Pilot Debrief

Cessna 750 near New York, NY — 2008-04-04

Final reportMIA08LA086
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Date
2008-04-04
Location
New York, NY, USA
Airport
KJFK
Aircraft
Cessna 750
Registration
N750WM
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Descent

Probable cause

The co-pilot's failure to maintain directional control during the landing roll. Contributing to the accident was a loss of system A hydraulic fluid for undetermined reasons and the flight crew's failure to follow the checklist sequence.

Contributing factors

Contributing to the accident was a loss of system A hydraulic fluid for undetermined reasons and the flight crew's failure to follow the checklist sequence.

NTSB narrative

The copilot (CP) was flying and air traffic control (ATC) was vectoring the airplane for an approach to a 10,000-foot long, 150-foot-wide runway, when an amber abnormal indicator light illuminated on the engine indicating and crew alert system (EICAS), indicating the hydraulic fluid on system A was low. The pilot-in-command (PIC) and the CP completed the checklist procedures down to the blow down of the landing gear. The flight crew did not follow the checklist sequence, and they did not evaluate the hydraulic pump to see if the hydraulic pump pressure could be restored. The flight crew turned on the A side pump, the power transfer unit was engaged, and the landing gear was lowered. The flight crew did not inform ATC of the loss of hydraulic fluid. The airplane touched down on the first 1,000 feet of runway 13L, and the CP informed the PIC that the brakes were not working. The PIC activated the emergency brakes one time, which appeared to work. The CP did not report any problems with nose wheel steering. The CP applied reverse thrust and the arm extend light illuminated on the right thrust reverser. The airplane started veering to the right and the CP could not maintain directional control. The PIC continued pulling the emergency brake handle as the airplane went off the right side of the runway, sheared off the left main landing gear, and came to a complete stop. Download of the EICAS system revealed the CP did not take the right thrust reverser out of reverse thrust. Review of airplane logbooks revealed the left hydraulic reservoir installed in the airplane was a repaired unit. The unit had been removed from another airplane due to an EICAS message stating it was empty when it was full. The switch was found to be out of adjustment. The unit was inspected and no anomalies were noted.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Flight crew did not report hydraulic problem to ATC or evaluate auxiliary hydraulic pump.

NTSB coding

Evidence available

  • CVR
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

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