NTSB Factual Report

HISTORY OF FLIGHT

On October 1, 2010, at 0830 eastern daylight time, a Cessna 550 Citation, N262Y, registered to Colnan Incorporated, overran runway 23 and came to rest into the Croatan Sound about 50 feet off the end of runway 23, at Dare County Regional Airport (MQI), Manteo, North Carolina. The certificated airline transport pilot, the certificated commercial copilot, and five passengers received minor injuries, and the airplane sustained substantial damage. The flight was operated as a corporate flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91, with an instrument flight rules flight plan filed. Instrument meteorological conditions prevailed at the time of the accident. The flight originated from Tampa International Airport, Tampa, Florida, at 0629.

According to written statements, the pilot-in-command (PIC) was the pilot flying and the copilot was the pilot monitoring. The en route portion of the flight was uneventful. As the flight approached MQI, the copilot obtained updated current weather information at MQI twice. Both times the weather had deteriorated. The PIC stated that they would fly one approach to MQI and take a look. If it did not look good, they would divert to Elizabeth City Regional Airport, Elizabeth City, North Carolina.

The flight crew further stated in phone interviews that they asked the Washington air route traffic control center for the global positioning system (GPS) runway 5 approach but didn't expect it due to airspace restrictions. They expected and received the GPS runway 23 approach, circle-to-land on runway 5. The airplane was initially fast on approach, and the copilot could not deploy approach flaps when the PIC requested, as 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) and on altitude, with the flaps and landing gear extended. The copilot completed the approach and landing checklist items but did not call out items as the PIC preferred copilots complete checklists quietly. The PIC then stated that they would not circle-to-land due to the low ceiling; however, a landing on runway 23 would be ok as the wind was at a 90-degree angle to the runway and there was no tailwind factor. The runway lights were still on from a departing King Air, and the copilot had the runway in sight about 200 feet above the minimum descent altitude, which was 440 feet. About 300 feet above the runway, the PIC stated that the airplane was high, and the copilot mentally prepared for a go-around but did not call for a go-around. The airplane touched down at 100 knots, between the 1,000-foot-marker and the runway intersection, which was about 1,200 feet beyond the approach end of the 4,305-foot-long runway. Both pilots stated that the speed brakes, thrust reversers, and brakes worked properly, but the airplane departed the end of the runway about 40 knots.

The copilot believed the landing was actually "too smooth" and the airplane hydroplaned on the wet runway. Immediately prior to touchdown, the PIC asked the copilot what he thought and the copilot remarked to the PIC that it was "his call." The copilot did not suggest a go around. Looking back on the event, the copilot believes that they did not have enough runway remaining to stop or go-around at that point.

During a subsequent telephone interview, the PIC remarked that he could not recall what speed he touched down at because he was flying visually but estimated Vref was about 104 to 106 knots and they lost a little speed in the flare.

The copilot’s statement was consistent with the PIC’s. The copilot added that the airplane touched down between the fixed distance markers and the runway intersection. He estimated that the airplane was 90-100 knots after the main landing gear touched down.

Witnesses on the airport stated that they observed the airplane on approach. They watched as it came over the threshold to runway 23 at a steep rate of descent, touching down just west of the Delta intersection, which was approximately 1,700 feet beyond the approach end of runway 23. The witnesses observed the reversers deploy for the remainder of the landing roll. Witnesses stated that as the airplane neared the end of runway 23, it was sliding a bit sideways. The airplane slid off the end of runway 23 and came to rest about 50 feet into the Croatan Sound. As witnesses arrived at the accident site, all of the occupants had exited the airplane and were climbing up the embankment.

PILOT INFORMATION

The PIC, age 67, held an airline transport pilot certificate, with a rating for airplane multiengine land. He also held a type rating for the Cessna 500. The PIC reported a total flight experience of 9,527 hours. His most recent FAA first-class medical certificate was issued on January 7, 2010. Of the total flight experience, the PIC had accumulated 2,025 hours in the Cessna 550. He flew 30 hours and 18 hours during the 90-day and 30-day periods preceding the accident, respectively.

The copilot, age 43, held a commercial pilot certificate, with a rating for airplane multiengine land. He also held a type rating for the Cessna 550. The copilot reported a total flight experience of 3,193 hours. His most recent FAA second-class medical certificate was issued on August 3, 2010. Of the total flight experience, the copilot had accumulated 150 hours in the Cessna 550. He flew 20 hours and 10 hours during the 90-day and 30-day periods preceding the accident, respectively. He also reported flying 2 hours during the 24-hour period prior to the accident.

AIRCRAFT INFORMATION

The eight-seat, low-wing, retractable tricycle gear airplane, serial number 550-291, was manufactured in 1981. It was powered by two Pratt and Whitney of Canada JT15D-4 engines, each capable of generating 2,500 pounds of thrust. The airplane was maintained under a continuous airworthiness program. The airplane’s most recent inspection was completed August 16, 2010. At that time, the airplane had accumulated 9,643 total hours of operation.

METEOROLOGICAL INFORMATION

The weather reported at MQI, at 0843, was: wind from 350 degrees at 4 knots; visibility 1.5 miles in heavy rain; broken ceiling at 400 feet, broken ceiling at 1,000 feet, and overcast ceiling at 1,300 feet; temperature 22 degrees C, dew point temperature 21 degrees C; altimeter setting 29.63 inches of mercury. Remarks: automated station with precipitation discriminator, precipitation since last report six-hundredths of an inch.

FLIGHT RECORDER

The airplane was equipped with a cockpit voice recorder (CVR), but not a flight data recorder (FDR). The CVR was forwarded to the NTSB Vehicle Recorders Laboratory, Washington, DC for data download and transcription.

Cockpit Voice Recorder

Review of the CVR recording revealed that both pilots were concerned about the weather. Landing gear, full flaps, and speed brakes, were deployed prior to touchdown. At touchdown the pilot stated “I don’t think we’re gonna do this”. The copilot responded “uh it’s up to you, your call”. There was no discussion or mention of landing speed (Vref 104 knots) on the recording prior to the landing.

WRECKAGE INFORMATION

Examination of the wreckage was performed on November 8 and 9, 2010, with emphasis on documenting the airplane’s ability to stop during the landing. The wings of the airplane with the attached main landing gear had been recovered and taken to an enclosed examination area at a salvage facility. The remainder of the airplane was recovered and placed behind the enclosed area.

In the right nose of the airplane, the brake pressure precharge indicator needle was at less than a light green line (675 +/- 25 psi) and in a red band at the bottom of the indicator scale. The pneumatic pressure gauge for the auxiliary brakes was found at about 1900 psi, which was close to the top of the green band. The brake reservoir had two observation windows for fluid level and fluid was not seen in either window. These readings were consistent with the loss of hydraulic pressure when the wings were removed from the airframe for transport.

The main door did not open and the cockpit was entered through the emergency exit. Neither set of shoulder harnesses in the cockpit were locked.

The airplane flight manual (AFM) was in the airplane but had swelled due to saltwater immersion and could not be extracted from its compartment. In the cockpit, the landing gear handle was found in the DOWN position and the Aux Gear control was in the stowed position. The Hobbs meter indicated 9661.4 hours. At the center pedestal, both thrust reverser switches were in the NORMAL positions. The flap selector and indicator were in the full down positions. The throttles were at the idle position with the reverser piggyback levers stowed.

Both engine pylon leading edges had been displaced aft from their leading edges to a depth of about 10 inches. The cowls were on both engines. The left engine inlet and exhaust had been taped over and were not opened for access. The right engine had dried salt in the engine inlet and exhaust. About six fan blades had been slightly bent and the exact number was hard to define because the deformation was gradual. The fan case had evidence of minor rubbing around the fan blades and the leading edges of several blades had been bent aft of the direction of travel for less than a 0.5 inch. No metal or foreign debris was found in the exhaust, other than the dried salt residue.

The nose of the airplane had extensive damage forward of the pressure bulkhead. The tip of the nose had collapsed down, to the left, and aft. The general nose structure had been collapsed around a large rounded object that had struck the bottom of the fuselage. The large crush was to the right of the nose landing gear. The left side of the fuselage crown exhibited compressive buckling over a distance of about 3 feet, beginning at the upper aft corner of the main cabin door. Compressive buckling for about the same distance was also found from the lower aft corner of the door. The right side of the fuselage was free of dents and impact marks.

Aft of the left wing root was minor crushing of a local area of fuselage skin. The aft edge of the right wing root also had a small amount of buckling that measured less than 5 inches in span.

The rudder, horizontal stabilizer, and elevators were found sitting next to the fuselage. None of the components had visible damage.

Both wings had been unbolted from the root, with some cutting of the wing skins performed for transport. The left wing was found intact and relatively undamaged, aside from minor scuffs and recovery cuts. The aileron remained attached and moved freely.

The right wing had been extensively damaged. The leading edge had been crushed aft to the forward spar and the inboard edge of the crush was at the span of the inboard end of the aileron. The forward spar had bent aft from 20 inches inboard of that point. The aileron remained attached at the root end, was bent in the mid-span, and ahead of the forward spar at the aileron tip.

ADDITIONAL INFORMATION

Landing Distance

According to a representative from the airplane manufacturer, the following is based on interpolating the data contained in the landing distance charts of the AFM section 4, for a landing weight of 11,500 pounds and a temperature of 22 degrees C.

At sea level, on a dry and level runway, with no wind, using the speeds of Vref = 104 knots indicated airspeed (KIAS) and approach speed (Vapp) = 113 KIAS, the landing distance should be approximately 2,190 feet. Based on the reported weather, a tailwind component of approximately 2 knots existed at the time of the accident and the pilot in a subsequent statement to the FAA acknowledged there was a tailwind about 20 degrees behind the right wing. The AFM only referenced a landing distance for a 10 knot tailwind, which would be approximately 2,680 feet.

Interpolating for the tailwind creates a landing distance of approximately 2,290 feet at sea level, on dry and level runway.

Landing distance on a contaminated runway is referenced using the advisory information in section 7 of the AFM. This section provides landing distances for a variety of runway contamination types. The first is a wet runway, which is defined as, "a runway is considered wet when there is sufficient moisture on the surface to appear reflective, but without significant areas of standing water." Second is a runway with standing water: "a runway is considered to be contaminated by standing water when more than 25 percent of the runway surface area (whether in isolated areas or not) within the required length and width being used, is covered by surface water more than 3 millimeters (0.125 inch) deep, or by slush, or loose snow, equivalent to more than 3 millimeters (0.125 inch) of water." There were two charts for landing with adverse runway conditions. One was with Vref and the other was with Vref plus 10 knots. To use either chart, the calculated dry runway distance was found on the chart and then the associated contaminated runway distances were referenced. Since the chart lists dry distances of 2,200 feet and 2,400 feet, the distance for 2,290 feet was interpolated.

Using the Vref contaminated runway distance chart, a landing distance required for a wet runway was 3,550 feet, while the landing distance for a runway with .125 inch of standing water was 5,625 feet. 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.

Using the Vref+10 contaminated runway distance chart, a landing distance required for a wet runway was 4,862 feet, while the landing distance for a runway with .125 inch of standing water was 7,350 feet. The chart also contained a note, “The published limiting maximum tailwind component for this airplane is 10 knots; however, Cessna does not recommend landings on precipitation-covered runways with any tailwind component. If a tailwind landing cannot be avoided, multiply the above data by the following factor…" If the factors are used, the wet runway distance remained 4,862 feet and the distance for .125 inch of standing water increased to 7,423 feet.

AIRWORTHINESS

The airplane had been modified to permit flight at a gross weight greater than what the original certification allowed. The installation of the gross weight Supplement Type Certificate (STC) SA4954NM was clearly marked with a placard at the captain’s left arm rest that stated: "THIS AIRCRAFT HAS BEEN MODIFIED BY BRANSON AIRCRAFT CORP WEIGHT INCREASE STC. SEE THE AFM SUPPLEMENT FOR APPROPRIATE PERFORMANCE DATA."

The Branson STC required that the aircraft wheels, tires, and brakes be replaced with nonstandard Cessna parts. The main landing gear tire requirement changed from Goodyear Model 220K08-3, with a 10-ply rating, to Model 220K28, with a 12-ply rating. The incorrect tires were found installed for compliance with the STC. The tires found on the main landing gear were 10-ply rated tires that applied to an unmodified Citation rather than the 12-ply rated tires that the STC called for. Review of the aircraft log records revealed the tires were replaced on March 28, 2007, by Southern Jet Center Stanford, Florida, Work Order Number 07-3679. Discrepancy/Response (items numbered 2 and 3) described installation of the Cessna tire part number. The treads of the accident airplane main gear tires exhibited a wear pattern, with the outer two of five tread ribs nearly missing and not continuous in profile to the center three of the tread ribs. The captain noted that the tires were due to be changed upon return t

NTSB 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.