Crash of a Cessna 550 Citation II in Butler

Date & Time: Jan 24, 2007 at 0905 LT
Type of aircraft:
Operator:
Registration:
N492AT
Flight Type:
Survivors:
Yes
Schedule:
Winchester - Butler
MSN:
550-0472
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22700
Captain / Total hours on type:
1200.00
Copilot / Total flying hours:
1758
Copilot / Total hours on type:
85
Aircraft flight hours:
10735
Circumstances:
The Citation 550 was being repositioned for an air ambulance transportation flight, and was on approach to land on a 4,801-foot-long, grooved, asphalt runway. The airplane was being flown manually by the copilot, who reported that the landing approach speed (Vref) was 106 knots. The pilot-in-command (PIC) estimated that the airplane "broke out" of the clouds about two miles from the runway. Both pilots stated that the airplane continued to descend toward the runway, while on the glide slope and localizer. Neither pilot could recall the airplane's touchdown point on the runway, or the speed at touchdown. Witnesses observed the airplane, "high and fast" as it crossed over the runway threshold. The airplane touched down about halfway down the runway, and continued off the departure end. It then struck a wooden localizer antenna platform, and the airport perimeter fence, before crossing a road, and coming to rest about 400 feet from the end of the runway. Data downloaded from the airplane's Enhanced Ground Proximity Warning System (EGPWS) revealed that the airplane's groundspeed at touchdown was about 140 knots. Review of the cockpit voice recorder suggested that the PIC failed to activate the airplane's speed brake upon touchdown. Braking action was estimated to be "fair" at the time of the accident, with about 1/4 to 1/2 inches of loose, "fluffy" snow on the runway. The PIC reported that he thought the runway might be covered with an inch or two of snow, which did not concern him. The copilot reported encountering light snow during the approach. Both pilots stated that they were not aware of any mechanical failures, or system malfunctions during the accident; nor were any discovered during post accident examinations. According to the airplane flight manual, the conditions applicable to the accident flight prescribed a Vref of 110 knots, with a required landing distance on an uncontaminated runway of approximately 2,740 feet. The prescribed landing distance on a runway contaminated with 1-inch of snow, at a Vref of 110 knots was approximately 5,800 feet. At Vref + 10 knots, the required landing distance increased to about 7,750 feet.
Probable cause:
The copilot's failure to maintain the proper airspeed, and failure to obtain the proper touchdown point, and the pilot-in-command's inadequate supervision, which resulted in an overrun. Contributing to the accident was the PIC's failure to activate the speed brake upon touchdown and the snow contaminated runway.
Final Report:

Crash of a Cessna 550 Citation II in Fort Yukon

Date & Time: Sep 30, 2005 at 1210 LT
Type of aircraft:
Operator:
Registration:
N77ND
Flight Phase:
Survivors:
Yes
Schedule:
Fairbanks - Fairbanks
MSN:
550-0005
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3712
Captain / Total hours on type:
948.00
Copilot / Total flying hours:
5696
Copilot / Total hours on type:
141
Aircraft flight hours:
4262
Circumstances:
The flight crew, an airline transport certificated captain, and a commercial certificated co-pilot, were flying a restricted category, icing research equipped airplane in instrument meteorological icing conditions under Title 14, CFR Part 91. The purpose of the flight was to locate icing conditions for a prototype helicopter's in-flight icing tests. While in cruise flight, the airplane encountered icing conditions, and had accumulated about 1" of ice on the leading edges of the wings. The captain reported that he activated the wing deicing pneumatic boots, and the ice was shed from both wings. About 4 minutes after activating the deice boots, both engines simultaneously lost all power. The crew attempted several engine restarts, but were unsuccessful, and made a forced landing on frozen, snow-covered terrain. During the landing, the airplane struck several small, burned trees, and sustained substantial damage. The airplane's ice control system is comprised of two separate systems, one an anti-ice, the other, a deice. The majority of the wings' surfaces are deiced by pneumatic, inflating boots. The inboard section of the wings, directly in front of the engine air inlets, and the engine air inlets themselves, utilize a heated, anti-ice surface to preclude any ice accretion and potential for ice ingestion into the engines. The anti-ice system is not automatic, and must be activated by the flight crew prior to entering icing conditions. A researcher in the aft cabin photographed the airplane's wings before and after the activation of the deice boots. The photographs taken prior to the deice boot activation depicted about 1" of ice on the wings, as well as on the anti-ice (heated) inboard portion of the wings. The photographs taken after the deice boot activation revealed that the ice had been removed from the booted portion of the wings, but ice remained on the inboard, anti-ice segment. An engineer from the airplane's manufacturer said that if the anti-ice system was activated after ice had accumulated on the wings, it would take 2-4 minutes for the anti-ice portion of the wings and engine inlets to heat sufficiently to shed the ice. A postaccident inspection of the anti-ice components found no anomalies, and there was no record of any recent problems with the anti-ice system. The flight crew reported that the anti-ice activation switch is on the captain's side, and they could not recall if or when the anti-ice system was activated. They stated that they did not discuss its use, or use a checklist that addressed the use of the anti-ice system. A section of the airplane's flight manual states: "Failure to switch on the [anti-ice] system before ice accumulation has begun may result in engine damage due to ice ingestion." An inspection by an NTSB power plant engineer disclosed catastrophic engine damage consistent with ice ingestion.
Probable cause:
The pilot's improper use of anti-icing equipment during cruise flight, which resulted in ice ingestion into both engines (foreign object damage), the complete loss of engine power in both engines, and an emergency descent and landing on tree covered terrain. Factors associated with the accident were the icing conditions, inadequate crew resource management, and failure to use a checklist.
Final Report: