Crash of a Cessna 550 Citation II in Southampton

Date & Time: May 26, 1993 at 0634 LT
Type of aircraft:
Registration:
G-JETB
Flight Type:
Survivors:
Yes
Schedule:
Oxford - Southampton - Eindhoven
MSN:
550-0288
YOM:
1981
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16700
Captain / Total hours on type:
850.00
Copilot / Total flying hours:
1322
Copilot / Total hours on type:
109
Aircraft flight hours:
4315
Aircraft flight cycles:
3306
Circumstances:
Cessna Citation G-JETB was to fly eight passengers from Southampton (SOU) to Eindhoven (EIN). Because G-JETB had arrived at Oxford (OXF) the previous evening, the airplane had to be ferried to Southampton early in the morning. This as a regular occurrence. The co-pilot had agreed with the airport authorities at both Oxford and Southampton that the aircraft would operate outside normal hours on the understanding that no fire cover would be provided. Following the takeoff from Oxford at 05:19 the crew contacted Brize Norton ATC and agreed a Flight Information Service. They maintained VMC for the transit at 2,400 feet QNH and called Southampton ATC on their alternate radio at 05:25 when they were approximately 30 nm from Southampton. The Southampton controller was surprised at their initial call and advised them that the airport did not open until 06:00. The crew informed him that arrangements had been made for an early arrival and the controller asked them to standby while he checked this agreement. At 05:27 he called G-JETB, informed the crew that they could land before the normal opening hours and asked them to confirm that no fire cover was required. The crew confirmed this and were then told that runway 02 was in use with a wind of 020 deg./14 kt and that there was a thunderstorm right over the airport. The crew then advised Brize Norton radar that they were going to Southampton ATC and left the Brize Norton frequency. Following a further check with Southampton they were given the 0520 weather observation: "Surface wind 040 deg/12 kt, thunderstorms, 2 oktas of stratus at 800 feet, 3 oktas of cumulonimbus at 1,800 feet, temperature 12 C, qnh 1007 mb, qfe 1006 mb, the runway is very wet." At 05:30 the controller asked the crew for the aircraft type and, after being told that it was a Citation II, told the crew that the visibility was deteriorating ("Now 2,000 metres in heavy thunderstorms" ) and cleared them to the Southampton VOR at 3,000 feet QNH. After checking that they were now IFR the controller confirmed the clearance, and the QNH of 1007 mb, and informed the crew that there was no controlled airspace and that he had no radar available to assist them. Shortly afterwards the controller advised the crew that: "Entirely at your discretion you may establish on the ILS localiser for runway 20 for visual break-off to land on runway 02." The commander accepted this offer and, within the cockpit, asked the co-pilot for the surface wind. He was informed that it was 040 degrees but that earlier they had been given 020 deg/14 kt. At 05:32 the commander had positioned on the ILS for runway 20 and began his descent; the co-pilot advised Southampton that they were established. The controller acknowledged this and again passed the QNH. Shortly afterwards he asked the crew to report at the outer marker and this message was acknowledged. At 05:33 the crew called that they were visual with the runway and the controller cleared them for a visual approach, left or right at their convenience, for runway 02. As this transmission was taking place, the commander informed his co-pilot that they would land on runway 20. The commander decided this because he could see that the weather at the other end of the runway appeared very black and he had mentally computed the tailwind component to be about 10 kt. After a confirmation request from the co-pilot to the commander, the co-pilot informed the Southampton controller that they would land on runway 20. The controller then advised them that: "You'll be landing with a fifteen knot, one five knot, tailwind component on a very wet runway" ; this was immediately acknowledged by the co-pilot with: "roger, copied thank you". The crew continued with their approach, initially at 15 kt above their computed threshold speed (VREF) of 110 kt and then at a constant VREF+10 kt. Within the cockpit the commander briefed the co-pilot that if they were too fast the co-pilot was to select flap to the takeoff position and they would go-around; they also discussed the use of the speedbrake and the commander stated that he would call for it when he wanted it. The speed at touchdown was within 5 kt of the target threshold speed and touchdown was in the vicinity of the Precision Approach Path Indicators (PAPIs), according to witnesses in the Control Tower and on the airport; the commander was certain that he had made a touchdown within the first 300 feet of the runway. The PAPIs are located 267 metres along the runway. Speedbrake was selected as the aircraft touched down and, although the commander applied and maintained heavy foot pressure on the brakes, no retardation was apparent; external observers reported heavy spray from around the aircraft. At some stage down the runway the commander stated that the brakes were not stopping them and the co-pilot called for a go-around ; the commander replied : "No we can't" as he considered that a go-around at that stage would be more dangerous. He maintained brake pressure and, in an attempt to increase distance, steered the aircraft to the right edge of the runway before trying to steer back left. Initially the aircraft nose turned to the left and the aircraft slid diagonally off the right side of the runway on to the grass. It continued across the grass for a distance of approximately 233 metres while at the same time yawing to the left. However, 90 metres beyond the end of the runway there is an embankment which forms the side of the M27 motorway and G-JETB slid down this embankment on to the motorway. The aircraft continued to rotate as it descended and came to rest, having turned through approximately 150 degrees, with its tail on the central barrier. During these final manoeuvres the aircraft collided with two cars travelling on the eastbound carriageway; the aircraft and one of the cars caught fire. During the approach of the aircraft, the airport Rescue and Fire Fighting Service (RFFS) duty officer had discussed with the duty ATC controller the imminent arrival of G-JETB. Although not all checks had been complete, the fire officer offered his two fire vehicles as a weather standby ; he did not declare his section operational but agreed with ATC that they would position themselves to the west of the runway. When the aircraft was 1/2 to 2/3 down the runway, the ATC controller considered that the aircraft would not stop in the runway available and activated the crash alarm. The fire section obtained clearance to enter the runway after G-JETB had passed their position and followed the aircraft. Assessing the situation on the move, the fire officer ordered the FIRE 2 vehicle to disperse through the crash gate to the motorway, and took his own vehicle (FIRE 1) to the edge of the embankment. On arrival, the fire section contained the fires. The occupants of the aircraft and cars escaped with minor injuries.
Probable cause:
The investigation identified the following causal factors:
- The commander landed with a reported tailwind of 15 knots which was outside the aircraft maximum tailwind limit of 10 knots specified in the Cessna 550 Flight Manual.
- The copilot did not warn the commander that he was landing with a reported tailwind component which was outside the aircraft limit.
- With a tailwind component of 10 knots, the landing distance available was less than the landing distance required.
Final Report:

