Macon, GA, USA
N428JD
BEECH 400
The pilot was seated in the left seat and was the flying pilot. The pilots reported that prior to departure, there were no known mechanical malfunctions or abnormalities with the airplane, including the brakes, flaps, anti-skid, or thrust reversers. The copilot, who was the pilot monitoring, calculated a Vref speed of 108 knots for the landing weight. Postaccident analysis determined that a more precise Vref based on weight would have been 110 knots. Both pilots reported that they set their airspeed index bugs to 108 knots about 11 miles from the airport. The pilot reported that the airplane touched down about 1,000 feet from the approach end of the runway. Both crewmembers reported that, although they used maximum thrust reversers, brakes, and ground spoilers, they could feel a "pulsation" in the brake system and that the airplane hydroplaned. The airplane overran the wet runway with standing water and came to rest 283 feet beyond the paved portion of the runway in a treed area off the airport. Postaccident examination of the airspeed index bugs revealed that the pilot's was set to 115 knots and that the copilot's was set to 105 knots, which correlated with their calculated and reported V1 and V2 departure speeds. It is likely that they did not move the airspeed bugs during the approach to landing. Postaccident testing of the brake system components did not reveal any mechanical malfunctions or abnormalities that would have precluded normal operation. Based on radar data, the airplane was likely 15 to 19 knots above the reference speed of 110 knots when it crossed the runway threshold. The data further revealed that the approach was flown with about a 4-degree glideslope approach angle instead of the recommended 3-degree glideslope angle. The pilots reported that the precision approach path indicator lights, which would have provided an approximate 3-degree approach, became inoperable shortly after activation. Although the touchdown location could not be accurately determined, given the approximate glideslope and the excessive speed, the airplane likely floated before touching down. It is also likely that the pilots, familiar with landing at their home airport, which is configured with a grooved runway that mitigates wet runway conditions more effectively, relied on their past wet runway experience and failed to calculate their landing distance using the appropriate performance chart for the contaminated runway. Based on the airplane's performance charts, on a contaminated runway, an airplane with a Vref of 110 knots would need a 4,800-foot runway; at Vref + 10 knots, the airplane would need 6,100 feet to land. The runway was 4,694 feet long. Hence, the lack of a clear understanding of the actual wet runway landing distance necessary to stop and the excessive approach speed resulted in the airplane crossing the approach end of the runway at a speed and flight profile unsuitable for the wet runway condition and without sufficient distance available to stop. Further, the pilots exhibited poor crew resource management by not using the appropriate chart for the contaminated runway, not recognizing the runway was too short based on the conditions, failing to reset their airspeed bugs before the approach, and not recognizing and addressing the excess approach speed.
HISTORY OF FLIGHT On September 18, 2012, about 1003 eastern daylight time (EDT), a Beech 400, N428JD, was substantially damaged when it overran runway 28 during landing at Macon Downtown Airport (MAC), Macon, Georgia. The airplane departed from Charleston Air Force Base/International Airport (CHS), Charleston, South Carolina, about 0930. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. Both Airline Transport Pilots (ATP) and one passenger sustained minor injuries. The airplane was owned by Dewberry, LLC and operated by The Aviation Department. The corporate flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. According to an interview with the pilots, they arrived at DeKalb-Peachtree Airport (PDK), Atlanta, Georgia, which was their home base airport, about 0400, and then drove about 4 1/2 hours to CHS for the 0930 flight. The flight departed on time, the airspeed index bug was set on the co-pilot's airspeed for a decision takeoff speed (V1) of about 102 knots and a single-engine climb speed (V2) on the pilot's side of 115 knots. The flight climbed to 16,000 feet prior to beginning the descent into MAC. When the flight was about 11 miles from the airport the flight crew visually acquired the airport and cancelled their IFR clearance with the Macon Radar Approach controller and proceeded to the airport visually. The second-in-command activated the runway lights utilizing the common traffic advisory frequency for the airport. Both crewmembers reported that about 3 seconds following activation of the lights and the precision approach path indicator (PAPI) lights, the PAPI lights turned off and would not reactivate. During the approach, the calculated reference speed (Vref) was 108 knots and was set on both pilots' airspeed indicator utilizing the index bug that moved around the outside face of the airspeed instrument. The landing was within the first 1,000 feet of the runway and during the landing rollout the airplane began to "hydroplane" since there was visible standing water on the runway and the water was "funneling into the middle." Maximum reverse thrust, braking, and ground spoilers were deployed; however, both pilots reported a "pulsation" in the brake system. The airplane departed the end of the runway into the grass, went down an embankment, across a road, and into trees. They further added that the airplane "hit hard" at the bottom of the embankment. They also reported that there were no mechanical malfunctions with the airplane prior to the landing. According to an eyewitness statement, a few minutes prior to the airplane landing, the airport experienced a rain shower with a "heavy downpour." The witness reported observing the airplane on approach, heard the engine thrust reverse, and then observed the airplane "engulfed in a large ball of water vapor." However, he did not observe the airplane as it departed the end of the runway. Another witness was located in a hangar on the west side of the airport and heard the airplane, looked outside and then saw the airplane with the reverse thrusters deployed. He watched it depart the end of the runway and travel into the nearby woods. PERSONNEL INFORMATION Pilot According to Federal Aviation Administration (FAA) records and the operator, the pilot, age 43, held an ATP certificate with a rating for multiengine land airplane, a commercial pilot certificate with a rating for airplane single-engine land, and held a type rating in the make and model of the accident airplane. He held a first class medical certificate, which was issued on August 21, 2012, that contained no waivers and no limitations. The pilot's most recent training in the accident make and model airplane was completed on December 7, 2012. The pilot reported that he had 7,350 total flight hours, of which 6,700 were as pilot in command. He reported having 4,600 total flight hours in the accident aircraft make and model, of which the entire amount was as pilot in command. He accrued 80 hours in the last 90 days of which 76 of those hours were in the accident airplane make and model, and 25 hours in the preceding 30 days. The pilot reported during a postaccident interview that he was notified of the trip the day prior and that the flight was scheduled to depart CHS at 0930. The evening before he completed some preliminary work by obtaining weather information, notices to airman (NOTAMS) for both airports, and filed a flight plan for the flight. On the morning of the flight he woke up about 0330 and he and the copilot met each other at PDK at 0400 and drove to CHS. The pilot drove approximately 2 hours at which point they stopped, got some coffee, and then switched drivers. After arriving at the airplane, they performed their preflight inspections and about 0905 they received a text message from the passenger that he was about 5 minutes away. After loading up the passenger, his dog, and some golf clubs he had notified the passenger there was some weather in the Macon area over the airport; however, at the time of arrival, the "weather should be good." He was seated in the left front seat for the flight, which departed at 0930. Co-Pilot According to FAA records, the co-pilot held an ATP certificate with ratings for airplane single-engine land, multiengine land, and also held a type rating in the make and model of the accident airplane. He held a first class medical certificate, which was issued on November 2, 2011, and it contained no waivers and no limitations. He reported 2,536 total flight hours, of which 1,485 of those hours were as pilot in command. He reported having 425 total flight hours in the accident aircraft make and model and none as pilot in command. He accrued 31 hours in the preceding 90 days, 8 hours in the last 30 days, of which 6 were in the accident airplane make and model, and 1 hour in the preceding 24 hours. AIRCRAFT INFORMATION The airplane, a Beech BE-400 model, serial number RJ-13, was a low-wing, twin-engine, tail-mounted jet aircraft certificated in the transport category. According to FAA records, the airplane was issued an airworthiness certificate on June 24, 1986, and was registered to the corporation on April 26, 2004, as N3113B and was changed to N428JD on November 23, 2004. It was equipped with two Pratt and Whitney JT15D-5 engines. According to maintenance records, both main tires were replaced on June 5, 2012 with a recorded Hobbs reading of 2155.7 hours and total cycles of 5747. Both left and right brake assemblies was overhauled and reinstalled on August 11, 2012, with a recorded time of 5387.6 total airframe hours and a Hobbs recording of 2177.6 hours, and at that time the airplane