# NTSB CEN23LA056: Learjet 45, N988MC, Batesville, AR, November 30, 2022 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: November 29, 2022, 19:10 local (Nov 30, 2022, 01:10 UTC) - Place: Batesville, AR · off end of runway adjacent to busy road - Coordinates: 35.726222, -91.647444 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.7262&lon=-91.6474&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: Minor injuries - Injuries: 2 minor, 6 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA, Accident Investigation and Prevention, Bombardier Aviation, Honeywell Aerospace, FAA, Flight Standards District Office - NTSB case key (mKey): 106387 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA056 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106387/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106387 - Page: https://openairdocs.org/ntsb/CEN23LA056 ## Probable cause The crew’s failure to execute a go-around during the unstable approach and long landing, which resulted in a runway excursion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: surface speed/braking](https://openairdocs.org/ntsb-findings/01062045): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Learjet 45, 1 case](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=5170805), [All aircraft, 238 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Learjet 45, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=5170805), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Copilot (probable cause); cases with it: [Learjet 45, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=5170805), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Planning/preparation: flight planning/navigation](https://openairdocs.org/ntsb-findings/02061025): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Learjet 45, 1 case](https://openairdocs.org/ntsb-findings/02061025/cases.md?model=5170805), [All aircraft, 179 cases](https://openairdocs.org/ntsb-findings/02061025/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: [Learjet 45, 2 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=5170805), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The two pilots were conducting a business flight with six passengers when the accident occurred. During the night arrival the captain flew a visual approach with excessive airspeed and the airplane crossed the runway threshold more than 50 knots above approach speed (Vref). The before-landing checklist was not completed, and the flaps were at an incorrect 20° position instead of 40°. The airplane touched down near the midfield point of the 6,022 ft non-grooved runway, which was wet due to earlier precipitation. The captain initially applied intermittent braking, then applied continuous braking starting about 2,069 ft from the end of the runway. The captain did not deploy the thrust reversers. The airplane exited the runway above 100 knots groundspeed, then continued into a ditch and airport perimeter fence, which resulted in substantial damage to the forward fuselage. Examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. The operator’s flight manual directed that all approaches were to be flown using the stabilized approach concept. For a visual approach, this included establishing and maintaining the proper approach speed and correct landing configuration at least 500 ft above the airport elevation. Neither pilot recognized the requirement to execute a go-around due to the excessive approach speed or the long landing on a wet runway, which resulted in the runway excursion. ## Factual narrative On November 29, 2022, about 1910 central standard time, a Learjet 45 airplane, N988MC, was substantially damaged when it was involved in an accident at Batesville Regional Airport (BVX), Batesville, Arkansas. The two pilots sustained minor injuries and the six passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. A review of automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane departed Waterloo Regional Airport (ACO), Waterloo, Iowa, about 1757 on an instrument flight rules (IFR) flight plan and climbed to cruise at flight level (FL) 410 en route to BVX. During the arrival to BVX, which was flown by the captain, air traffic control (ATC) cleared the flight for the RNAV (GPS) Rwy 8 approach. According to the cockpit voice recorder, at 19:08:28, after the crew visually acquired the runway environment, the copilot cancelled the IFR flight plan with ATC. At 19:08:54, the captain disconnected the autopilot as the airplane crossed the final approach fix (FAF) at 265 knots groundspeed. At 19:09:12, the captain said, “my goodness, slow down”, then several seconds later called for flaps 20 and extension of the landing gear. At 19:10:08, the captain said, “disregard this”. Soon after, a sound similar to spoiler handle movement occurred, as well as a single chime consistent with a master caution aural alert, which is triggered when a caution message posts on the engine indicating and crew alerting system (EICAS). When the airplane is in flight and spoilers are extended with flaps extended more than 3°, a SPOILERS EXT caution message will post on the EICAS, accompanied by a master caution aural alert (single chime). The flight manual prohibits extending the spoilers with flaps extended while airborne, except as specified in emergency and/or abnormal procedures. At 19:10:23, the copilot said, “still really fast”, and the captain responded, “yeah”. At 19:10:24, the automated MINIMUMS callout was annunciated. The airplane crossed the runway threshold at 185 knots groundspeed/180 knots airspeed, according to onboard flight data. The calculated Vref was 123 knots based on an airplane weight of 19,200 lbs. The crew did not complete the before-landing checklist before landing, and the flaps remained at 20° extended instead of 40°. Landing distance information was not discussed by the crew during the flight. The airplane touched down near the midfield point of the 6,022 ft non-grooved, asphalt runway, which was wet due to earlier precipitation. Near the midfield point, ground-based ADS-B receiver data indicated the airplane’s groundspeed