also held an ATPL, joined in July 2006, with 2475 total hours, 173 on Learjet 35. Duty time was 7.2 hours after a 261‑hour rest. Both completed a FlightSafety International Learjet 35/36 initial course, which included CRM training. The simulator used for training had a low hydraulic pressure light and drag chute; the accident aircraft lacked both. During training, low hydraulic pressure scenarios were simulated, requiring activation of the auxiliary hydraulic pump and emergency brake handle. The crew believed the aircraft had a low hydraulic pressure light.
Aircraft Condition and Investigation
Examination revealed the flaps at 20°, spoilers retracted, and hydraulic fluid streaks on the lower fin and fuselage. The hydraulic reservoir level was not visible. The left main gear down‑and‑locked light was confirmed burnt out. A “B” nut connecting a nose gear retract hydraulic line to a one‑way valve was found slightly loose. Recent maintenance records showed no work in that area. The aircraft was not dispatched with the landing gear light inoperative under the MEL; such dispatch was not permitted by the operator’s approved MEL.
The CVR had a 30‑minute capacity; the cockpit area microphone channel malfunctioned for most of the recording. The aircraft had been maintained per the company’s High Utilisation Maintenance Program, last checked five days before the occurrence.