Key West, FL, USA
N938D
CESSNA 550
The pilot-in-command (PIC) stated that he flew the downwind leg at 1,500 feet at 130 knots indicated airspeed and turned onto final approach at 1,000 feet, which he flew at 106 knots. He then touched down 800 feet down the runway at 95 to 100 knots. At touchdown, he extended the speed brakes, and, after traveling another 800 feet, he began to apply wheel braking, but the brake pedals felt "hard" and would not move. He then attempted to apply the emergency brake, but there was no braking action when he pulled it. The airline transport pilot who was in the right seat and acting as the second-in-command reported also trying to apply wheel braking after the PIC was unsuccessful and stated that it did not work. The airplane then overran the runway into the engineered material arresting system. Review of the radar data for the descent and approach portions of the flight indicated that at times the airplane was fast and the approach was unstabilized. However, the touchdown occurred at a reference speed of 103 to 106 knots. Examination of airport security camera images and deceleration values (determined by using time, distance, and velocity calculations) indicated that the airplane's deceleration was consistent with a lack of braking. Examination of the normal hydraulic braking system and antiskid system did not reveal any malfunctions or failures that would have precluded normal operation of the brakes. Examination of the cockpit revealed that the T-handle for the emergency gear extension system had been activated. This handle is located immediately to the right of the emergency braking handle and was most likely pulled during the incident landing instead of the emergency brake handle. Examination of the emergency braking/landing gear blow-down nitrogen bottle revealed that it was empty; no indication of leakage was discovered, and the witness wire on the landing gear blow-down cable at the nitrogen bottle was intact, indicating that the bottle was most likely empty before the incident flight, since adequate nitrogen should have been available from a properly serviced air bottle even if the landing gear had been extended pneumatically. Review of maintenance records that were provided by the operator nonetheless listed the airplane's most recent inspection as being completed on September 5, 2011, "in accordance with the instructions and procedures of a current manufacturer's recommended inspection program." According to a signed inspection document, 13 phase inspections were completed, including a phase 5 inspection containing 126 separate tasks, comprising inspection of the emergency brake control valve, the brake reservoir, the antiskid components, and the antiskid system, as well as replacement of the antiskid motor/pump filter, operational check of the antiskid brake system, operational check of the emergency brake system, replacement of the brake reservoir air filter, and cleaning of the brake reservoir supply line and system filter. The document also indicated that servicing of the "emergency brake and gear Nitrogen" had been accomplished. The landing checklist in the airplane flight manual cautions that if a "hard brake pedal-no braking condition" is encountered during landing, the pilot should operate the emergency brake system. It also noted that to obtain maximum braking performance from the antiskid system, the pilot must apply continuous maximum effort (no modulation) to the brake pedals. The Pilot's Abbreviated Checklist also contains emergency procedures for wheel brake failure and antiskid failure. However, examination of the incident airplane revealed that neither of these documents was in the cockpit. Instead, the cockpit contained a double-sided laminated checklist from a training provider titled "Normal Procedures." No emergency procedures were printed on the checklist and "For Training Purposes Only" appeared at the bottom. Based on the available evidence, it could not be determined that a failure of the normal braking system occurred or that the pilots applied maximum braking effort, as indicated by the airplane manufacturer's guidance. Further, had the braking system actually failed, the pilots did not apply the emergency brakes, instead activating the landing gear extension handle.
