Crash of a Cessna 550 Citation II in Manteo

Date & Time: Oct 1, 2010 at 0830 LT
Type of aircraft:
Operator:
Registration:
N262Y
Survivors:
Yes
Schedule:
Tampa - Manteo
MSN:
550-0291
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9527
Captain / Total hours on type:
2025.00
Copilot / Total flying hours:
3193
Copilot / Total hours on type:
150
Aircraft flight hours:
9643
Circumstances:
According to postaccident written statements from both pilots, the pilot-in-command (PIC) was the pilot flying and the copilot was the pilot monitoring. As the airplane approached Dare County Regional Airport (MQI), Manteo, North Carolina, the copilot obtained the current weather information. The automated weather system reported wind as 350 degrees at 4 knots, visibility at 1.5 miles in heavy rain, and a broken ceiling at 400 feet. The copilot stated that the weather had deteriorated from the previous reports at MQI. The PIC stated that they would fly one approach to take a look and that, if the airport conditions did not look good, they would divert to another airport. Both pilots indicated in phone interviews that, although they asked the Washington air route traffic control center controller for the global positioning system (GPS) runway 5 approach, they did not expect it due to airspace restrictions. They expected and received a GPS approach to runway 23 to circle-to-land on runway 5. According to the pilots' statements, the airplane was initially fast on approach to runway 23. As a result, the copilot could not deploy approach flaps when the PIC requested because the airspeed was above the flap operating range. The PIC subsequently slowed the airplane, and the copilot extended flaps to the approach setting. The PIC also overshot an intersection but quickly corrected and was on course about 1 mile prior to the initial approach fix. The airplane crossed the final approach fix on speed (Vref was 104) at the appropriate altitude, with the flaps and landing gear extended. The copilot completed the approach and landing checklist items but did not call out items because the PIC preferred that copilots complete checklists quietly. The PIC then stated that they would not circle-to-land due to the low ceiling. He added that a landing on runway 23 would be suitable because the wind was at a 90-degree angle to the runway, and there was no tailwind factor. Based on the reported weather, a tailwind component of approximately 2 knots existed at the time of the accident, and, in a subsequent statement to the Federal Aviation Administration, the pilot acknowledged there was a tailwind about 20 degrees behind the right wing. The copilot had the runway in sight about 200 feet above the minimum descent altitude, which was 440 feet above the runway. The copilot reported that he mentally prepared for a go around when the PIC stated that the airplane was high about 300 feet above the runway, but neither pilot called for one. The flight crew stated that the airplane touched down at 100 knots between the 1,000-foot marker and the runway intersection-about 1,200 feet beyond the approach end of the 4,305-foot-long runway. The speed brakes, thrust reversers, and brakes were applied immediately after the nose gear touched down and worked properly, but the airplane departed the end of the runway at about 40 knots. According to data extracted from the enhanced ground proximity warning system, the airplane touched down about 1,205 feet beyond the approach end of the 4,305-foot-long wet runway, at a ground speed of 127 knots. Data from the airplane manufacturer indicated that, for the estimated landing weight, the airplane required a landing distance of approximately 2,290 feet on a dry runway, 3,550 feet on a wet runway, or 5,625 feet for a runway with 0.125 inch of standing water. The chart also contained a note that the published limiting maximum tailwind component for the airplane is 10 knots but that landings on precipitation-covered runways with any tailwind component are not recommended. The note also indicates that if a tailwind landing cannot be avoided, the above landing distance data should be multiplied by a factor that increases the wet runway landing distance to 3,798 feet, and the landing distance for .125 inch of standing water to 6,356 feet. All distances in the performance chart are based on flying a normal approach at Vref, assume a touchdown point 840 feet from the runway threshold in no wind conditions, and include distance from the threshold to touchdown. The PIC's statement about the airplane being high at 300 feet above the runway reportedly prompted the copilot to mentally prepare for a go around, but neither pilot called for one. However, the PIC asked the copilot what he thought, and his reply was " it's up to you." The pilots touched down at an excessive airspeed (23 knots above Vref), more than 1,200 feet down a wet 4,305-foot-long runway, leaving about 3,100 feet for the airplane to stop. According to manufacturer calculations, about 2,710 feet of ground roll would be required after the airplane touched down, assuming a touchdown speed at Vref; a longer ground roll would be required at higher touchdown speeds. Although a 2 knot crosswind component existed at the time of the accident, the airplane's excessive airspeed at touchdown (23 knots above Vref) had a much larger effect on the outcome of the landing.
Probable cause:
The pilot-in-command's failure to maintain proper airspeed and his failure to initiate a go-around, which resulted in the airplane touching down too fast on a short, wet runway and a subsequent runway overrun. Contributing to the accident was the copilot's failure to adequately monitor the approach and call for a go around and the flight crew's lack of proper crew resource management.
Final Report:

