# NTSB DCA15MA029: Embraer EMB-500, N100EQ, Gaithersburg, MD, December 8, 2014

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: December 8, 2014, 10:41 local (15:41 UTC)
- Place: Gaithersburg, MD
- Coordinates: 39.180278, -77.180557
- Nearby events: https://openairdocs.org/map.md?lat=39.1803&lon=-77.1806&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-IFR final approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Fatal
- Injuries: 6 fatal; on the ground: 3 fatal
- Status: Completed, report June 21, 2016
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Major Investigations Division
- Parties: Transportation Safety Board of Canada, Aeronautical Accidents Investigation and Preventio, Federal Aviaton Administration
- Safety recommendations: Yes
- NTSB case key (mKey): 90473
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA15MA029.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90473/pdf
- Board report AAR1601 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1601.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90473
- Page: https://openairdocs.org/ntsb/DCA15MA029

## Probable cause

the pilot's conduct of an approach in structural icing conditions without turning on the airplane's wing and horizontal stabilizer deice system, leading to ice accumulation on those surfaces, and without using the appropriate landing performance speeds for the weather conditions and airplane weight, as indicated in the airplane's standard operating procedures, which together resulted in an aerodynamic stall at an altitude at which a recovery was not possible.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Embraer-Empresa Brasileira De EMB-500, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=3260402), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Planning/preparation](https://openairdocs.org/ntsb-findings/02061000): Personnel issues › Task performance · Pilot; cases with it: [Embraer-Empresa Brasileira De EMB-500, 1 case](https://openairdocs.org/ntsb-findings/02061000/cases.md?model=3260402), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md)
- [Loading](https://openairdocs.org/ntsb-findings/01011500): Aircraft › Aircraft handling/service · Related operating info; cases with it: [Embraer-Empresa Brasileira De EMB-500, 1 case](https://openairdocs.org/ntsb-findings/01011500/cases.md?model=3260402), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01011500/cases.md)
- [Ceiling/visibility/precip](https://openairdocs.org/ntsb-findings/03035000): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Embraer-Empresa Brasileira De EMB-500, 1 case](https://openairdocs.org/ntsb-findings/03035000/cases.md?model=3260402), [All aircraft, 65 cases](https://openairdocs.org/ntsb-findings/03035000/cases.md)
- [Ice/rain protection system: airfoil anti-ice, deice](https://openairdocs.org/ntsb-findings/01023010): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Embraer-Empresa Brasileira De EMB-500, 1 case](https://openairdocs.org/ntsb-findings/01023010/cases.md?model=3260402), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01023010/cases.md)
- [Indicating/recording systems](https://openairdocs.org/ntsb-findings/01023100): Aircraft › Aircraft systems · Not installed/available; cases with it: [Embraer-Empresa Brasileira De EMB-500, 1 case](https://openairdocs.org/ntsb-findings/01023100/cases.md?model=3260402), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01023100/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-descent: Structural icing](https://openairdocs.org/ntsb-events/210); cases with it: [Embraer-Empresa Brasileira De EMB-500, 1 case](https://openairdocs.org/ntsb-events/210/sequence.md?model=3260402), [All aircraft, 102 cases](https://openairdocs.org/ntsb-events/210/sequence.md)
- [Approach-IFR final approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Embraer-Empresa Brasileira De EMB-500, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=3260402), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Approach-IFR final approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Embraer-Empresa Brasileira De EMB-500, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=3260402), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-16/01. On December 8, 2014, about 1041 eastern standard time, an Embraer EMB-500 airplane (marketed as the Phenom 100), N100EQ, registered to and operated by Sage Aviation LLC, crashed while on approach to runway 14 at Montgomery County Airpark (GAI), Gaithersburg, Maryland. The airplane impacted three houses and the ground about 3/4 mile from the approach end of the runway. A postcrash fire involving the airplane and one of the three houses, which contained three occupants, ensued. The pilot, the two passengers, and the three people in the house died as a result of the accident. The airplane was destroyed by impact forces and postcrash fire. The flight was operating on an instrument flight rules (IFR) flight plan under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed at the time of the accident.

## Factual narrative

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-16/01. On December 8, 2014, about 1041 eastern standard time, an Embraer EMB-500 airplane (marketed as the Phenom 100), N100EQ, registered to and operated by Sage Aviation LLC, crashed while on approach to runway 14 at Montgomery County Airpark (GAI), Gaithersburg, Maryland. The airplane impacted three houses and the ground about 3/4 mile from the approach end of the runway. A postcrash fire involving the airplane and one of the three houses, which contained three occupants, ensued. The pilot, the two passengers, and the three people in the house died as a result of the accident. The airplane was destroyed by impact forces and postcrash fire. The flight was operating on an instrument flight rules (IFR) flight plan under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed at the time of the accident.

## Aircraft

- Registration: [N100EQ](https://openairdocs.org/deregistered/N100EQ-2018-03-16), registration cancelled 2018-03-16, S/N 50000082, built 2009 (OpenAirDocs)
- Reported make and model: EMBRAER EMB-500
- Registry model: [Embraer-Empresa Brasileira De EMB-500](https://openairdocs.org/model/embraer-empresa-brasileira-de-emb-500) (registry code 3260402) (OpenAirDocs)
- Registry engine: [Pratt & Whitney Canada PW617F-E](https://openairdocs.org/engine/pratt-whitney-canada-pw617f-e) (registry code 52293, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 50000082
- Year built: 2009
- Airframe hours: 633.8
- Engines: P&W CANADA PW617F-E turbo jet; P&W CANADA PW617F-E turbo jet
- Damage: Destroyed
- Fire: On-Ground
- Flight: Personal, Part 91
- Operator: Sage Aviation LLC
- Registered owner: Sage Aviation LLC
- Airworthiness certificate: Standard, Normal
- Last inspection: Continuous airworthiness, November 14, 2014
- Departed: IGX, Chapel Hill, NC
- Destination: GAI, Gaithersburg, MD
- Flight plan: IFR
- Airport: GAI, Montgomery County Airpark, runway 14, 4,202 × 75 ft, asphalt
- Equipment: Stall warning system, Data recorder

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 66; injuries: fatal; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review April 28, 2014; seat: left; toxicology performed; flight hours: 4,736.5 total, 135.8 in this make and model

## Weather

- Conditions: Instrument (IMC), Day
- Wind: 40° at 6 knots
- Visibility: 10 statute miles
- Lowest ceiling: 3,200 ft overcast
- Temperature: 30 °F, dew point 19 °F
- Altimeter: 30.61 inHg
- Observed at: GAI

## 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 20141208024529A](https://openairdocs.org/incident/20141208024529A), Dec 8, 2014: Embraer-Empresa Brasileira De EMB-500, Gaithersburg, MD, Destroyed, 3 fatal. On December 8, 2014, about 1041 eastern standard time, the Embraer EMB-500 ?phenom? Business jet, impacted trees and residential homes about 4,000 feet from…

## Docket (39 files)

The files NTSB released with the investigation on January 20, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90473. 93.1 MB in all.

- Cockpit Voice Recorder - Group Chairman's Factual Report (item 1, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435770&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%20-%20Group%20Chairman%27s%20Factual%20Report-Master.PDF
- Personal Electronic Devices - Specialist's Factual Report (item 2, .PDF, 9 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435721&FileExtension=.PDF&FileName=Personal%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Powerplant Group Chairman's Report (item 3, .PDF, 32 photos, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435722&FileExtension=.PDF&FileName=Powerplant%20Group%20Chairman%27s%20Report-Master.PDF
- Maintenance Records (item 4, .PDF, 371 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435723&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF
- Meteorology (item 5, .PDF, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435724&FileExtension=.PDF&FileName=Meteorology-Master.PDF
- Structures Factual Report (item 6, .PDF, 31 photos, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435725&FileExtension=.PDF&FileName=Structures%20Factual%20Report-Master.PDF
- Systems Factual Report (item 7, .PDF, 950 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435726&FileExtension=.PDF&FileName=Systems%20Factual%20Report-Master.PDF
- Errata - Systems Group Chairman's Factual (item 8, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440819&FileExtension=.PDF&FileName=Errata%20-%20Systems%20Group%20Chairman%27s%20Factual-Master.PDF
- ATC Factual Report (item 9, .PDF, 347 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435727&FileExtension=.PDF&FileName=ATC%20Factual%20Report-Master.PDF
- ATC Factual Report - Attachment 1 (item 10, .PDF, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435728&FileExtension=.PDF&FileName=ATC%20Factual%20Report%20-%20Attachment%201-Master.PDF
- ATC Factual Report - Attachment 2 (item 11, .PDF, 265 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435729&FileExtension=.PDF&FileName=ATC%20Factual%20Report%20-%20Attachment%202-Master.PDF
- ATC Factual Report - Attachment 3 (item 12, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435730&FileExtension=.PDF&FileName=ATC%20Factual%20Report%20-%20Attachment%203-Master.PDF
- ATC Factual Report - Attachment 4 (item 13, .PDF, 495 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435731&FileExtension=.PDF&FileName=ATC%20Factual%20Report%20-%20Attachment%204-Master.PDF
- ATC Factual Report - Attachment 5 (item 14, .PDF, 553 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435732&FileExtension=.PDF&FileName=ATC%20Factual%20Report%20-%20Attachment%205-Master.PDF
- Survival Factors - Specialist's Factual Report (item 15, .PDF, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435733&FileExtension=.PDF&FileName=Survival%20Factors%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Flight Data Recorder - Specialist's Factual Report (item 16, .PDF, 998 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435734&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Flight Data Recorder - Attachment 1 (FDR tabular data for event flight) (item 17, .CSV, 55.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435735&FileExtension=.csv&FileName=Flight%20Data%20Recorder%20-%20Attachment%201%20(FDR%20tabular%20data%20for%20event%20flight)-Master.csv
- Flight Data Recorder - Attachment 2 (FDR tabular data for previous flight) (item 18, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435736&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%20-%20Attachment%202%20(FDR%20tabular%20data%20for%20previous%20flight)-Master.PDF
- Garmin Integrated Avionics (GIA) Units - Specialist's Factual Report (item 19, .PDF, 1 photo, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435737&FileExtension=.PDF&FileName=Garmin%20Integrated%20Avionics%20(GIA)%20Units%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Garmin Integrated Avionics (GIA) Units - Attachment 1 (item 20, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435738&FileExtension=.PDF&FileName=Garmin%20Integrated%20Avionics%20(GIA)%20Units%20-%20Attachment%201-Master.PDF
- Garmin Integrated Avionics (GIA) Units - Attachment 2 (item 21, .PDF, 324 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435739&FileExtension=.PDF&FileName=Garmin%20Integrated%20Avionics%20(GIA)%20Units%20-%20Attachment%202-Master.PDF
- Flight Data Recorder Addendum - Additional Parameters (item 22, .PDF, 340 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440820&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%20Addendum%20-%20Additional%20Parameters-Master.PDF
- Flight Data Recorder Addendum - Additional Parameters Attachement 1 (Tabular data for additional parameters) (item 23, .CSV, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440821&FileExtension=.csv&FileName=Flight%20Data%20Recorder%20Addendum%20-%20Additional%20Parameters%20Attachement%201%20(Tabular%20data%20for%20additional%20parameters)-Master.csv
- Operations Group Factual Report (item 24, .PDF, 406 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435740&FileExtension=.PDF&FileName=Operations%20Group%20Factual%20Report-Master.PDF
- Operations - Attachment 1 - Interview Summaries (item 25, .PDF, 360 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435741&FileExtension=.PDF&FileName=Operations%20-%20Attachment%201%20-%20Interview%20Summaries-Master.PDF
- Operations - Attachment 2 - POH excerpt - Ice Protection System (item 26, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435742&FileExtension=.PDF&FileName=Operations%20-%20Attachment%202%20-%20POH%20excerpt%20-%20Ice%20Protection%20System-Master.PDF
- Operations - Attachment 3 - POH excerpt - Stall Warning System (item 27, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435743&FileExtension=.PDF&FileName=Operations%20-%20Attachment%203%20-%20POH%20excerpt%20-%20Stall%20Warning%20System-Master.PDF
- Operations - Attachment 4 - POH excerpt - Landing Performance (item 28, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435744&FileExtension=.PDF&FileName=Operations%20-%20Attachment%204%20-%20POH%20excerpt%20-%20Landing%20Performance-Master.PDF
- Operations - Attachment 5 - Weight and Balance Information (item 29, .PDF, 496 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435745&FileExtension=.PDF&FileName=Operations%20-%20Attachment%205%20-%20Weight%20and%20Balance%20Information-Master.PDF
- Operations - Attachment 6 - GAI RNAV (GPS) RWY 14 IAP (item 30, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435746&FileExtension=.PDF&FileName=Operations%20-%20Attachment%206%20-%20GAI%20RNAV%20(GPS)%20RWY%2014%20IAP-Master.PDF
- Operations - Attachment 7 - Pilot Training Records (item 31, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435747&FileExtension=.PDF&FileName=Operations%20-%20Attachment%207%20-%20Pilot%20Training%20Records-Master.PDF
- Operations - Attachment 8 - Pilot Logbook (02.10.15) (item 32, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435748&FileExtension=.PDF&FileName=Operations%20-%20Attachment%208%20-%20Pilot%20Logbook%20(02.10.15)-Master.PDF
- Operations - Attachment 9 - Quick Reference Handbook - Excerpts - Landing Performance (item 33, .PDF, 387 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435749&FileExtension=.PDF&FileName=Operations%20-%20Attachment%209%20-%20Quick%20Reference%20Handbook%20-%20Excerpts%20-%20Landing%20Performance-Master.PDF
- Operations Attachment 10 -- Quick Reference Handbook -- Excerpts -- Checklists (item 34, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440822&FileExtension=.PDF&FileName=Operations%20Attachment%2010%20--%20Quick%20Reference%20Handbook%20--%20Excerpts%20--%20Checklists-Master.PDF
- Operations Attachment 11 - Photographs of non-standard checklist (item 35, .PDF, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440823&FileExtension=.PDF&FileName=Operations%20Attachment%2011%20-%20Photographs%20of%20non-standard%20checklist-Master.PDF
- Aircraft Performance Study (item 36, .PDF, 8 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435750&FileExtension=.PDF&FileName=Aircraft%20Performance%20Study-Master.PDF
- Aircraft Performance Study Addendum 1 - CVDR Extraction (item 37, .PDF, 541 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440825&FileExtension=.PDF&FileName=Aircraft%20Performance%20Study%20Addendum%201%20-%20CVDR%20Extraction-Master.PDF
- Aircraft Performance Study Addendum 2 - LEWICE Icing Report (item 38, .PDF, 878 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440826&FileExtension=.PDF&FileName=Aircraft%20Performance%20Study%20Addendum%202%20-%20LEWICE%20Icing%20Report-Master.PDF
- Aircraft Performance Study Errata (item 39, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440827&FileExtension=.PDF&FileName=Aircraft%20Performance%20Study%20Errata-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.

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