had 5771 total cycles. On June 15, 2011, a recorded "A" airframe inspection was accomplished with a reported total time of 5187 flight hours. The airplane was equipped with electrically controlled hydraulically actuated fowler flaps that ran approximately the full span of each wing, and had 3 positions; 0, 10, and 30 degrees. Flap position transmitters located on the flap operating system sent a signal to the alternating current (AC) powered flap position indicator, and also to a flap asymmetry detector to stop flap operation if a 5 to 7 degree discrepancy occurred between the left and right flaps. The flap on each wing consisted of a main and aft flap, which were hydraulically actuated with one actuator per side. The main flap drove the aft flap; the left and right side of the flaps were interconnected by a cable system to ensure symmetric flap extension. The airplane was equipped with hydraulically actuated retractable tricycle landing gear; each main landing wheel was equipped with full powered multiple segmented brakes operated by toe action of the pilot or co-pilot's rudder pedals. Application of the brake pedals at either seat position delivered pressure to the directly connected master cylinder, which transferred it to a power brake valve through mixing valves. The power brake amplified the master cylinder pressure thereby increasing the pressure to the respective main landing gear brake. An electrically controlled anti-skid system was also incorporated in the power brake system. A stationary wheel speed transducer was mounted inside each main gear axle, and it electrically sensed any change in wheel rotation speed. By design, with the system on, as a skid is detected by the stationary wheel speed transducer, an electrical signal was supplied to the system which releases brake pressure. The system continued to operate as long as the brake pressure was sufficient to result in the skidding condition, but not below approximately 10 knots. A ground safety system was also installed, which allowed for safe operation of several systems either in flight or on ground, including thrust reverser application for ground use only. Control was accomplished by the left and right squat switches that connected or removed an electrical ground from the coils of ground safety relays, which in turn enabled or disabled their respective systems according to the position of the safety switches. METEOROLOGICAL INFORMATION The 0953 recorded weather observation at Middle Georgia Regional Airport (MCN), located approximately 9 miles to the south southwest of the accident location, included wind from 180 degrees at 6 knots, visibility 7 miles due to light rain, broken clouds at 11,000 feet above ground level (agl), temperature 22 degrees C, dew point 21 degrees C and barometric altimeter 29.97 inches of mercury. AIRPORT INFORMATION The airport was a publically owned airport and at the time of the accident and it did not have an operating control tower. The airport was equipped with two runways designated as runway 10/28 and 15/33. Runway10/28 was reported as "in good condition" and runway 15/33 was reported as "in fair condition." Runway 10/28 was a 4,694-foot-long by 150-foot-wide non-grooved runway and runway 15/33 was a 2,614-foot-long by 75-foot-wide runway. The airport elevation was 437 feet above mean sea level. The airport was not equipped with an instrument landing system (ILS) approach but was serviced with 5 non-precision approaches. In 2008, Runway 10/28 was resurfaced; the runway edge markings were painted at 50 feet from the centerline, which allowed an actual runway width of 100 feet with 25 feet on each side paved but not available for use during takeoff or landing. On June 10, 2011, the Georgia Department of Transportation conducted an airport inspection. During the inspection, Runway 28 was noted as meeting the minimum state licensing requirement but failed to meet federal requirements of a 34:1 obstruction-free non-precision approach surface. The obstructions were noted as trees 510 feet from the threshold and 200 feet to the left of the extended runway centerline. There were also trees and brush located about 250 feet from the centerline near the approach and along the bank. Runway 28 was equipped with a 4-light PAPI located on the left side of the runway. The PAPI system consisted of four identical light units, installed in a single row. Each unit produced a beam of light split horizontally, with aviation white light in the top sector of the beam and aviation red light in the bottom sector. The PAPI provided the pilot with glidepath information that could be used for day or night approaches. Maintaining the proper glidepath provides the pilot with adequate obstacle clearance and allowed the airplane to touchdown within a specified portion of the runway. At the time of the accident, the pilots reported to the NTSB Investigator in Charge that shortly after activation of the runway lights, the PAPI lights ceased operation. At the request of the NTSB, the Airport Authority investigated the PAPI lights and issued a notice to airman that the PAPI lights were not operational. Subsequent investigation of the lights revealed a blown circuit breaker. Four days following the accident the circuit breaker was repaired and the lights were considered operational. Home Base Airport According to the flight crew, they departed and landed regularly at PDK. At the time of the accident PDK had 4 runways, one of the runways was designated 3R/21L and according to the pilot this was the primary runway they utilized. The runway was 6,001 feet-long and 100 feet-wide, was concrete, grooved, and considered in good conditions. The landing distance available (LDA) on runway 21L was 4,801 feet and the LDA on runway 3R was 5,411. According to a postaccident interview with the pilots, the normal stopping distance at PDK when the runways were wet was between 3,000 and 4,000 feet. FLIGHT RECORDERS The cockpit voice recorder (CVR) was forwarded to the NTSB Vehicle Recorders Laboratory in Washington, DC for readout. The CVR was a Fairchild GA-100, serial number 01572. The thirty-minute recording consisted of four channels of audio information. Good quality audio information was recorded from both pilots mircrophones. The unit was undamaged and audio content was extracted without difficulty. A CVR group was not convened. The entire recording was not transcribed and in agreement with the investigator-in-charge, a summary of key events recorded on the CVR was transcribed. The transcription began at 09:37:37 (hh:mm:ss) and the recording contained events from cruise, descent, landing, and the accident sequence. At 09:39:30, the pilot monitoring (PM) stated that he ran the approach/descent checklist down to engine syncs item. About three minutes later, air traffic control (ATC) cleared the flight to descend to 11,000 feet followed five minutes later with a clearance to descend to 8,000 feet. At 09:48:44, ATC informed the crew that rain was over the field and cleared the flight to descend to 4000 feet. During the next, approximately 8 minutes, the flight was cleared to descend to 3,000 feet and then 2,200 feet. At 09:59:52, the crew reported the airport in sight and was cleared for the visual approach. At 10:00:10, an increase in background noise similar to the landing gear being extended was noted. At 10:00:14, the crew canceled their IFR flight plan. At 10:00:27, the pilot flying (PF) called for flaps 20. At 10:00:37, the PM called three green, no red. At 10:01:11, the PF called for flaps 30 At 10:01:38, the PM reported that winds at "other airport" were "220 at 4 knots." From 10:01:50 to 10:02:20, there were three distinct recordings of several microphone "clicks." At 10:02:41, a 500 foot automated call out was recorded. At 10:03:11, the PM called "ref and 10." At 10:03:19, a sound similar to touchdown on the runway was recorded. At 10:03:20, the PF called for speedbrakes and the PM confirmed. At 10:03:23, the PM called "hydroplaning." At 10:03:26, a sound of increasing engine thrust similar to thrust reverser operation was recorded. At 10:03:42, a sound similar to the airplane exiting the runway was recorded. At 10:03:57, a power interruption was recorded. One second after the power was restored the aircraft movement stopped and 14 seconds after the power restoration the sounds similar to an engine being shutdown was recorded. The CVR stopped recording about 4:47 minutes after the power restoration. For additional information on the CVR and its audio recording, refer to the "Cockpit Voice Recorder Specialist's Summary Report," located in the public docket for this accident investigation. An examination of the Garmin GPS 500 reported that the battery was too depleted to record and save data. The pilot had a Garmin 496 GPS, which was downloaded at the NTSB Vehicle Recorder Laboratory. The unit included a built-in Jeppesen database and was capable of receiving XM Satellite radio information. The unit was examined, power was applied, and the recorded point, route and tracklog data was successfully downloaded. The last recorded data point was about 5 minutes prior to the accident; at that point, the airplane was at a recorded altitude of 2,946 feet and approximately 16 nautical miles to the east of MAC. The XM radio subscription was current when the unit was tested and downloaded; however, no historical information was recorded. WRECKAGE AND
The pilot’s failure to maintain proper airspeed, which resulted in the airplane touching down too fast on the wet runway with inadequate runway remaining to stop and a subsequent runway overrun. Contributing to the landing overrun were the flight crewmembers’ failure to correctly use the appropriate performance chart to calculate the runway required to stop on a contaminated runway and their general lack of proper crew resource management.
Source: NTSB Aviation Accident Database
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