Crash of a Cessna 550 Citation II in Bwagaoia: 4 killed

Date & Time: Aug 31, 2010 at 1615 LT
Type of aircraft:
Registration:
P2-TAA
Survivors:
Yes
Schedule:
Port Moresby – Bwagaoia
MSN:
550-0145
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
14591
Copilot / Total flying hours:
872
Aircraft flight hours:
14268
Circumstances:
The aircraft was conducting a charter flight from Jackson’s International Airport, Port Moresby, National Capital District, Papua New Guinea (PNG), to Bwagaoia Aerodrome, Misima Island, Milne Bay Province, PNG (Misima). There were two pilots and three passengers on board for the flight. The approach and landing was undertaken during a heavy rain storm over Bwagaoia Aerodrome at the time, which resulted in standing water on the runway. This water, combined with the aircraft’s speed caused the aircraft to aquaplane. There was also a tailwind, which contributed the aircraft to landing further along the runway than normal. The pilot in command (PIC) initiated a baulked landing procedure. The aircraft was not able to gain flying speed by the end of the runway and did not climb. The aircraft descended into terrain 100 m beyond the end of the runway. The aircraft impacted terrain at the end of runway 26 at 1615:30 PNG local time and the aircraft was destroyed by a post-impact, fuel-fed fire. The copilot was the only survivor. Other persons who came to assist were unable to rescue the remaining occupants because of fire and explosions in the aircraft. The on-site evidence and reports from the surviving copilot indicated that the aircraft was serviceable and producing significant power at the time of impact. Further investigation found that the same aircraft and PIC were involved in a previous landing overrun at Misima Island in February 2009.
Probable cause:
Contributing safety factors:
• The operator’s processes for determining the aircraft’s required landing distance did not appropriately consider all of the relevant performance factors.
• The operator’s processes for learning and implementing change from the previous runway overrun incident were ineffective.
• The flight crew did not use effective crew resource management techniques to manage the approach and landing.
• The crew landed long on a runway that was too short, affected by a tailwind, had a degraded surface and was water contaminated.
• The crew did not carry out a go-around during the approach when the visibility was less than the minimum requirements for a visual approach.
• The baulked landing that was initiated too late to assure a safe takeoff.
Other safety factors:
• The aircraft aquaplaned during the landing roll, limiting its deceleration.
• The runway surface was described as gravel, but had degraded over time.
• The weather station anemometer was giving an incorrect wind indication.
Final Report:

Crash of a Cessna 550 in Wilmington

Date & Time: Jan 4, 2009 at 0209 LT
Type of aircraft:
Operator:
Registration:
N815MA
Survivors:
Yes
Schedule:
La Isabela - Wilmington
MSN:
550-0406
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6914
Captain / Total hours on type:
1400.00
Copilot / Total flying hours:
1717
Aircraft flight hours:
11123
Circumstances:
During a night, northbound, international over water flight that paralleled the east coast of the southeast United States, the airplane encountered headwinds. Upon arrival at the intended destination, the weather was below forecasted conditions, resulting in multiple instrument approach attempts. After the first missed approach, the controller advised the crew that there was an airport 36 miles to the north with "much better" weather, but the crew declined, citing a need to clear customs. During the third missed approach, the left engine lost power, and while the airplane was being vectored for a fourth approach, the right engine lost power. Utilizing the global positioning system, the captain pointed the airplane toward the intersection of the airport's two runways. Approximately 50 feet above the ground, he saw runway lights, and landed. The captain attempted to lower the landing gear prior to the landing, but it would not extend due to a lack of hydraulic pressure from the loss of engine power, and the alternate gear extension would not have been completed in time. The gear up landing resulted in damage to the underside of the fuselage and punctures of the pressure vessel. The captain stated that the airplane arrived in the vicinity of the destination with about 1,000 pounds of fuel on board or 55 minutes of fuel remaining. However, air traffic and cockpit voice recordings revealed that the right engine lost power about 14 minutes after arrival, and the left engine, about 20 minutes after arrival. Federal air regulations require, for an instrument flight rules flight plan, that an airplane carry enough fuel to complete the flight to the first airport of landing, fly from that airport to an alternate, and fly after that for 45 minutes at normal cruising speed. The loss of engine power was due to fuel exhaustion, with no preaccident mechanical anomalies noted to the airplane.
Probable cause:
A loss of engine power due to the crew's inadequate in-flight fuel monitoring.
Final Report:

Crash of a Cessna 550 Citation II in Reading

Date & Time: Aug 3, 2008 at 1519 LT
Type of aircraft:
Operator:
Registration:
N827DP
Flight Type:
Survivors:
Yes
Schedule:
Pottstown - Reading
MSN:
550-0660
YOM:
1990
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12100
Captain / Total hours on type:
2690.00
Copilot / Total flying hours:
1779
Copilot / Total hours on type:
65
Aircraft flight hours:
5008
Circumstances:
The air traffic controller, with both ground and local (tower) responsibilities, cleared the accident airplane to land when it was about 8 miles from the runway. Another airplane landed in front of the accident flight, and the controller cleared that pilot to taxi to the hangar. The controller subsequently cleared a tractor with retractable (bat wing) mowers, one on each side, and both in the “up” position, to proceed from the terminal ramp and across the 6,350-foot active runway at an intersection about 2,600 feet from the threshold. The controller then shifted his attention back to the airplane taxiing to its hangar, and did not see the accident airplane land. During the landing rollout, the airplane’s left wing collided with the right side of the tractor when the tractor was “slightly” left of runway centerline. Calculations estimated that the airplane was about 1,000 feet from the collision point when the tractor emerged from the taxiway, and skid marks confirmed that the airplane had been steered to the right to avoid impact. Prior to the crossing attempt, the tractor operator did not scan the runway, and was concentrating on the left side bat wing. Federal Aviation Administration publications do not adequately address the need for ground vehicle operators to visually confirm that active runways/approaches are clear, prior to crossing with air traffic control authorization, thus overlooking an additional means to avoid a collision.
Probable cause:
The air traffic controller’s failure to properly monitor the runway environment. Contributing to the accident was the tractor operator’s failure to scan the active runway prior to crossing, and the Federal Aviation Administration’s inadequate emphasis on vehicle operator visual vigilance when crossing active runways with air traffic control clearance.
Final Report: