Accident Details
Probable Cause and Findings
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.
Aircraft Information
Registered Owner (Historical)
Analysis
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 airpl...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA12IA060