NTSB Factual Report

HISTORY OF FLIGHT

On 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 INFORMATION

According 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 INFORMATION

The 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 INFORMATION

The 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 INFORMATION

Key West International Airport is located approximately 160 miles southwest of Miami on US highway 1. It is located on the last Key in the Florida Keys chain of islands, and is the southernmost airport in the continental United States.

Aircraft operations averaged 172 per day of which, 52 percent were transient general aviation, 21 percent were air taxi, 14 percent were local general aviation, 13 percent were commercial, and 1 percent were military.

There were 61 aircraft based at the field of which, 39 were single-engine airplanes, 21 were multi-engine airplanes, and 1 helicopter.

The airport covered an area of 255 acres and has one runway oriented in a 09/27 configuration. Runway 09 was asphalt, grooved, and in good condition. The total length of the runway was 4,801 feet, and its width was 100 feet. It was equipped with nonprecision runway markings, in good condition, medium intensity runway edge lights, runway end identifier lights, and a 4-box visual approach slope indicator on the left side of the runway which provided a 3-degree glide path.

Engineered Material Arresting System

Runway 09 was not equipped with a standard 1,000 foot runway safety area (RSA) on the end of the runway as required by 14 CFR Part 139 due to the proximity of a mangrove swamp near the end of the runway. As a result, an engineered material arresting system (EMAS) was installed to comply with the requirements for an RSA in less space, on the end of runway 09, which due to prevailing winds was the primary use runway.

The EMAS at EYW was designed in accordance with the system design requirements listed in Advisory Circular 150/5220-22A and consisted of a bed of customized cellular cement material, designed to crush under the weight of an aircraft, thus providing predictable controlled deceleration.

The bed was approximately 340 feet long by 121 feet wide and was setback from the end of the runway. It was designed with a predicated 70 knot stopping power for the critical aircraft (ERJ-135) operating at maximum takeoff weight and an 80 percent maximum landing weight in accordance with FAA Order 5200.9.

FLIGHT RECORDERS

The airplane was equipped with a cockpit voice recorder (CVR) that records a minimum of the last 30 minutes of aircraft operation; this is accomplished by recording over the oldest audio data. When the CVR is deactivated or removed from the airplane, it retains only the most recent 30 minutes of CVR operation. This model CVR, the Fairchild GA-100, records 30 minutes of analog audio on a continuous loop tape in a four-channel format: one channel for each flight crew and one channel for the cockpit area microphone (CAM).

Examination of the CVR revealed that it had not sustained any heat or structural damage during the overun and the audio information was extracted from the recorder normally, without difficulty.

The recording consisted of four channels of poor quality audio information; however none of the audio was pertinent to the incident investigation. The audio was consistent with the CVR being inoperative prior to the event or being overwritten by subsequent events.

An internal inspection of the CVR revealed that the hour meter indicated beyond the 5,000 hour scale and corrosion was evident on the inside of the case. When power was applied to the CVR the tape mechanism would not turn.

The limited audio content was consistent with ground operation of the aircraft. The recording consisted of a few power cycles; brief periods of singing; and sounds similar to a door opening.

WRECKAGE AND IMPACT INFORMATION

Examination 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 airplane revealed that the wing flaps were in the "LAND" position (40 degrees), the speed brakes were in the "EXTEND" position, and during the overrun the airplane had received minor damage. The nose landing gear tire and bottom of the nose landing gear trunnion had separated from the airplane, the left landing gear door had partially separated from its mounting location, numerous scrapes were present on the lower fuselage skins and nose gear doors, the battery hold down clamp wing nuts were loose and not safety wired, and the engines had ingested dirt, and dust.

TESTS AND RESEARCH

Landing Distance Calculations

At the request of the NTSB, Cessna Aircraft Company calculated the landing distances for the incident airplane. Using a landing weight of 12,700 pounds, an elevation of sea level, a dry runway, and temperature of 30 degrees C, the following landing distances were obtained from data in the Aircraft Flight Manual (AFM):

• 10 knot tailwind; 3,220 feet.

• No wind; 2,340 feet.

• 10 knot headwind 2,210 feet.

While the reported temperature prior to the incident was 27 degrees C, no extrapolation was done between the published values of 25 degrees C and 30 degrees C as the landing distance would only have decreased approximately 10 feet in a no wind condition.

These landing distances were based on the following criteria published in the AFM concerning landing distance and technique:

• Landing preceded by a steady approach down to the 50-foot height point with airspeed at Vref (the airspeed equal to the landing 50-foot height point speed of 1.3 times the stalling speed or minimum steady flight speed) in landing configuration (landing flaps and gear down).

• Thrust setting during approach was selected to control the rate of descent to approximately 800 to 1,000 feet per minute.

• Idle thrust was established at the 50-foot height point and throttles remained in that setting until the airplane had stopped.

• Rotation to a three-point attitude after touchdown was accomplished at a normal rate.

• Maximum pilot braking effort was initiated immediately on nose wheel contact and continued throughout the landing roll.

• The antiskid system was "ON".

• Speed brakes were not used (not required to meet the performance requirements).

Radar Data

Review of FAA air traffic control radar data revealed that the airplane was first acquired by radar at approximately 1136 edt as it climbed out of FLL. It then continued to climb and eventually reached a cruising altitude of 14,000 feet above mean sea level (msl). At approximately 1156 edt, the airplane began its initial descent into EYW. Groundspeed peaked at 325 knots in the descent. As the airplane passed through 10,000 feet msl, groundspeed was 302 knots. The airplane continued to descend and reached 1,600 feet msl at approximately 1208 edt. The airplane then entered a right downwind for runway 9 at EYW at a ground speed of 256 knots.

At 12:11:10.31, the airplane had descended to 1,000 feet msl, was still on the downwind leg of the traffic pattern, and had slowed to 169 knots.

At 12:12:11:14, the airplane had descended to 500 feet, was on the base leg of the traffic pattern, and had slowed to 130 knots.

At 12:12:47.33, the airplane had descended 100 feet, was on final approach, had slowed to approximately 112 knots, and was approximately 1 mile from the runway threshold.

Video Study

Video recording obtained from a surveillance system installed at EYW, was provided to the NTSB Vehicle Recorder Division by the Monroe County Sheriff's Office. Images from the surveillance system were used to calculate the airplane's position and ground speed at several locations during the landing rollout.

Examination of the video revealed that it contained images captured from three separate cameras, all located on the north side of the air traffic control tower at EYW. The recordings covered the timespan from 12:13:00 to 12:14:44.

The images from each camera were examined for landmarks and references suitable for calculating the airplane's position as it traveled down the runway during the landing. A line-of-sight method was used for position calculations, using landmarks that were identifiable in both the surveillance images, and satellite imagery of the airport, using a geographical information system. This method was applied at 15 different locations of the airplane along the runway, and a 3-degree glide path reference was also superimposed along a profile view and perspective view leading from the aiming point markings back up the approach path.

Review of the last of the radar data points recorded and the images of the airplane on final indicated that the airplane was below the normal glide path.

Review of the images of the airplane while traveling along the runway, revealed that the airplane's wing flaps were down. The airplane however was too far from the cameras to determine the condition of the speed brakes (deployed or stowed).

Further review of the images also indicated that after touchdown, at approximately 1,935 feet from the threshold, the airplane had decelerated to about 80 knots.

At approximately 2,443 feet from the threshold, the airplane had decelerated to about 73 knots.

At approximately 3,769 feet from the threshold, the airplane had decelerated to about 63 knots, and was now within 1,000 feet of the end of the paved portion of the usable runway surface.

At approximately 4,

NTSB Probable Cause

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.