HISTORY OF FLIGHTOn November 3, 2011, about 1213 eastern daylight time, a Cessna 550, N938D, operated by South Aviation, received minor damage during a runway overrun at Key West International Airport (EYW), Key West, Florida. The two certificated airline transport pilots and their three passengers were uninjured. Visual meteorological conditions prevailed, and an IFR flight plan had been filed for the business flight, which departed Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida, and was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the airline transport pilot (ATP) who was the pilot-in-command (PIC) of the flight, he conducted a visual approach to runway 9 at EYW. He flew the downwind leg at 1,500 feet at 130 knots indicated airspeed, turned onto final approach at 1,000 feet and flew the final approach at 106 knots and touched down 800 feet down the runway at 95 to 100 knots. At touch down he extended the speed brakes, and after traveling another 800 feet, he went to apply wheel braking but, there was no braking, and the brake pedals felt "hard" and would not move. He then attempted to apply the emergency brake but, there was "no brake at all" when he pulled it. The airplane then overran the runway. He felt that he had to stop and could not go around. According to the ATP who was in the right seat and acting as the second-in-command (SIC), the airplane had last been operated approximately two months prior to the incident. The purpose of the incident flight was to demonstrate the airplane to a potential buyer. The PIC of the flight was a contract pilot to his company which was trying to sell the airplane on behalf of the owner. The takeoff from FLL, the cruise portion, and the approach to EYW was uneventful. The touchdown occurred at the reference speed of 103 knots and was uneventful. The PIC applied the wheel brakes, and there was no braking. He then tried them also and the brakes "were not working." According to a passenger who was a pilot and was in the cabin, when they taxied out at FLL, the brakes were working fine. After landing in EYW he felt no braking whatsoever. He felt that they should have gone around. PERSONNEL INFORMATIONAccording to Federal Aviation Administration (FAA) records, the PIC held an airline transport certificate with ratings for airplane multi-engine land, commercial privileges for airplane single-engine land, and type ratings for the BE-300, BE-400, CE-500, CE-560XL, and MU-300. He also possessed a flight instructor certificate with ratings for airplane single-engine, and instrument airplane. His most recent FAA first-class medical certificate was issued on July 30, 2010. He reported that he had accrued 14,200 total hours of flight experience, 1,200 of which, was in the incident airplane make and model. According to FAA records, the SIC held an airline transport certificate with ratings for airplane multi-engine land, commercial privileges for airplane single-engine land, and a type rating for the HS-125. He did not possess a type rating for the incident airplane. His most recent FAA second-class medical certificate was issued on December 27, 2010. On that date, he reported that he had accrued 7,000 total hours of flight experience. AIRCRAFT INFORMATIONThe incident aircraft was a seven passenger low wing, pressurized, twin engine, airplane of conventional construction. It was certificated under 14 CFR Part 25. It was equipped with an anti-skid system and manually operated speed brakes. It was not equipped with thrust reversers. It was powered by two Pratt & Whitney Canada JT15D-4 turbofan engines, each producing 2,500 pounds of thrust. It could operate up to 43,000 feet above mean sea level, and travel up to 1,840 nautical miles at a maximum cruise speed of 385 knots. According to FAA records it was manufactured in 1982. According to maintenance records the airplane was being maintained under the continuous inspection program which is Cessna Aircraft Company's recommended inspection program. The program was divided into five primary phases which covered all inspection requirements up through the 1200-hour interval inspection items. The Phase 1 inspection focused on the nose area, cockpit, and interior; the Phase 2 inspection on the landing gear and empennage; the Phase 3 inspection on the tail cone area; and the Phase 4 inspection on the engines. The more intensive and comprehensive Phase 5 airframe inspection was due every 1,200 hours or 36 months, whichever came first. According to CAMP Systems maintenance tracking system records, the last Phase 1 through 4 inspections were completed on December 12, 2008. The next Phase 1 through 4 inspections were required to be completed by December 31, 2010. The last Phase 5 inspection was listed as being accomplished on December 29, 2008. The next Phase 5 inspection which contained 126 separate tasks, included inspection of the emergency brake control valve, the brake reservoir, the antiskid components, and the antiskid system. It also included replacement of the antiskid motor/pump filter, operational check of the antiskid brake system, operational check of the emergency brake system, replacement of the brake reservoir air filter, and cleaning of the brake reservoir supply line system filter. The inspection was required to be completed by December 28, 2011. No maintenance transaction reports had been supplied to CAMP Systems since 2009. According to maintenance records provided by the operator however, the airplane's most recent inspection was completed September 5, 2011, "in accordance with