Crash of a Cessna 550 Citation II in Billings: 8 killed

Date & Time: Dec 18, 1992 at 1645 LT
Type of aircraft:
Operator:
Registration:
N6887Y
Flight Type:
Survivors:
No
Schedule:
Watertown - Billings
MSN:
550-0293
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
6200
Captain / Total hours on type:
4415.00
Aircraft flight hours:
5275
Circumstances:
During descent into Billings, the Citation was sequenced behind a Boeing 757, and both airplanes were eventually cleared for visual approaches. About 1-1/2 mile from the runway the Citation was observed to roll rapidly to the inverted position and descended almost vertically into the ground. According to ATC transcripts and the airplane's cockpit voice recorder, the crew of the Citation had maintained visual awareness of the position of the B757 throughout the approach. At the time of the upset, the vertical separation between airplanes was 600 - 1,000 feet, and the horizontal separation was decreasing below 2.6 miles. One of the Citation captain's last comments was 'almost ran over a seven fifty seven.' Winds were 5 knots. All eight occupants were killed.
Probable cause:
The pilot-in-command's failure to follow established vortex avoidance procedures, as published in the airman's information manual, to provide his own wake turbulence separation.
Final Report:

Crash of a Cessna 550 Citation S/II in São Paulo

Date & Time: Dec 1, 1992 at 1205 LT
Type of aircraft:
Operator:
Registration:
PT-LKT
Flight Type:
Survivors:
Yes
Schedule:
São Paulo - São Paulo
MSN:
550-0117
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed São Paulo-Congonhas Airport for a local training flight, carrying two pilots under supervision and two instructors. Weather conditions were marginal with ceiling down to 300 metres, horizontal visibility 3 km with rain. After touchdown on wet runway 17R, the aircraft was unable to stop within the remaining distance. It overran, went down an embankment and came to rest. All four occupants escaped uninjured while the aircraft was destroyed.

Crash of a Cessna 550 Citation II in Ashaka: 3 killed

Date & Time: May 21, 1991
Type of aircraft:
Operator:
Registration:
5N-AMR
Survivors:
No
Schedule:
Bauchi - Ashaka
MSN:
550-0045
YOM:
1978
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On final approach to Ashaka Airport in poor weather conditions, the crew apparently initiated a go-around procedure when the aircraft crashed short of runway threshold. All three occupants were killed.