was about 160 knots, and onboard data indicated about 155 knots. Shortly after touchdown, the copilot said “you’re gonna need to…that’s the end of the runway”. About 2 seconds later, the captain responded “that is right there?” About 3,021 ft from the end of the runway, tire marks consistent with intermittent braking applicationstarted. About 2,069 ft from the end of the runway, tire marks consistent with continuous anti-skid braking application began and continued until the end of the runway. The airplane exited the end of the runway above 100 knots groundspeed, then continued into a ditch and the airport perimeter fence, which resulted in substantial damage to the forward fuselage. Following the accident, the captain reported that the airplane touched down fast on the runway and hydroplaned after touchdown. During the landing roll, he initially applied intermittent braking and subsequently applied constant, heavy braking. He did not recall the flap position during the landing or whether the before-landing checklist was completed. He reported he did not deploy or consider deploying the thrust reversers during the landing and recalled the landing weight was about 19,000 lbs. Onboard engine data indicated the thrust reversers were not deployed during the landing rollout. Following the accident, the copilot reported that he had informed the captain that the approach was high and fast. During a portion of the visual approach, he lost sight of the departure end of the runway due to the overcast clouds at 1,000 ft above ground level. He recalled the airplane touched down near midfield and thought the airplane could still be stopped on the runway, but that the brakes didn’t appear to work very well. He did not recall the flap position during the landing or if thrust reversers were used during the landing roll. He reported the landing weight was between 19,000 and 19,500 lbs. Examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. The spoilers were found in the deployed position, which matched the cockpit spoiler handle position (extend). The cockpit flap handle was at the 20° position, which matched the position of the left and right flap surfaces. The normal flaps position for landing is 40° extended. The investigation calculated actual landing distance as 4,845 ft for a landing approach speed at Vref with a landing weight of 19,200 lbs, field elevation 463 ft above mean sea level, temperature 18° C, flaps at 40°, 3 knot tailwind, thrust reversers stowed, and a wet runway. Stabilized Approach Information The accident airplane crossed the runway threshold more than 50 knots above Vref with the flaps positioned at 20° instead of 40°. The operator’s flight operations manual included the following guidance concerning a stabilized approach: All approaches, whether IFR or VFR, will be conducted using the stabilized approach concept. A stabilized approach for turbojet aircraft means that the aircraft must be in an approved landing configuration (including a circling configuration, if appropriate), must maintain the proper approach speed with the engines spooled up, and must be established on the proper flight path before descending below the minimum stabilized approach height specified for the type of operation being conducted.These conditions must be maintained throughout the rest of the approach for it to be considered a stabilized approach. A stabilized approach must be established before descending below the following minimum stabilized approach heights: • 500 ft height above airport (HAA) during VFR or visual approaches and during straight-in instrument approaches in VFR weather conditions. • Circling minimum descent altitude (MDA), not lower than 500 ft HAA, if a circling maneuver is to be conducted after completing an instrument approach. • 1000 ft HAA or height above touchdown (HAT) during any straight-in instrument approach in instrument flight conditions. The Flight Safety Foundation (FSF) and Air Charter Safety Foundation (ACSF) recommend a maximum airspeed of Vref + 20 knots at the minimum stabilized approach heights listed above and recommend that an immediate go-around should occur if Vref + 20 is exceeded at or below that height. In November 2023, the National Business Aviation Association (NBAA) published a guide to reduce runway excursions that encouraged the use of flight data monitoring by operators: Work-as-imagined is often described as the description of how tasks are to be completed in manuals, checklists, policies, and procedures. Work-as-done is described as how that same work is actually being performed by frontline employees. Do the two coincide 100%? Well, when it comes to the actual operation of the aircraft, there is a way to gain better insight into this question. A functioning flight data monitoring program will maintain anonymity of the crews operating each flight and focus more on overall trends in the data, rather than finding specific faults on any particular flight. By doing so, an operator can gain invaluable knowledge on how well work-as-done coincides with work-as-imagined. Compliance with all manner of runway performance-related activities (stabilized approach and go-around policies, touchdown points, flare distances, rates of rotation, etc.) can easily be gleaned from this dataset. Additionally, it can be compared to other participating operators flying similar aircraft, thus benchmarking your operation against the broader fleet. If, upon further analysis, it appears that compliance is not as consistent as imagined, this can be addressed with flight crews through sharing of the data, conversations about expectations and training, as needed. Flight data monitoring and analysis is yet another tool, one that is rapidly improving and seeing vastly wider adoption, that enables a business aviation operator to have true insight into how its aircraft are being operated, allowing negative trends to be mitigated before they become a runway excursion or other accident. ## Aircraft - Registration: [N988MC](https://openairdocs.org/aircraft/N988MC), registered now, S/N 352, built 2007 (OpenAirDocs) - Reported make and model: LEARJET INC 45 - Registry model: [Learjet 45](https://openairdocs.org/model/learjet-45) (registry code 5170805) (OpenAirDocs) - Registry engine: [Honeywell TFE731-20AR](https://openairdocs.org/engine/honeywell-tfe731-20ar) (registry code 33918, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 352 - Year built: 2007 - Airframe hours: 2490 - Engines: Honeywell TFE731-20BR-1B 3650 lbs thrust turbo fan; Honeywell TFE731-20BR-1B 3650 lbs thrust turbo fan - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Creamer Pilot Services LLC, doing business as Jett Aircraft - Registered owner: Creamer Pilot Services LLC - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, October 28, 2022, 50 hours before - Departed: ALO, Waterloo, IA - Destination: BVX, Batesville, AR - Flight plan: IFR - Airport: BVX, Batesville Regional Airport, runway 8, 6,002 × 150 ft, asphalt - Equipment: ADS-B, Stall warning system, Onboard weather, Electronic primary flight display, Electronic multifunction display, Angle of attack indicator, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: minor; airline transport, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review September 27, 2022; seat: left; restraint: 5-point; flight hours: 3,910 total, 1,560 in this make and model, 285 in the last 90 days, 103 in the last 30 days, 3 in the last 24 hours - Co-pilot; age 23; injuries: minor; commercial; airplane ratings: single-engine land, multi-engine land; medical: class 1, without waivers/limitations; last flight review October 25, 2022; seat: right; restraint: 5-point; flight hours: 505 total, 263 in this make and model, 166 as pilot in command, 175 in the last 90 days, 48 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night - Wind: 240° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: 1,000 ft overcast - Temperature: 63 °F, dew point 61 °F - Altimeter: 29.68 inHg - Observed at: KBVX - METAR: KBVX 300110Z AUTO 24005KT 10SM OVC010 17/16 A2968 RMK T01700160 ## 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 20221129018219A](https://openairdocs.org/incident/20221129018219A), Nov 29, 2022: Learjet Inc 45, Batesville, AR, Substantial damage. On November 29, 2022, about 19:10PM, a lear 45XR was substantially damaged when it was involved in a runway overrun at Batesville, AR (kbvx). 2 crew and 6… ## Docket (19 files) The files NTSB released with the investigation on April 10, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106387. 21.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16396260&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Airport video of accident airplane (item 2, MP4, 13.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16399554&FileExtension=mp4&FileName=Airport%20Video%20-%20Appendix%20F-Rel.mp4 - Pilot in command - interview (item 3, PDF, 2 pages, 367 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16398126&FileExtension=pdf&FileName=PIC%20Interview_Redacted-Rel.pdf - Second in command - interview (item 4, PDF, 2 pages, 502 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16398583&FileExtension=pdf&FileName=SIC%20Interview_Redacted-Rel.pdf - Passenger interviews (item 5, PDF, 4 pages, 368 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16397652&FileExtension=pdf&FileName=Passenger%20Interviews_Redacted-Rel.pdf - Correspondence with FAA inspector (item 6, PDF, 1 page, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16400322&FileExtension=pdf&FileName=Correspondence%20with%20FAA%20Inspector-Rel.pdf - Operator's general operations manual - excerpt (item 7, PDF, 1 page, 450 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16400453&FileExtension=pdf&FileName=GOM%20-%20excerpt-Rel.pdf - ADS-B - raw data (item 8, CSV, 502 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16396511&FileExtension=csv&FileName=49662_20221129235500_Once-Rel.csv - ADS-B - google view (item 9, KMZ, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16395900&FileExtension=kmz&FileName=49662_20221129235500_Once-Rel.kmz - Aircraft examination and accident information summary (item 10, PDF, 6 pages, 732 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16406938&FileExtension=pdf&FileName=Aircraft%20Exam%20and%20Accident%20Info%20-%20CEN23LA056-Rel.pdf - EGPWS download summary (item 11, PDF, 1 page, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16420857&FileExtension=pdf&FileName=EGPWS%20Download%20Summary-Rel.pdf - Landing performance information (item 12, PDF, 6 pages, 642 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16491759&FileExtension=pdf&FileName=Landing%20data%20-%20Bombardier%20memo-Rel.pdf - Summary of digital electronic engine controls (deec) download (item 13, PDF, 1 page, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16492090&FileExtension=pdf&FileName=DEEC%20Download%20Summary-Rel.pdf - Stabilized approach information - flight safety foundation (item 14, PDF, 6 pages, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16399510&FileExtension=pdf&FileName=Stabilized%20approach%20criteria%20-%20FSF-Rel.pdf - Stabilized approach information - air charter safety foundation (item 15, PDF, 1 page, 978 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16399961&FileExtension=pdf&FileName=Stabilized%20Approach%20-%20ACSF%20Poster-Rel.pdf - Nbaa reducing runway excursions guide (item 16, PDF, 25 pages, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16421589&FileExtension=pdf&FileName=NBAA-Reducing-Runway-Excursions-in-Business-Aviation-2023-Rel.pdf - Statement of party representatives to NTSB investigation (item 17, PDF, 2 pages, 428 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16396788&FileExtension=pdf&FileName=Party%20form%20-%20combined_Redacted-Rel.pdf - Wreckage release (item 18, PDF, 1 page, 591 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16432243&FileExtension=pdf&FileName=Wreckage%20release_Redacted-Rel.pdf - Cockpit voice recorder group chair's factual report and transcript (item 19, PDF, 30 pages, 395 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16990611&FileExtension=pdf&FileName=CVR%20Factual%20FINAL-Rel.pdf 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.