the instructions and procedures of a current manufacture's recommended inspection program". According to the signed inspection document, among other things, 13 phase inspections including a phase 5 inspection had been recently completed along with a "CVR operational test" and servicing of the "emergency brake and gear Nitrogen". At the time of the inspection, the airplane had accrued 9,896.5 total hours of operation. METEOROLOGICAL INFORMATIONThe reported weather at EYW, at 1153, included: variable winds at 6 knots, 10 miles visibility, clear, temperature 27 degrees C, dew point 20 degrees C, and an altimeter setting of 30.08 inches of mercury. AIRPORT INFORMATIONThe incident aircraft was a seven passenger low wing, pressurized, twin engine, airplane of conventional construction. It was certificated under 14 CFR Part 25. It was equipped with an anti-skid system and manually operated speed brakes. It was not equipped with thrust reversers. It was powered by two Pratt & Whitney Canada JT15D-4 turbofan engines, each producing 2,500 pounds of thrust. It could operate up to 43,000 feet above mean sea level, and travel up to 1,840 nautical miles at a maximum cruise speed of 385 knots. According to FAA records it was manufactured in 1982. According to maintenance records the airplane was being maintained under the continuous inspection program which is Cessna Aircraft Company's recommended inspection program. The program was divided into five primary phases which covered all inspection requirements up through the 1200-hour interval inspection items. The Phase 1 inspection focused on the nose area, cockpit, and interior; the Phase 2 inspection on the landing gear and empennage; the Phase 3 inspection on the tail cone area; and the Phase 4 inspection on the engines. The more intensive and comprehensive Phase 5 airframe inspection was due every 1,200 hours or 36 months, whichever came first. According to CAMP Systems maintenance tracking system records, the last Phase 1 through 4 inspections were completed on December 12, 2008. The next Phase 1 through 4 inspections were required to be completed by December 31, 2010. The last Phase 5 inspection was listed as being accomplished on December 29, 2008. The next Phase 5 inspection which contained 126 separate tasks, included inspection of the emergency brake control valve, the brake reservoir, the antiskid components, and the antiskid system. It also included replacement of the antiskid motor/pump filter, operational check of the antiskid brake system, operational check of the emergency brake system, replacement of the brake reservoir air filter, and cleaning of the brake reservoir supply line system filter. The inspection was required to be completed by December 28, 2011. No maintenance transaction reports had been supplied to CAMP Systems since 2009. According to maintenance records provided by the operator however, the airplane's most recent inspection was completed September 5, 2011, "in accordance with the instructions and procedures of a current manufacture's recommended inspection program". According to the signed inspection document, among other things, 13 phase inspections including a phase 5 inspection had been recently completed along with a "CVR operational test" and servicing of the "emergency brake and gear Nitrogen". At the time of the inspection, the airplane had accrued 9,896.5 total hours of operation. WRECKAGE AND IMPACT INFORMATIONExamination of the runway revealed that after the incident airplane had left the marked area of runway 9, it traveled 35 feet across the pavement between the painted runway end line and the start of the EMAS bed, and then traveled into the installed EMAS. Both main wheels broke the top surface of the EMAS bed as they entered it. A tire track for the nose gear was observed on top of the EMAS for the first 40 feet of travel into the EMAS bed. The top cover of the EMAS bed exhibited fractures under the nose wheel tire track, but did not appear to be broken through. After traveling 40 feet, the nose wheel broke through the top of the EMAS bed cover and entered the material below. Measurements taken of the ruts made in the EMAS by the landing gear of the incident airplane revealed that the EMAS had decelerated the airplane to a stop in approximately 144 feet. Examination of the airplane revealed that the wing flaps were in the "LAND" position (40 degrees), the speed brakes were in the "EXTEND" position, and during the overrun the airplane had received minor damage. The nose landing gear tire and bottom of the nose landing gear trunnion had separated from the airplane, the left landing gear door had partially separated from its mounting location, numerous scrapes were present on the lower fuselage skins and nose gear doors, the battery hold down clamp wing nuts were loose and not safety wired, and the engines had ingested dirt, and dust. ADDITIONAL INFORMATIONPost incident Sale and Inspection After the incident the airplane was sold as salvage by the insurance carrier. Examination by the new owner also revealed no evidence of any anomalies which would have precluded normal operation of the brakes, and the airplane was successfully flown on a ferry permit from EYW to the operator's facility in Vermont. RSA Improvement Program In 2000, the FAA developed an RSA improvement program to improve runways that did not meet FAA design standards. When the program began, only 30 percent of RSAs met full FAA design standards and 55 percent met 90 percent of the FAA design standards. Many airports were developed