# NTSB CHI05FA059: Learjet 35A, N911AE, Kansas City, MO, January 29, 2005 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: January 28, 2005, 22:17 local (Jan 29, 2005, 04:17 UTC) - Place: Kansas City, MO - Coordinates: 39.123054, -94.592781 - Nearby events: https://openairdocs.org/map.md?lat=39.1231&lon=-94.5928&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report February 26, 2007 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Million Air - NTSB case key (mKey): 60987 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI05FA059 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60987/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60987 - Page: https://openairdocs.org/ntsb/CHI05FA059 ## Probable cause The contaminated runway conditions during landing. Contributing factors were the operation of the airplane without thrust reversers, flight to the planned alternate airport not performed by the flightcrew, and the insufficient runway information. Additional factors were the airport property and terrain that the airplane impacted. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Overrun, landing - roll - flight to destination alternate - not performed, flightcrew (contributing factor) - information insufficient, flightcrew (contributing factor) - thrust reverser - inoperative (contributing factor) - airport facilities,runway/landing area condition - other (cause) - other system - inoperative - On ground/water collision with object, landing - roll - object - antenna (contributing factor) - object - fence (contributing factor) - object - other (contributing factor) - On ground/water encounter with terrain/water, landing - roll ## Analysis The Learjet 35A received substantial damage on impact with airport property and terrain during a landing overrun on runway 19 (7,002 feet by 150 feet, grooved asphalt) at Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The airplane was operated by a commercial operator as a positioning flight to Kansas City International Airport (MCI), Kansas City, Missouri, with a filed alternate destination of Lincoln Airport (LNK), Lincoln, Nebraska. Night instrument meteorological conditions prevailed at the time of the accident. LNK was a certificated airport with a snow removal plan and was served by runway 17R (12,901 feet by 200 feet, grooved asphalt and concrete). The flight was en route to MCI to pick up passengers and continue on as an on-demand charter but diverted to MKC following the closure of MCI. MCI was closed due to a McDonnell Douglas MD83 sliding off a taxiway during an after landing taxi on contaminated runway/taxiway conditions. MKC held a limited airport certificate that did not have a snow removal plan and was served by runway 19. Following a precision approach and landing on runway 19 at MKC, the Learjet 35A slid off the departure end of the runway and impacted airport property and terrain. The Learjet 35A was operated with inoperative thrust reversers as per the airplane's minimum equipment list at the time of the accident. About 1:05 hours before the accident, runway 19 Tapley values were recorded as 21-22-22 with 1/2 inch of wet snow. About 17 minutes before the accident, MKC began snow removal operations. About 7 minutes before the accident, the MKC air traffic control tower (TWR) instructed the snow removal vehicles to clear the runway for inbound traffic. TWR was advised by airport personnel that runway 19 was plowed and surface conditions were 1/4 inch of snow of snow; friction values were not taken or reported. While inbound, the Learjet 35A requested any braking action reports from TWR. The first airplane to land was a Cessna 210 Centurion, and the pilot reported braking action to the TWR as "moderate", which was then transmitted by TWR as "fair" from a Centurion in response to the Learjet 35A's query. The Cessna 210 Centurion pilot did not use brakes during landing and did not indicate this to TWR during his braking action report. The Aeronautical Information Manual states that no correlation has been established between MU values and the descriptive terms "good," fair," and "nil" used in braking action reports. The Airport Winter Safety and Operations advisory circular (AC) states that "pilot braking action reports oftentimes have been found to vary significantly, even when reported on the same frozen contaminant surface conditions." The AC also states, "It is generally accepted that friction surveys will be reliable as long as the depth of snow does not exceed 1 inch (2.5 cm) and/or depth of wet snow/slush does not exceed 1/8 inch (3mm). The Learjet 35A flightcrew calculated a landing distance 5,400 feet. Two of the cockpit voice recording channels, which normally contain the pilot and copilot audio panel information, were blank. ## Factual narrative HISTORY OF FLIGHT On January 28, 2005, at 2217 Central Standard Time (CST), a Learjet 35A, N911AE, operated by Business Aviation Management Group Inc. (d.b.a. Million Air), overran runway 19 during landing rollout at Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The airplane received substantial damage when it impacted airport property and terrain. Night instrument meteorological and contaminated runway conditions prevailed at the time of the accident. The Title 14 Code of Federal Regulations (CFR) Part 91 positioning flight was operating on an instrument rules flight plan with a filed alternate destination of Lincoln Airport (LNK), Lincoln, Nebraska. The pilot and copilot were uninjured. The flight originated from Salt Lake City International Airport (SLC), Salt Lake City, Utah, at 1905 Mountain Standard Time, and was en route to Kansas City International Airport (MCI), Kansas City, Missouri, when it diverted to MKC. The positioning flight was to pick up five passengers at MCI for a return Title 14 CFR Part 135 flight to SLC. At 2102 CST, the Learjet 35A was on approach to MCI when a McDonnell Douglas MD83 slid off runway 19L at taxiway E during an after landing taxi resulting in the closure of MCI for approximately 90 minutes. The Learjet 35A then diverted to MKC. A Federal Aviation Administration (FAA) partial transcript of transmissions from MKC Air Traffic Control Tower (TWR), N911AE, FLX745 (Cessna 210 Centurion), Airport Vehicles (ARPT) 5, 10, 24, 26, and MCI Approach Control (APP) follows. 2206:50 CST; TWR; and ah airport five 2206:59 CST; ARPT 5; airport five 2207:01 CST; TWR; airport five why don't you guys ahead ah start to ah exiting on runway one niner and all vehicles please report clear traffic on nine mile final 2207:03 CST; ARPT 5; airport five we copy 2207:10 CST; TWR; look like I am going to have three right in a row inbound and I'll get you guys going again 2207:12 CST; ARPT 24; airport twenty four is clear 2207:33 CST; FLX745; downtown tower flight express seven forty five on the I L S for one niner 2207:33 CST; ARPT 5; airport five is clear 2207:35 CST; TWR; flight express seven forty five downtown tower continue inbound at the present time I do have plows on the runway they will be exiting here shortly 2207:36 CST; FLX 745; ah roger flight express seven forty five 2207:37 CST; TWR; o k ah I had a couple of you are stepping on each other I know that twenty four is clear, twenty five is clear who else 2207:38 CST; ARPT 26; airport twenty six 2207:39 CST; ARPT 10; airport ten is clear 2207:41 CST; ARPT 5; airport five is clear 2207:47 CST; TWR; roger understand all vehicles are clear of the runway thank you hold short of runway one niner for landing traffic you can proceed onto runway three two one just remain clear of the intersection to runway one 2208:02 CST; TWR; flight express seven forty five is cleared to land on runway one niner and r v r is ah better than six thousand five hundred the runway has been plowed fifty feet either side of the centerline 2208:09 CST; FLX745; roger cleared to land flight express seven forty five understand they just plowed the runway 2208:24 CST; TWR; affirmative and once your down just ah I'd appreciate any pilot reports you can give me regarding ice and [braking] action 2208:30 CST; FLX745; roger flight express seven forty five 2208:41 CST; TWR; approach downtown 2208:43 CST; APP; approach 2208:45 CST; TWR; hey our runway one niner has been plowed fifty feet ah either side of the centerline 2208:46 CST; APP; o k 2208:47 CST; TWR; but I don't have a [braking] action yet 2208:48 CST; APP; alright t t 2208:49 CST; TWR; d x 2211:12 CST; FLX745; ah tower the ride down was pretty good there's quite a bit of fog right before you get to the runway though 2211:20 CST; TWR; roger thanks 2211:22 CST; FLX745; icing was just a trace of rime 2211:23 CST; TWR; roger thanks 2211:32 CST; N911AE; downtown tower lear jet one one alpha echo at two thousand six hundred on the I L S one niner 2211:38 CST; TWR; lear niner one one alpha echo downtown tower runway one niner cleared to land centurion ahead reported a trace of rime on the decent runway has been plowed fifty feet either side of the centerline 2211:48 CST; N911AE; o k ah cleared to land runway one niner and any [braking] reports 2212:00 CST; TWR; one alpha echo I am sorry I was on another frequency say again 2212:03 CST; N911AE; ah any [braking] reports on runway one niner one alpha echo 2212:06 CST; TWR; I'll have it for you in just a second 2212:07 CST; N911AE; thank you 2212:21 CST; TWR; flight express seven forty five how's the [braking] action 2212:22 CST; FLX745; ah we are just slipping just a little bit it's pretty good I'd say it's moderate to ah (unintelligible) 2212:27 CST; TWR; understand that breaking action is fair 2212:29 CST; FLX745; ah yea I'd call it fair 2212:35 CST; TWR; o k use caution down from there it hasn't been touched at all foxtrot looks like it's been plowed proceed into the ramp this frequency good night 2212:37 CST; FLX745; roger we'll stay with you flight express seven forty five 2212:43 CST; MKLC TWR; lear one alpha echo centurion that just landed reported [braking] action fair and I'd appreciate a [braking] action report from you also 2214:48 CST; N911AE; will do one alpha echo 2217:45 CST; TWR; lear one alpha echo tower 2217:48 CST; N911AE; o k we are all right 2217:49 CST; MKC TWR; o k are you off the runway sir 2217:51 CST; N911AE; we are 2218:04 CST; TWR; one alpha echo understand you are on your way to the ramp I don't have you in sight sir 2218:09 CST; N911AE; one alpha echo off the end of the runway pass the localizer 2218:14 CST; TWR; o k understand you are off the end of the runway 2218:18 CST; N911AE; we have departed the end of the runway through the perimeter fence The copilot stated that following the closure of MCI, APP indicated at least a one-hour holding time was to be expected and numerous aircraft were diverting to Omaha. The copilot asked APP if MKC was available and was issued a clearance to MKC. He obtained Automated Terminal Information Service (ATIS) Echo, which reported a visibility of 1/2 statute mile (sm) with light snow and freezing fog. He told APP that MKC was below approach minimums and requested clearance to their alternate, LNK. After turning to a direct route to LNK, APP reported ATIS information Foxtrot as: 1 1/4 sm visibility in light snow and mist; sky condition as few at 1,000 feet above ground level (agl) and scattered at 1,800 feet agl with instrument landing system (ILS) 19 approach in use. They were then cleared to MKC. The copilot stated that he heard TWR talking to an aircraft that just landed regarding braking action. The copilot stated TWR then reported braking action to the Learjet 35A as fair but did not specify the aircraft type that reported the braking action. The copilot stated that the approach was flown "stabilized" with a speed of REF + 30 until flaps were selected, then REF + 10 for the remainder of the approach, slowing to REF + 5 over the fence. The glideslope was followed to touchdown, about 1,000 feet from the threshold. The touchdown was made to the right. The deceleration appeared "normal" as brakes were applied, until 1,500 - 2,000 feet from the departure end of the runway when the speed appeared to "stabilize" about 20-30 knots. The copilot stated that he called for maximum braking and they both noted the brakes were "ineffective" at slowing the airplane and they knew that they would not stop by the end of the runway. The pilot of FLX745 stated that he was cleared for approach and heard TWR asking the snow removal crew to get clear of the runway. As he broke out of the clouds, he could see the runway was not completely cleared; however, it was cle ## Aircraft - Registration: [N911AE](https://openairdocs.org/deregistered/N911AE-2009-01-22), registration cancelled 2009-01-22, S/N 109 (OpenAirDocs) - Reported make and model: Learjet 35A - Registry model: [Gates Learjet 35A](https://openairdocs.org/model/gates-learjet-35a) (registry code 5170602) (OpenAirDocs) - Category: Airplane - Serial number: 109 - Airframe hours: 11138.9 - Engines: Allied Signal TFE 731-2-2B 3500 lbs thrust turbo fan - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Business Aviation Management Group Inc, doing business as Million Air - Registered owner: Keystone Aviation LLC - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, October 1, 2004, 102.4 hours before - Departed: SLC, Salt Lake City, UT - Destination: MKC, Kansas City, MO - Flight plan: IFR - Airport: MKC, Charles B. Wheeler Downtown, runway 19, 7,002 × 150 ft, snow ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1; last flight review January 1, 2005; seat: left; flight hours: 5,127 total, 1,236 in this make and model, 3,886 as pilot in command, 99 in the last 90 days, 50 in the last 30 days, 2 in the last 24 hours - Co-pilot; age 38; injuries: none; flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1; last flight review January 1, 2005; seat: right; flight hours: 4,301 total, 482 in this make and model, 3,621 as pilot in command, 76 in the last 90 days, 38 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night - Wind: 0° at 0 knots - Visibility: 0.75 statute miles - Lowest ceiling: 1,600 ft broken - Temperature: 30 °F, dew point 28 °F - Altimeter: 30.19 inHg - Observed at: MKC ## 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 20050128002139A](https://openairdocs.org/incident/20050128002139A), Jan 28, 2005: Lear 35A, Kansas City, MO, Substantial damage. (-23) Flight crew of N911AE attempted a landing on runway 19 @kmkc (7,002 feet) after calculating a landing distance requirement of 5,400 feet (a multiplier of… ## Docket (17 files) The files NTSB released with the investigation on January 16, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60987. 5.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 397 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398012&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statements (item 2, .PDF, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398013&FileExtension=.PDF&FileName=Pilot%20Statements-Redacted.PDF - Meteorology 5 - Factual Report of Group Chairman (item 3, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241594&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Weather (item 4, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40270945&FileExtension=.PDF&FileName=Weather-Master.PDF - Lincoln Airport Field Condition (item 5, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398014&FileExtension=.PDF&FileName=Lincoln%20Airport%20Field%20Condition-Redacted.PDF - ATC Partial Transcript (item 6, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268950&FileExtension=.PDF&FileName=ATC%20Partial%20Transcript-Master.PDF - Aircraft Radar Track Data (item 7, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268951&FileExtension=.PDF&FileName=Aircraft%20Radar%20Track%20Data-Master.PDF - Airport Information (item 8, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268952&FileExtension=.PDF&FileName=Airport%20Information-Master.PDF - Aircraft Registration and Airworthiness Certificate (item 9, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398015&FileExtension=.PDF&FileName=Aircraft%20Registration%20and%20Airworthiness%20Certificate-Redacted.PDF - Airplane Minimum Equipment List (item 10, .PDF, 253 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398016&FileExtension=.PDF&FileName=Airplane%20Minimum%20Equipment%20List-Redacted.PDF - MCI Statements and Field Conditions (item 11, .PDF, 376 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398018&FileExtension=.PDF&FileName=MCI%20Statements%20and%20Field%20Conditions-Redacted.PDF - Aeronautical Information Manual (item 12, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268956&FileExtension=.PDF&FileName=Aeronautical%20Information%20Manual-Master.PDF - Airplane Landing Performance Information (item 13, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268957&FileExtension=.PDF&FileName=Airplane%20Landing%20Performance%20Information-Master.PDF - Airplane Weight and Balance Information (item 14, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398019&FileExtension=.PDF&FileName=Airplane%20Weight%20and%20Balance%20Information-Redacted.PDF - Airport Winter Safety and Operations (item 15, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40268959&FileExtension=.PDF&FileName=Airport%20Winter%20Safety%20and%20Operations-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 16, .PDF, 308 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398020&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 17, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274960&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-Master.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.