Crash of a Cessna 550 Citation II in Roxboro: 2 killed

Date & Time: Oct 1, 1989 at 2207 LT
Type of aircraft:
Operator:
Registration:
N53CC
Survivors:
No
Schedule:
Tampa - Roxboro
MSN:
550-0400
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7986
Captain / Total hours on type:
2643.00
Aircraft flight hours:
5111
Circumstances:
During arrival, flight was vectored for NDB runway 06 approach, and advised Raleigh-Durham weather was 500 feet overcast, visibility 3 miles with fog, wind from 140° at 12 knots, altimeter 30.01. After clearance for approach, aircraft crossed final approach fix (faf) at 2,100 feet msl. Radar service was terminated and frequency change was approved. When aircraft did not arrive, search was initiated. The wreckage was found about 2.5 miles southwest of runway 06, where aircraft hit trees and crashed. Elevation of crash site was about 600 feet msl. MDA for approach was 1,160 feet msl (with local altimeter setting; 1,260 feet with Raleigh-Durham setting). Exam revealed aircraft hit trees, while on runway heading in wings level attitude; configured for landing. No preimpact part failure/malfunction was found. Toxicological check of pic's blood showed 0.10 mg/l of diazepam and 0.09 mg/l of nordiazepam. Check of his urine showed metabolite of marijuana (11- nor-delta-9-tetrahydrocannabinol-9-carboxylic acid) at level of 0.117 mg/l. After surgery for malignant lymphoma (feb 89), pic was restored to flight status on 8/9/89 and cleared for pic duty one week later. He continued flying tho he received maintenance chemotherapy and associates noted that he tired easily. Both occupants were killed.
Probable cause:
Impairment of the pilot-in-command (pic) due to drugs/medication, chemotherapy and fatigue; failure of the pic to assure that the IFR (instrument) approach procedure was followed; and his failure to maintain the minimum descent altitude (MDA). Inadequate surveillance of the operation by company/operator/management personnel was a related factor.
Final Report:

Crash of a Cessna S550 Citation II in Poughkeepsie

Date & Time: Feb 27, 1989 at 0808 LT
Type of aircraft:
Operator:
Registration:
N29X
Flight Type:
Survivors:
Yes
Schedule:
White Plains - Poughkeepsie
MSN:
550-0096
YOM:
1986
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6135
Captain / Total hours on type:
635.00
Aircraft flight hours:
703
Circumstances:
Witnesses reported aircraft was high during approach and landed nosewheel 1st about 1,600 feet beyond threshold, then became airborne and bounced 2 times. Pilot stated that before touchdown, he started to 'spool up' engines, but noted lack of response, then retarded throttles and landed. He said he applied brakes and selected 'full reverse' and noted no response. Reportedly, nosewheel 'skipped into air' while aircraft still had flying speed. With insufficient runway remaining to stop, he elected to stow reversers and began go-around. He noted no response from engines, tho aircraft had became airborne. Aircraft then settled beyond departure end of runway and crashed on rough terrain. Examination revealed engines had ingested twigs, grass and dirt. Reverse load limiters (l/l) on both engines were found in tripped position. Flight man stated that to avoid actuation of l/l, do not advance primary throttle after returning reverse thrust lever to stow until unlock light is out; maint required to reset actuated l/l. L/l was incorporated on thrust reverser to reduce engine power to idle, if inadvertently deployed in flight. During post-accident check, both engines were operated to 85% after l/l reset.
Probable cause:
The pilot's improper use of the powerplant controls, which resulted in actuation (tripping) of the reverse load limiters on the thrust reversers and subsequent reduction of available power in both engines. Factors related to the accident were: the pilot's misjudgement of distance, excessive airspeed, and improper flare during the landing.
Final Report:

Crash of a Cessna S550 Citation S/II in Rio de Janeiro

Date & Time: Sep 6, 1988
Type of aircraft:
Operator:
Registration:
PT-LGJ
Survivors:
Yes
MSN:
550-0025
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a wrong approach configuration, the aircraft descended too high on the glide and landed too far down a wet runway. After touchdown, unable to stop within the remaining distance (insufficient distance available and poor braking action due to a wet runway surface), the aircraft overran and collided with a dyke. All seven occupants were rescued while the aircraft was damaged beyond repair.

Crash of a Cessna 550 Citation II in Houston

Date & Time: Feb 6, 1983 at 1817 LT
Type of aircraft:
Operator:
Registration:
N222WL
Flight Phase:
Survivors:
Yes
Schedule:
Houston - Lafayette
MSN:
550-0208
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4393
Captain / Total hours on type:
132.00
Aircraft flight hours:
547
Circumstances:
After landing on runway 31L, the aircrew of N100VV requested clearance to turn off to the right at midfield onto runway 22. The request was approved and the aircrew was instructed to use caution for a Cherokee proceeding from the opposite direction. The pilot of N100VV stated that after he turned right onto runway 04/22 and was clear of the Cherokee, he attempted to contact the tower to advise of his intentions. However, the frequency was too busy, so he switched to the ground frequency and transmitted that he was 'off 31L, going to Atlantic.' This transmission ended just as N100VV was entering the intersection of runway 22 and 31R. Just prior to that, N222WL had been cleared for takeoff on runway 31R and had begun its takeoff roll. N222WL was at approximately 70 knots when its aircrew saw N100VV starting to cross the active runway. The pilot of N222WL attempted to takeoff and avoid a collision, but was unable to clear N100VV. N222WL crashed and slid to a stop approximately 400 feet beyond the impact point with N100VV, then burned. All three occupants escaped uninjured.
Probable cause:
Occurrence #1: in flight collision with object
Phase of operation: takeoff - initial climb
Findings
1. (f) light condition - dusk
2. (c) visual lookout - inadequate - pilot of other aircraft
3. (f) diverted attention - pilot of other aircraft
4. (c) procedures/directives - not followed - pilot of other aircraft
5. (f) object - aircraft moving on ground
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: