NTSB Factual Report

HISTORY OF THE FLIGHT

On September 29, 2013, at 1820 Pacific daylight time, a Cessna 525A Citation, N194SJ, veered off the right side of runway 21 and collided with a hangar at the Santa Monica Municipal Airport (SMO), Santa Monica, California. The private pilot and three passengers were fatally injured, and the airplane was destroyed by a post-crash fire. The airplane was registered to CREX-MML LLC, and operated by the pilot under the provision of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight originated from Hailey, Idaho, about 1614.

Witnesses reported observing the airplane make a normal approach and landing, on centerline and within the runway touchdown zone markings. The airplane started to drift to the right side of the runway during the roll out, the nose pitched up suddenly and dropped back down, then the airplane veered off the runway, and impacted the 1,000-foot runway distance remaining sign. It continued to travel in a right-hand turn, and impacted a hangar structural post with the right wing. The airplane came to rest inside the hangar, and the damage to the hangar structure caused the roof to collapse onto the airplane. A post-accident fire quickly ensued.

On-scene examination of the wreckage and runway revealed that there was no airplane debris on the runway. The three landing gear tires were inflated and exhibited no unusual wear patterns. The Federal Aviation Administration (FAA) control tower local controller reported that the pilot did not express over the radio any problems prior to or during the landing.

PERSONNEL INFORMATION

The pilot, age 63, held a private pilot certificate with ratings for airplane single & multiengine land, and instrument airplane, issued March 27, 2004, and a third-class medical certificate issued May 21, 2012, with the limitation that he must wear corrective lenses. The pilot's current logbook was not located. An examination of copies from the pilot's previous logbook showed the last entry was dated June 5-7, 2009, and totaled his flight time as 3,463.1 hours, with 1,236.2 hours in the Cessna 525A. On the pilot's May 21, 2012, application for his FAA medical certificate he reported 3,500 hours total time, and 125 hours within the previous 6 months. The pilot had logbook endorsements from Flight Safety International, Orlando, Florida, for flight reviews and proficiency checks dated January 19, 2002, November 2, 2002, November, 15, 2003, June 4, 2004, March 2, 2005, March 22, 2006, March 21, 2007, and March 31, 2008. Training records provided by Flight Safety showed that he had completed the Citation Jet (CE525) 61.58 Recurrent PIC training on February, 27, 2013.

The person occupying the right seat in the cockpit was a non-pilot rated passenger.

AIRCRAFT INFORMATION

The low wing, six-seat, retractable landing gear, business jet, serial number 525A0194, was manufactured in 2003, and was based at the Santa Monica Airport. It was powered by two Williams International FJ44-2C engines, each capable of producing 2,400 pounds of static thrust at sea level. A review of the maintenance records revealed that the most recent maintenance was performed on September 7, 2013, and included hydrostatic test of the fire extinguisher bottles, battery functional check, pitot-static system check, transponder calibration check, visual corrosion inspections on the landing gear and horizontal/vertical stabilizer spars, and a generator control unit wire bundle service bulletin. The records showed that as of September 7, the total airframe hours were 1,932.8. Total time on the number one engine (SN 126257) was 1,932.8 hours with 1,561 cycles, and the total time on the number two engine (SN 126256) was 1,932.8 hours with 1,561 cycles. Total landings were 1,561. The aircraft was not equipped with a flight data recorder or a cockpit voice recorder.

Flap Position & Speed Brakes

The flap system description from the Cessna 525 Operating Manual states: "The trailing edge flaps are electrically controlled and hydraulically actuated by the main hydraulic system. Normal flap travel is from 0 to 35 degrees and any intermediate position can be selected. A mechanical detent is installed at the takeoff and approach (15 degrees) position of the flap lever. The full flap position (35 degrees) is reached by pushing down on the flap lever when passing through the takeoff and approach detent."

"The flaps have an additional position called GROUND FLAPS (60 degrees) which provides additional drag during the landing roll."

The speed brake system description from the Operating Manual states: "The speed brakes are installed on the upper and lower surfaces of each wing to permit rapid rates of descent, rapid deceleration, and to spoil lift during landing roll. The speed brakes are electrically controlled and hydraulically actuated by a switch located on the throttle quadrant and may be selected to the fully extended or fully retracted positions. When the speed brakes are fully extended a white SPD BRK EXTEND annunciator will illuminate to remind the pilot of the deployed status of the speed brakes. The angular travel for the upper speed brake panels is 49 degrees, +2 or -2 degrees and the lower panels travel 68 degrees, +2 or -2 degrees. The lower speed brake panels close with the upper panel. The speed brakes will also automatically deploy when GROUND FLAPS position or selected on the flap handle."

Brake System

The brake system description from the Operating Manual states: "An independent power brake and anti-skid system is used for wheel braking. The closed center hydraulic system is comprised of an independent power pack assembly (pump, electric motor, and filter), accumulator and reservoir which provides pressurized hydraulic fluid to the brake metering valve and anti-skid valve. A hand-controllable pneumatic emergency brake valve is provided in the event of a power brake failure. Pneumatic pressure is transmitted to the brakes though a shuttle valve integral to each brake assembly."

"The brake metering valve regulated a maximum of 1,000 psi +50/-20 psi to the brakes based upon pilot/copilot input to the left and right rudder pedals. RPM transducers at each wheel sense the onset of a skid and transmit information to the anti-skid control box. The anti-skid control box reduces brake pressure by sending electronic inputs to the anti-skid valve. Pressure to the brake metering valve is controlled by mechanical input through a bellcrank and push-rod system from either the pilot or the copilot's rudder pedals. A manually operated parking brake valve allows the pilot to increase the brake pressure while the brake is set, and provide thermal relief at 1,200 psi. After thermal relief, pressure will drop to no less than 600 psi, and the pilot or copilot must restore full brake pressure prior to advancing both engines to take-off power."

"Pneumatic pressure from the emergency air bottle is available as a backup to the normal system."

METEOROLOGICAL INFORMATION

Recorded weather data from the Santa Monica Airport automated surface observation system (ASOS elevation 177 feet) at 1824 showed the wind was from 240 degrees at 4 knots, visibility was 10 statute miles with clear sky, temperature was 21 degrees C and dew point 12 degrees C, and the altimeter was 29.97 inHg.

Sun position was calculated using the National Oceanic and Atmospheric Administration (NOAA) solar position calculator. The Los Angeles location of 34 degrees, 3 minutes, 0 seconds latitude, and 118 degrees, 13 minutes, 59 seconds longitude was used for the solar position calculation on September 29, 2013, at 1820 PDT. The solar azimuth was calculated to be 264.33 degrees, and solar elevation was 3.59 degrees above the horizon. This position placed the Sun near horizon level, about 54 degrees to the right of the centerline of runway 21.

AERODROME INFORMATION

The Santa Monica Municipal Airport (KSMO), is at an elevation of 177 feet msl. The airport consists of a single 4,973 by 150-foot asphalt/grooved runway oriented southwest to northeast (03/21), with a downhill gradient to the west of 1.2%. There are no overrun areas for either runway, and the departure end of runway 21 terminates in an approximately 50-foot drop off into residential housing to the west and south (residential homes are located approximately 220 feet from the departure end of both runways). Along the last 3rd of the northern side of runway 21 are privately-owned hangars with an approximately 30-foot rising embankment behind the hangars. The runway physical condition was good with no evidence of broken asphalt, debris, pot holes, or water on the runway at the time of the accident.

WRECKAGE & IMPACT INFORMATION

Visible tire track marks from the right main landing gear tire on the runway started at 2,840 feet from the threshold of runway 21; the airplane veered right, colliding with the 1,000-foot runway remaining sign, crossing over the tarmac between taxiway A2 and A1, and finally colliding with the last row of hangars on the northwest corner of the airport. The tire marks on the runway consisted of light scuff marks from the right main landing gear tire and became dark black transfer marks of all three landing gear tires after the airplane had veered off the runway and impacted the 1,000-foot remaining sign. The collision with the hangar resulted in the hangar collapsing over the airplane. A post-accident fire erupted, damaging adjacent hangars.

The collapsed hangar structure was lifted using cranes and shored up using wood timbers. The wreckage was removed by attaching chains to the airframe structure and pulling it out of the hangar with a forklift loader. The fuselage had separated from the wing structure in scissor fashion. The fuselage had rotated counter clockwise about 60 degrees around the longitudinal axis so that the cabin door was pointed towards the ground. The pilot was located in the left front seat, an adult female passenger was in the right front seat, an adult female was located with her back against the cabin door, and an adult male was sitting in a right-hand seat mid cabin. The remains of two cats and a dog were also located within the cabin. The tail section aft of the pressure bulkhead was exposed to extreme heat/fire. The nose landing gear was extended with the wheel and tire attached to the mount. The continuity between the nose wheel steering linkage up to the cockpit rudder pedals was verified. The tire was inflated and exhibited no usual wear.

The right wing had separated from the fuselage at the attach points. The wing spar had broken outboard of the wheel well rib, and a semicircular leading edge indentation was evident at the fuel filler cap location. Aileron and flaps were attached to the wing, and the speed brake/spoiler was deployed. The aileron control cable was attached to the aileron bell crank and the cables were traced to the center fuselage. The right main landing gear was extended with the wheel and tire attached. The tire was inflated and did not exhibit any unusual bald or flat spots.

The tail section aft of the pressure bulkhead separated from the airframe due to extreme fire damage, and was the only part of the airplane that remained outside of the collapsed hangar structure. The horizontal stabilizer was present with both elevators attached. The vertical stabilizer was present with the rudder attached. Both engines remained attached to their respective engine mounts. The emergency locator transmitter (ELT), manufactured by ACR Electronics, was located in the tail section, exhibited minor heat damage and was transmitting during the time immediately following the accident.

The left wing exhibited extreme fire damage at the wing root, and the wing extending outboard of the root was discolored gray/black. There was slight denting along the leading edge of the wing. The flap and aileron were attached to the wing, and the speed brake/spoiler was deployed. The aileron control cables were traced from the aileron bell crank to the center fuselage section.

The fuel control cables were attached to both engines fuel control units; both engine's bleed valves were movable. The left engine N1 section had seized and the visible fan blades were free of dirt or soot. The right engine N1 section could be rotated by hand, and the intake fan blades were evenly coated with black soot. Borescope examination of the high pressure compressor of both engines showed soot and small particulate matter within the compressor section, consistent with the engines operating while ingesting smoke, soot, and ash.

MEDICAL & PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on October 3, 2013, by the Los Angeles County Coroner. The cause of death was ascribed to the combined effects of inhalation of combustion products and thermal burns.

The FAA Civil Aerospace Medical Institute (CAMI) performed toxicology on specimen from the pilot with negative results for ethanol, and positive results for 10 ug acetaminophen detected in urine, and Rosuvastatin detected in urine.

An autopsy was performed on the passenger, who was in the cockpit's right seat, on October 3, 2013, by the Los Angeles County Coroner. The cause of death was ascribed to the combined effects of inhalation of combustion products and thermal burns.

The FAA Civil Aerospace Medical Institute (CAMI) performed toxicology on specimen from the passenger with negative results for ethanol, and positive results for 0.077 ug/ml diazepam detected in liver, 0.042 ug/ml diazepam detected in blood, 0.524 ug/ml dihydrocodeine detected in liver, 0.109 ug/ml dihydrocodenine detected in blood, 0.659 ug/ml hydrocodone detected in liver, 0.258 ug/ml hydrocodone detected in blood, 0.132 ug/ml nordiazepam detected liver, and 0.064 ug/ml nordiazepam detected in blood.

ADDITIONAL INFORMATION

Brake System Examinations

The following airplane brake system components were removed from the wreckage; skid control unit fault display, left and right wheel transducers, brake control valve assembly, and the skid control box. The components were examined at Crane Aerospace, Burbank, California, on January 22, 2014, under the oversight of the NTSB investigator-in-charge (IIC). Each component was examined and tested per Crane Aerospace acceptance testing procedures. No discrepancies or anomalies were identified that would have precluded normal operation of the components. The complete examination report is available in the public docket of this investigation.

Both the left and right main brake assemblies were examined at UTC Aerospace Systems, Troy, Ohio, under the oversight of the NTSB IIC, on February 11, 2014. A hydraulic fitting was placed on the primary port of the shuttle valve and pressurized to 100 psi. No leakage was observed, piston movement was observed on all 5 pistons, and the rotors could not be moved by hand. Hydraulic pressure was released and adjuster assemblies were observed to return to their normal position. The system was pressurized to 850 psi, no leaks were observed and the rotors could not be moved by hand. The wear pins extensions indicated about 2/3 wear on both brake assemblies. The system held pressure at 850 psi for 5 minutes. The system was depressurized to 9 psi. The pistons retracted and a feeler gauge measured a gap between rotor and stator disks. The hydraulic fitting was removed from the primary port and placed on the pneumatic port (emergency system). When pressurized to 100 psi the shuttle valve could be heard to move from primary to emergency, indicating the last actuation was via the normal (primary) brake system. The system was pressurized to 850 psi, no leaks were observed, and piston movement was evident. The complete examination factual report is available in the public docket of this investigation.

The parking brake valve assembly had been exposed to extreme thermal heat and was deformed in such a way that disassembly by normal means was impossible. To determine the parking brake internal configuration and condition, the parking brake valve was subjected to x-ray computed tomography (CT) scanning. The scanning was

NTSB Probable Cause

The pilot’s failure to adequately decrease the airplane’s ground speed or maintain directional control during the landing roll, which resulted in a runway excursion and collision with an airport sign and structure and a subsequent postcrash fire.