Aviation Crash Map

Cessna 550 N938D

3 November 2011 · Key West, Florida, United States · No injuries

Summary

On 3 November 2011 at about 16:13 local time, a Cessna 550 registered N938D, operated by South Aviation, was involved in an incident near Key West, Florida, United States. 5 people were on board and nobody was injured. The aircraft was slightly damaged. The NTSB has published a probable cause for this accident; it is quoted in full below.

The record

Date
at 16:13
Classification
Incident
Location
Key West, Florida, United States
Nearest airport
Key West International (EYW)
Coordinates
24.5561, -81.7594
Aircraft
Cessna 550
Registration
N938D
Category
Airplane
Year built
1982
Engines
2
Operator
South Aviation
Operating rule
Part 91: General Aviation
Purpose of flight
Business
Phase of flight
Not recorded
Route
Fort Lauderdale → Key West
Aircraft damage
Minor
Weather
VMC
Light
Day
NTSB number
ERA12IA060

People

Nobody was injured.

On board Died Serious Minor Uninjured
5 0 0 0 5

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.

Quoted verbatim from the NTSB record. This site does not paraphrase or interpret it.

Read the full NTSB narrative

The pilot-in-command (PIC) stated that he flew the downwind leg at 1,500 feet at 130 knots indicated airspeed and turned onto final approach at 1,000 feet, which he flew at 106 knots. He then touched down 800 feet down the runway at 95 to 100 knots. At touchdown, he extended the speed brakes, and, after traveling another 800 feet, he began to apply wheel braking, but the brake pedals felt "hard" and would not move. He then attempted to apply the emergency brake, but there was no braking action when he pulled it. The airline transport pilot who was in the right seat and acting as the second-in-command reported also trying to apply wheel braking after the PIC was unsuccessful and stated that it did not work. The airplane then overran the runway into the engineered material arresting system. Review of the radar data for the descent and approach portions of the flight indicated that at times the airplane was fast and the approach was unstabilized. However, the touchdown occurred at a reference speed of 103 to 106 knots. Examination of airport security camera images and deceleration values (determined by using time, distance, and velocity calculations) indicated that the airplane's deceleration was consistent with a lack of braking. Examination of the normal hydraulic braking system and antiskid system did not reveal any malfunctions or failures that would have precluded normal operation of the brakes. Examination of the cockpit revealed that the T-handle for the emergency gear extension system had been activated. This handle is located immediately to the right of the emergency braking handle and was most likely pulled during the incident landing instead of the emergency brake handle. Examination of the emergency braking/landing gear blow-down nitrogen bottle revealed that it was empty; no indication of leakage was discovered, and the witness wire on the landing gear blow-down cable at the nitrogen bottle was intact, indicating that the bottle was most likely empty before the incident flight, since adequate nitrogen should have been available from a properly serviced air bottle even if the landing gear had been extended pneumatically. Review of maintenance records that were provided by the operator nonetheless listed the airplane's most recent inspection as being completed on September 5, 2011, "in accordance with the instructions and procedures of a current manufacturer's recommended inspection program." According to a signed inspection document, 13 phase inspections were completed, including a phase 5 inspection containing 126 separate tasks, comprising inspection of the emergency brake control valve, the brake reservoir, the antiskid components, and the antiskid system, as well as 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 and system filter. The document also indicated that servicing of the "emergency brake and gear Nitrogen" had been accomplished. The landing checklist in the airplane flight manual cautions that if a "hard brake pedal-no braking condition" is encountered during landing, the pilot should operate the emergency brake system. It also noted that to obtain maximum braking performance from the antiskid system, the pilot must apply continuous maximum effort (no modulation) to the brake pedals. The Pilot's Abbreviated Checklist also contains emergency procedures for wheel brake failure and antiskid failure. However, examination of the incident airplane revealed that neither of these documents was in the cockpit. Instead, the cockpit contained a double-sided laminated checklist from a training provider titled "Normal Procedures." No emergency procedures were printed on the checklist and "For Training Purposes Only" appeared at the bottom. Based on the available evidence, it could not be determined that a failure of the normal braking system occurred or that the pilots applied maximum braking effort, as indicated by the airplane manufacturer's guidance. Further, had the braking system actually failed, the pilots did not apply the emergency brakes, instead activating the landing gear extension handle.

Quoted verbatim from the NTSB record.

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All 63 records for this type

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