# NTSB CEN19LA090: Beech 400, N750TA, Richmond, IN, February 11, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 2 · Limited · Final report - Date: February 11, 2019, 10:07 local (15:07 UTC) - Place: Richmond, IN - Coordinates: 39.750831, -84.852218 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.7508&lon=-84.8522&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 2 - NTSB office: Central Region - Parties: Federal Aviation Administration, Pratt & Whitney Canada, Textron Aviation, Transportation Safety Board of Canada - NTSB case key (mKey): 99038 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA090 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99038/pdf - Page: https://openairdocs.org/ntsb/CEN19LA090 ## Probable cause The flight crew's decision to continue an unstable approach under conditions that exceeded the airplane's landing performance capabilities, which resulted in a runway overrun and impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info](https://openairdocs.org/ntsb-findings/02063000): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Raytheon 400A, 1 case](https://openairdocs.org/ntsb-findings/02063000/cases.md?model=7150010), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Raytheon 400A, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7150010), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Raytheon 400A, 4 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=7150010), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) - [Runway/land/takeoff/taxi surface: snow/slush/ice covered surface](https://openairdocs.org/ntsb-findings/03023015): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Raytheon 400A, 1 case](https://openairdocs.org/ntsb-findings/03023015/cases.md?model=7150010), [All aircraft, 219 cases](https://openairdocs.org/ntsb-findings/03023015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Raytheon 400A, 4 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7150010), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The flight crew was approaching the destination airport on an instrument flight rules cross-country flight in instrument meteorological conditions. The captain stated that, after visually acquiring the runway environment during the approach, he saw that the runway "had a very light coating of snow," but he chose to continue the approach and apply full thrust reversers and braking after touchdown. The cockpit voice recorder revealed that the first officer advised the captain that the airplane was high while on final approach. The airplane crossed the runway threshold at 150 knots, touched down about 3,100 ft along the 5,502-ft-long runway at 125 knots, continued down the remaining runway, through an antenna array, and across a road before coming to rest about 750 ft beyond the paved surface. The airplane's landing approach reference speed (Vref) was between 110 and 114 knots. On a dry runway with calm wind conditions, the airplane required between about 3,200 ft and 3,500 ft runway stopping distance after touchdown; on a runway contaminated with wet or compacted snow, this distance increased to 5,300 ft. Although the captain reported that the engines shut down without his input following the accident, images from the accident site showed that the nose landing gear collapsed, deforming the surrounding structure, which included the area of the throttle quadrant. It is likely that the collapsed structure impacted the throttle quadrant and resulted in the engine shutdown. The captain reported that there were no other mechanical malfunctions or anomalies with the airplane. The captain and first officer conducted a preflight inspection of the airplane and checked the weather several times on the morning of the flight. The captain reported that the weather conditions were improving, and he did not recall seeing any new NOTAMs regarding runway conditions. The pilots' decision to continue the unstable approach and landing to the snow-covered runway despite that the distance available was inadequate resulted in the runway overrun; however, given the airplane's excessive approach speed and touchdown point over halfway down the runway, it is likely that the crew would have been unable to stop the airplane on the remaining runway even if it had been uncontaminated. ## Factual narrative Performance Information An NTSB airplane performance study indicated that the airplane crossed the runway threshold at a speed of 150 knots and touched down 3,100 ft beyond the threshold of the runway at 125 knots. About 4 seconds after touchdown, the thrust reversers were deployed. The airplane traveled beyond the end of the runway and came to rest about 750 ft beyond the runway. According to the pilot checklist, the airplane's landing reference speed (Vref) was between 110 and 114 knots. The airplane flight manual indicated that, for a dry runway with calm wind, the airplane's stopping distance was between about 3,234 ft and about 3,546 ft. For wet or compacted snow, the stopping distance was 5,300 ft. Landing distance calculations do not account for thrust reverser deployment. The captain's report indicated that instrument landing system for runway 24 was out of service. However, the airport was serviced by an area navigation (RNAV) GPS approach to runway 24. The RNAV (GPS) approach to runway 24 began at the PEWEZ waypoint, which was the published initial fix. A 4 nm holding pattern was collocated with this waypoint and was depicted with a block altitude between 2,700 and 6,000 ft. The final approach course was 238°. On crossing UYOKO, pilots established themselves on the 068-degree course and remained at or above 2,700 ft until reaching the final approach fix, the WANKU waypoint, which after crossing; pilots could descend to at or above 1,820 ft until crossing the NINRE waypoint, located 2.7 nm from the end of the runway. On crossing NINRE, pilots could continue their descent to the published minimum descent altitude of 1,320 ft, if the airplane is I-NAV equipped, which is 384 ft above the runway elevation. The weather minimums to fly the straight-in approach were 400 ft ceiling and 1 mile visibility. The operator, Stein's Aircraft Services, LLC, was a 19-year-old company that started as an aircraft management company and had grown into two full-service fixed base operators managing 15 corporate aircraft and 1 joint Part 135 and Part 91 aircraft. The operator employed about 15 full-time pilots and had an additional 6 pilots on contract. All Stein full-time pilots were trained at simulator training vendors. The contract pilots were also simulator trained and their currency verified. The operator reported that their normal procedures were to schedule the pilots more than 24 hours prior to their assigned flights and pilots to show about an hour or more before the flight. The day prior to a trip, lead pilots were required to preflight and discuss the trips and responsibilities with the other flight crew members. A Flight Risk Assessment Tool (FRAT) was required by the company for all legs of the trip and the risks had to be met to dispatch aircraft. The FRAT was required to be updated within 12 hours of the flight. The operator reported that the FRAT was not updated within the 12-hour time slot required for approval. After the accident, theoperator emphasized the importance of good cockpit resource management (CRM) and restated that pilots "can and have the ability to cancel or change their trip." Additionally, the operator emphasized to the current simulator training vendor to pay close attention to CRM during training sessions. The airplane flight manual supplement for operation on wet or contaminated runways, in part, stated: INTRODUCTION TO PERFORMANCE The contaminated runway performance assumes that any dry snow, wet snow, slush or standing water is a uniform depth and density, does not exceed 0.5 inch in depth…. Runway Contaminated by Standing Water, Slush or Loose Snow A runway is considered to be contaminated when more than 25% 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 mm (0.125 inch) deep, or by slush or loose snow equivalent to more than 3 mm (0.125 inch) of water. RID was equipped with two runways, designated 6/24 and 15/33. Runway 24, a grooved asphalt runway, was 5,502 ft long and 150 ft wide with a gradient of about 0.1%. A four-light precision approach path indicator was located on the left side of runway 24, which provided a 3-degree glidepath. According to published FAA information, the airport was serviced by an Automated Weather Observing Systems (AWOS) IIIP. Advisory Circular (AC) 150/5220-16E, in part, describes types of certified non-Federal AWOS. They are defined based on their certified sensors. An AWOS IIIP measures and reports wind data, temperature, dew point, altimeter, density altitude, visibility, precipitation accumulation, and cloud height and has a precipitation type/intensity sensor. Between 0853 and 0856, RID airport management issued several NOTAMs indicating that there was 2 inches of wet snow on all runways, taxiways, and aprons. Airport management also issued a NOTAM indicating that the airport was closed from 1025 on February 11, 2019, through 1025 on February 12, 2019. On February 11, 2019, about 1007 eastern standard time, a Beech 400A airplane, N750TA, was substantially damaged when it was involved in an accident near Richmond, Indiana. The two pilots and one passenger were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The captain stated that he reviewed the flight plan the night before and discussed with the first officer the possibility of having to cancel the flight due to weather conditions. He recalled that the cloud ceiling was 100 ft above ground level (agl) and visibility was 1/2 mile with fog and mist. He reviewed the NOTAMs and he did not recall any concerning runway conditions. The captain and first officer conducted a preflight inspection of the airplane and checked the weather several times on the morning of the flight. The captain reported that the weather conditions were improving, and he did not recall seeing any new NOTAMs regarding runway conditions. Theflight departed Waukesha County Airport (UES), Waukesha, Wisconsin, about 0917; throughout the flight, the crew continued to monitor the weather conditions at the destination. the captain stated that the reported conditions included 1.5 miles visibility, a cloud ceiling of 1,500 ft agl, wind from 090° at 4 kts, with fog and mist. The crew discussed the approach to runway 24 and the 4-knot quartering tailwind. During the approach, the first officer advised the captain that the airplane was high on final; the captain requested that the first officer configure the airplane for landing. The captain reported that, as the destination, Richmond Municipal Airport (RID), Richmond, Indiana, came into view during the approach, the runway appeared to have a "very light coating of snow on it." The captain elected to land and apply full thrust reversers and braking. After touchdown, the captain asked the first officer about the spoilers, and the first officer confirmed that the spoilers were deployed. A few seconds later, the captain thought that the airplane was not slowing much and advised the first officer that the airplane was going to go off the end of the runway. The airplane continued off the end of the runway and across a road. Data recorded by the airplane's G5000 avionics system showed that the airplane touched down about 10:06:58 at 129 kts and came to a stop about 10:07:25. The captain reported no mechanical malfunctions of the airplane during the flight; however, he stated that the engines were not visibly damaged, and that they shut down uncommanded after the airplane came to rest. After the accident, the captain used his iPad to review the NOTAMs again. At that time, he saw that the airport was closed and that the runway condition codes were “3-3-3”, i.e., braking deceleration is noticeably reduced for the wheel braking effort applier or direction control is noticeably reduced for each third of the runway. At 0955, the recorded weather at RID included wind from 080° at 4 kts; visibility 1/2 statute mile; fog; scattered clouds at 300 ft agl, overcast clouds at 1,500 ft agl; temperature 0°C; dew point 0°C; altimeter 30.12 inches of mercury. At 1015, the recorded weather at RID included wind from 080° at 4 kts; visibility 1 statute mile; mist; scattered clouds at 300 ft agl, overcast clouds at 1,500 ft agl; temperature 0°C; dew point 0°C; altimeter 30.13 inches of mercury. Linear witness marks in the snow consistent with the landing gear started about halfway down runway 24, near the intersection with runway 15/33, continued down the remaining runway, through a localizer antenna array, and ended at the wreckage site. The nose landing gear (NLG) collapsed and deformed the fuselage and structure behind the NLG. The throttle quadrant was abeam this structure. No other damage was found that would have precluded normal operation of the airplane. ## Aircraft - Registration: [N750TA](https://openairdocs.org/deregistered/N750TA-2021-10-30), registration cancelled 2021-10-30, S/N RK-226, built 1999 (OpenAirDocs) - Reported make and model: Beech 400 (A) - Registry model: [Raytheon 400A](https://openairdocs.org/model/raytheon-400a) (registry code 7150010) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada JT15D 5 series](https://openairdocs.org/engine/pratt-whitney-canada-jt15d-5-series) (registry code 52113, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: RK-226 - Year built: 1999 - Airframe hours: 6244.5 - Engines: P & W Canada JT15D-5 2965 lbs thrust turbo fan; P & W Canada JT15D-5 2965 lbs thrust turbo fan - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Stein's Aircraft Services, LLC - Registered owner: Premier Beechcraft LLC - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, April 25, 2014 - Departed: UES, Waukesha, WI - Destination: RID, Richmond, IN - Flight plan: IFR - Airport: RID, Richmond Muni, runway 24, 5,502 × 150 ft, asphalt - Equipment: Electronic multifunction display, Angle of attack indicator, ADS-B, Stall warning system, Satellite tracking device, Onboard weather, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; commercial, flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, waiver time limited special; last flight review June 18, 2018; seat: left; flight hours: 11,915 total, 718 in this make and model, 8,024 as pilot in command, 89 in the last 90 days, 38 in the last 30 days - Co-pilot; age 53; injuries: none; airline transport, military; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review March 19, 2018; seat: right; flight hours: 4,082 total, 181 in this make and model, 3,980 as pilot in command, 11 in the last 90 days, 4 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 80° at 4 knots - Visibility: 0.5 statute miles - Lowest ceiling: 1,500 ft overcast - Temperature: 32 °F, dew point 32 °F - Altimeter: 30.12 inHg - Observed at: RID, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20190211010129A](https://openairdocs.org/incident/20190211010129A), Feb 11, 2019: Raytheon Aircraft Company 400A, Richmond, IN, Substantial damage. On February 11, 2019, at approximately 10:10 eastern standard time (1510 zulu), Beechcraft be 400A, N750TA landed and slid off the departure end of runway 24… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.