on land with limited space making it difficult to improve RSAs to meet changing standards. As a result the FAA implemented a number of RSA improvement options including construction and expansion of RSAs, Modifications or relocations of runways, removal of objects that were not fixed by function, implementation of declared distances, and installations of EMAS beds (such as the one on the end of runway 9 at EYW), the purpose of which was to stop an aircraft overrun with no human injury and minimal aircraft damage (usually none). The loss of energy required to crush the EMAS material slows the aircraft. An EMAS is similar in concept to a runaway truck ramp made of gravel or sand. It is intended to stop aircraft that have overshot a runway when there is an insufficient free space for a standard RSA. To date, EMAS has a 100 percent success rate. At the time of this report, EMAS is installed at 66 runway ends at 45 airports in the United States, with additional EMAS installations planned through 2015. Contrasting Overrun On October 31, 2011(three days prior to the incident involving N938D), A Gulfstream G150, N480JJ overran runway 27 during landing at EYW (ERA12FA056). During the approach in night visual meteorological conditions, after losing sight of the runway once, and going around, the flight crew continued the approach, even though the PIC stated that he thought they were going to land long. The PIC stated that the main landing gear touched down near the 1,000-foot marker of the 4,901-foot-long runway, about the Vref of 120 knots. The PIC stated that he then applied the brakes but thought they were not working; he had not yet activated the thrust reversers. He alerted the SIC who also depressed the brake pedals with no apparent results. The PIC suggested a go-around, but the SIC responded that it was too late. The airplane subsequently traveled off the end of the runway, and in contrast to the overrun of runway 9, where N938D received minor damage after traveling into the EMAS bed, and being brought to a stop, N480J received substantial damage, one passenger was seriously injured, and three passengers received minor injuries when it struck a gravel berm, and came to rest about 816 feet beyond the end of the runway. Originally only 100 feet of safety area was present off the end of runway 27, which led into a salt pond and embankment. In May 2011, as part of the RSA improvement program, a 600-ft unpaved safety area was added off the end of runway 27 to provide a more expansive safety buffer. On August 16, 2013, the FAA and Monroe County Board of Commissioners entered into a grant agreement for airport improvements at EYW which included improvements to the runway 27 safety area (EMAS-Phase 1). FLIGHT RECORDERSThe airplane was equipped with a cockpit voice recorder (CVR) that records a minimum of the last 30 minutes of aircraft operation; this is accomplished by recording over the oldest audio data. When the CVR is deactivated or removed from the airplane, it retains only the most recent 30 minutes of CVR operation. This model CVR, the Fairchild GA-100, records 30 minutes of analog audio on a continuous loop tape in a four-channel format: one channel for each flight crew and one channel for the cockpit area microphone (CAM). Examination of the CVR revealed that it had not sustained any heat or structural damage during the overun and the audio information was extracted from the recorder normally, without difficulty. The recording consisted of four channels of poor quality audio information; however none of the audio was pertinent to the incident investigation. The audio was consistent with the CVR being inoperative prior to the event or being overwritten by subsequent events. An internal inspection of the CVR revealed that the hour meter indicated beyond the 5,000 hour scale and corrosion was evident on the inside of the case. When power was applied to the CVR the tape mechanism would not turn. The limited audio content was consistent with ground operation of the aircraft. The recording consisted of a few power cycles; brief periods of singing; and sounds similar to a door opening. TESTS AND RESEARCHLanding Distance Calculations At the request of the NTSB, Cessna Aircraft Company calculated the landing distances for the incident airplane. Using a landing weight of 12,700 pounds, an elevation of sea level, a dry runway, and temperature of 30 degrees C, the following landing distances were obtained from data in the Aircraft Flight Manual (AFM): • 10 knot tailwind; 3,220 feet. • No wind; 2,340 feet. • 10 knot headwind 2,210 feet. While the reported temperature prior to the incident was 27 degrees C, no extrapolation was done between the published values of 25 degrees C and 30 degrees C as the landing distance would only have decreased approximately 10 feet in a no wind condition. These landing distances were based on the following criteria published in the AFM concerning landing distance and technique: • Landing preceded by a steady approach down to the 50-foot
The pilots’ failure to appropriately apply the landing gear wheel brakes after landing, to properly perform the hard brake pedal-no braking condition procedure following the reported brake failure and to apply the emergency brakes. The reason for the reported brake failure could not be determined because postincident examination did not reveal any malfunctions or failures that would have precluded normal operation of the brakes.
Source: NTSB Aviation Accident Database
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