NTSB Factual Report

HISTORY OF FLIGHT

On May 1, 2002, at 1653 eastern daylight time, a Beechjet 400A, N498CW, a fractionally-owned and operated airplane managed by Flight Options, Incorporated, was substantially damaged during a landing overrun at Baltimore-Washington International Airport (BWI), Baltimore, Maryland. The two certificated airline transport pilots and the four passengers were not injured. Visual meteorological conditions prevailed, and the airplane was operating on an instrument flight rules flight plan. The executive transport flight originated at Reading Regional/Carl A. Spaatz Field (RDG), Reading, Pennsylvania, and was operated under 14 CFR Part 91.

When interviewed at the scene, the captain stated that the flight from Reading was routine, and that he was at the flight controls during the approach and landing. When the airplane was 6 miles from the airport, he didn't hear that they were cleared for the visual approach. "The FMS [Flight Management System] locked up on me, so I was distracted."

The airplane was on an assigned heading, at an altitude that the captain thought "was higher than...we should be." The captain asked the first officer, "Are we cleared for the visual?" and the first officer reported that they were. The captain then "turned down the runway," but was "fast and...high." The captain lowered the flaps and the landing gear, and said, 'We're high and we're fast, but we'll be okay." The first officer responded, "Hey man, we need to go around," but the airplane was over the threshold and the captain thought they were "okay."

The captain landed the airplane, but didn't know how far down the runway it touched down. The first officer said, "We're not going to make it," but the captain thought they would, and also thought that it was too late to abort the landing, even with full throttle. The airplane subsequently departed the end of the runway, and the captain "just tried to keep it straight."

When asked what the airspeed was when the airplane crossed the runway threshold, the captain responded, "Vref plus 25. Vref was 113 knots, and we were doing about 140."

The captain also noted that when the FMS system malfunctioned, he was "locked out" because both pilots were attempting to program the system simultaneously. He first had to clear his inputs for the first officer to be able to program his side.

When asked about the airplane's performance and handling, the captain stated, "The airplane was fine." The captain also stated that there weren't any mechanical anomalies, but noted that during the system checks prior to the takeoff from Reading, the anti-skid feature of the braking system initially did not test properly, "then there was a delay in the responses on the second test, but it worked satisfactorily." The captain also noted that even if the anti-skid hadn't worked properly, it wouldn't have grounded the airplane. "If it doesn't work, you consult the checklist and increase your landing distances."

The first officer was also interviewed at the scene, and asked to describe the events prior to and during the flight. He concurred that the flight from Reading was uneventful until the approach for landing. According to the first officer, they were assigned a heading of "210 or 220 at 4,000 feet and we were given direct to the airport. At that time, I was putting the ILS into the FMS at the same time [the captain] was putting in the frequencies."

The crew was also cleared for the visual approach during that same time. The captain continued on the assigned heading and asked, "Are we cleared for the visual?" The first officer responded that they were, and as the airplane turned onto the final approach, he thought they were too high. In addition, the tower controller called and asked if they "could make it." The first officer responded that they could, but it subsequently appeared to him that they couldn't. At 1/4 mile from the runway, he said, "I think we should go around." When the airplane was 1,000 feet down the runway and hadn't touched down yet, he said, "We need to go around."

A couple of seconds later the airplane touched down and the first officer said, "We're not going to make it." At that point, the first officer felt "there was no chance." The thrust reversers were already deployed, and he "popped the speed brakes."

When asked what the airspeed was as the airplane crossed the landing threshold, the first officer responded that he thought it was "Vref (113 knots) plus 40, and coming down at 1,700 feet per minute." When asked where the airplane touched down, he stated, "maybe 50 to 60 percent of the runway remained."

The first officer also stated that he had flown the airplane earlier in the day, and when he landed it on a 5,000-foot runway, it seemed to operate "just fine" and "normally." The first officer further stated that he had flown other Beechjets, and noticed the braking on the accident airplane wasn't as good as others, "but nothing major." On the last leg of flight, "we didn't have any problems at all."

The passengers were interviewed briefly at the scene, and later submitted written statements that were consistent with their original interviews. According to one passenger, the flight was uneventful; however, approaching the airport, he was thinking that the descent was "fairly steep," but since he was usually on large commercial jetliners, he may have been "unused to the normal takeoff and landing patterns of small jets."

The airplane landed "fairly hard, but again not anything unusual." As soon as the airplane touched down, the pilot applied the brakes "at what seemed to be full force." The airplane began to slow, but as the passenger looked forward, through the cockpit window, it was clear that they were going to run out of runway. The passenger told his fellow passengers "we aren't going to make it," and they all braced for an impact.

The airplane then departed the end of the runway, onto the grass, went through some "modest" barriers and a couple of light poles, then over an embankment, and slid down a gentle slope, before finally coming to rest at the bottom of the slope. The passengers and crew then quickly but calmly exited the airplane through the exit door, and moved away from the airplane.

The passenger also noted that the airplane had landed with "maybe 1,000 feet or less to go" and had "little chance to stop due to a lack of rolling space." The amount of time that braking occurred "seemed quite short before we hit the end of the runway, and I estimate we hit the barrier doing maybe 60 mph."

The passenger was not aware of any problems of a mechanical, weather or traffic nature prior to the landing. After the accident, crewmembers were "clearly shaken up (as were we all) but they did not visibly panic, and they got the exit hatch open quickly, and urged us out of the plane. Their behavior after the accident was, in my view, proper and satisfactory." In addition, the cushioned seats and three point lap/shoulder harness system was a safety feature that "worked as designed, and allowed us all to walk away shaken but without visible injury."

A review of air traffic control (ATC) transcripts and radar data revealed that a radar target identified as the accident airplane, callsign Options 498, was 5 miles from the airport, at 3,000 feet above mean sea level (msl), with a groundspeed of 238 knots, when the approach controller asked, "Are you going to be able to get down?"

Forty seconds later, at 16:51:55, the airplane was still at 3,000 feet msl, with a groundspeed of 207 knots, and had closed to within 3 miles of the airport, when the crew received clearance for the visual approach to runway 15L. At 16:52:13, when the airplane was at 2,300 feet, about 2 miles from the airport, with a groundspeed of 190 knots, the crew was cleared to land.

A Safety Board air traffic specialist plotted the last five radar returns for the airplane. The radar track was superimposed over a diagram of the airport. The track depicted the target as it aligned with the runway. At 16:52:56, the airplane was over the runway threshold, at 300 feet msl, with a groundspeed of 166 knots.

The cockpit voice recorder was transported to the Safety Board for review. According to the group chairman's factual report:

At 1641, approaching Baltimore, the first officer received information Sierra, which advised calm winds and an altimeter setting of 29.84, and to expect a visual approach to runway 33 right. The first officer subsequently relayed the information to the captain.

At 1642, the center controller advised the crew that the airplane was cleared direct to Baltimore, and requested that they reduce to 250 knots, which the first officer acknowledged.

At 1643, while the first officer was on radio #2 with a fixed based operator, the captain received and acknowledged a descent to 8,000 feet on radio #1. Shortly thereafter, the crew proceeded through the descent checklist, and determined the reference speeds to be 113, 121 and 135 knots.

At 1644:21, Baltimore Approach Control advised that Baltimore Airport was changing to runway 15, and asked if runway 15 Left (15L) would be acceptable. The winds were then from 180 degrees at 8 knots. The first officer, after asking the captain, responded that 15L would be fine. The controller then advised the crew to expect vectors for the visual approach to runway 15L, and to fly heading 220.

At 1645:13, the captain stated, "crew briefing do visual for one five left backed up by an i-l-s."

At 1645:27, the controller advised the crew to descend to 4,000 feet, which the first officer acknowledged.

At 1646:26, the captain asked, "one fifty seven on the course?" and the first officer responded, "that is correct."

At 1646:41, there was a sound similar to an autopilot disconnect tone, and the captain stated, "what the [expletive, unknown] flying to?" The first responded, "i don't know."

At 1648:03, the controller requested the crew to contact another Baltimore sector controller, which the first officer acknowledged.

Shortly thereafter, the captain noted that the heading bug had moved from 220 to 210, and after a brief discussion with the first officer, told him to just contact Baltimore and see what they wanted them to do.

At 1649:19, the first officer reported that the airplane was at 4,000 feet. The controller then responded, " 'kay great proceed direct to baltimore descend maintain two thousand five hundred report the airport in sight," which the first officer acknowledged.

At 1649:39, the captain stated, "eh how about you give me direct baltimore here first," and the first officer responded, "didn't i?"

At 1649:47, the first officer stated, "you are direct baltimore."

At 1649:58, the captain stated, "i can't you can't give me direct baltimore when you're using yours you have to give me direct baltimore on yours."

At 1650:03, the first officer asked, "okay you want me to just turn it?" and the captain responded, "using (baltimore/both of them) at the same time."

At 1650:09, the first officer stated, "okay well I was giving you the visual," and the captain responded, "cancel yours go to baltimore."

At 1650:16, the first officer asked, "you want direct?" then stated, "baltimore. there you go," and the captain responded, "thanks."

At 1650:27, the controller advised the crew, "there's ah traffic a couple of helicopters ah about four and six miles respectively south of your position they're gonna cross the final for fifteen left south of you two helicopters," which the first officer acknowledged.

At 1650:58, the first officer asked the captain, "okay you got one five left?" and the captain responded, "well did you give me runway on here?"

At 1651:02, the first officer responded, "yeah it's all on there," and the captain stated, "all- all right give me that."

At 1651:06, the captain stated, "give me that runway."

At 1651:11, the captain stated, "wait what's going on here?" and the first officer asked, "did you want your [unintelligible]?"

At 1651:18, the captain asked, "we're cleared for the visual?"

At 1651:19, the controller stated, "... let me know if you have the airport you going to be able to get down?" and at 1651:21, the first officer responded, "ahh we're looking."

At 1651:25, the captain stated, "[expletive]. just don't talk anymore for me for a second let me. are we cleared for the approach?"

At 1651:29, the first officer responded, "yes you are."

At 1651:30, the captain stated, "oh say something about that then..." and the first officer responded, "i did it..."

At 1651:32, the captain stated, "...i asked you three times," and the first officer stated, "...cleared for the visual."

At 1651:33, the first officer stated, "it's," and the captain responded at 1651:34, "just don't say anything. don't tell me what the runway. just tell me if we're cleared for the approach or not."

At 1651:38, the first officer stated, "okay."

At 1651:51, the controller asked, "options four ninety eight you have the airport?" and the first officer responded, "that's affirmative we'll be able to get down."

At 1651:54, the controller stated, "all right cleared visual approach one five left tower nineteen four," and the first officer acknowledged. The controller then advised the crew to switch over to the tower radio frequency.

At 1652:09, the first officer reported to Baltimore Tower, "with you on the visual one nine left... er five left."

At 1652:13, the tower controller cleared the airplane to land, and the first officer acknowledged.

At 1652:30, the first officer asked the captain, "you gonna be able to make it?" and there was no response.

At 1652:50, the captain asked, "how much runway we have here?" and the first officer responded, "five thousand...feet."

At 1653:00, the first officer stated, "you're ref plus forty...there's no way."

At 1653:09, the first officer stated, "there's no way."

At 1653:10, the first officer stated, "go around."

At 1653:15, the first officer again stated, "go around."

At 1653:16, there was a sound similar to touchdown, followed by clicks and increasing background noise.

Beginning at 1653:22, there were a series of expletives by the captain, interrupted at 1653:25, by a "thump" and at 1653:28, by a sound similar to impact.

At 1653:40, there was a sound similar to decreasing engine rpm.

The accident occurred during daylight hours, in the vicinity of 39 degrees, 10.6 minutes north latitude, 76 degrees, 39.2 minutes west longitude.

PILOT INFORMATION

The captain held an airline transport pilot certificate with a rating for airplane multi-engine land and BE-400/MU-300 type ratings. He reported 3,000 hours of flight experience, of which, 1,100 hours were in the Beechjet. His most recent Federal Aviation Administration (FAA) first class medical certificate was issued on December 9, 2001.

A review of FAA records revealed that the captain had been a pilot for about 10 years. In 1992 he obtained his private pilot certificate after passing his second practical test attempt. In 1994, he obtained his instrument rating - airplane after passing his third practical test attempt. The captain also obtained his commercial pilot certificate in 1994, having passed the practical test on his first attempt. In 1996, the captain obtained his flight instructor certificate after passing his second practical test attempt. The captain subsequently had no more test failures.

In 1996, the captain began his first professional flying employment, with Cleveland Airports. In 1998, the captain obtained his airplane multi-engine rating. He subsequently worked as a pilot for A.L.S., Inc. and Grand Aire, Inc.

The captain was hired by Flight Options on June 5, 2000. He completed his operator and aircraft initial training the same month, and satisfactorily completed all 14 CFR Part 135 proficiency checks at Flight Safety International. On June 30, 2000, he obtained his airline transport pilot certificate and BE-400/MU-300 type ratings.

The captain completed his initial operating experience (IOE) check ride with Flight Options on February 2, 2001, in a Beech 400A. He was graded "prof

NTSB Probable Cause

The captain's failure to go around. Factors included the captain's preoccupation with the flight management system, the crew's failure to adhere to company standard operating procedures, and the lack of proper crew coordination.