Pilot Debrief

RAYTHEON AIRCRAFT COMPANY 400A near Cleveland, OH — 2018-02-05

Final reportCEN18LA094
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Date
2018-02-05
Location
Cleveland, OH, USA
Airport
KBKL
Aircraft
RAYTHEON AIRCRAFT COMPANY 400A
Registration
N570TM
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

The airplane's reduced braking performance due to an ice-covered runway, which resulted in a runway excursion. Contributing to the accident was the crew's selection of a runway with a tailwind.

NTSB narrative

The two airline-transport pilots and two passengers departed on a cross-country flight in the chartered airplane. Preflight planning had noted the destination airport's runway conditions as "good." As the flight neared the destination airport and the crew conducted the approach checklist, the captain stated, "light snow ... maybe slippery." When the crew checked the airport's automated terminal information service, the broadcast included "light freezing rain." The flight was transferred to the tower controller, who told the crew that the airport operations crew was on the runway about 20 minutes earlier and advised that it was starting to pick up traces of ice. The captain acknowledged the transmission and, after conducting a missed approach to runway 6L, requested to land on runway 24R. During the approach to runway 24R, the tower controller reported wind at 020° at 25 knots and also at 010° at 25 knots. The crewmembers reported that, after touchdown, they applied maximum braking; however, the airplane did not slow and skidded off the end of the runway into the engineered material arresting system (EMAS), which resulted in substantial damage to the fuselage and a collapsed nose gear. The crew stated that the runway grooves had been "smoothed out" by ice accumulations. A first responder reported that the ramp and taxiways were very icy, adding that the end of the runway and EMAS had a sheet of ice. A review of the airport's snow and ice control plan noted that the airport did not have pavement surface sensors and that operations personnel would monitor the airfield as conditions dictated. An airport operations log entry for a runway and field inspection, recorded about 24 minutes before the accident, noted a temperature of 31°F and a braking coefficient of 40+, with runways and taxiways wet. A log entry for a runway and field inspection recorded about 6 minutes after the accident noted a braking coefficient of 30-35, with runways and taxiways wet. The Runway Condition Assessment Matrix contained in Advisory Circular 150/5200-30D states that a braking coefficient of 40 or higher is the equivalent of a pilot-reported braking action of "good," while a braking coefficient of 30-35 would be medium to poor. The field conditions noted during the pilots' preflight planning indicated "good" braking conditions; however, the captain's statement of "light snow ... maybe slippery," along with the tower controller's report that the runway was starting to pick up traces of ice, indicated that the crew was aware of the potential for braking conditions that were less than good, which would decrease braking action and increase the stopping distance. Further, the crew's selection of runway 24R, which led to the presence of a tailwind, also would decrease braking action.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Crew could have aborted the approach earlier due to reported icy conditions.

NTSB coding

Evidence available

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

Docket documents9

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