ERA09LA538

NTSB accident investigation · Bombardier CL-600-2B16 · Vineyard Haven, MA · September 27, 2009

Accident · No injuriesLimited investigationFinal report
Date
September 27, 2009, 15:50 local (19:50 UTC)
Place
Vineyard Haven, MA
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N190MPBombardier CL-600-2B16
Defining event
Landing-flare/touchdown: Hard landing
Weather
Instrument (IMC) · Day
Status
Completed · report March 16, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Bombardier Aerospace, Transportation Safety Board of Canada
FAA report
20090927017339A
Case key
74820

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's improper flare while landing in gusting wind, which resulted in a hard landing.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: landing flareAircraft › Aircraft oper/perf/capability · Not attained/maintainedAll aircraft: 1,285 casesProbable cause
Flight control system: tE flap control systemAircraft › Aircraft systems · Incorrect use/operationAll aircraft: 74 cases
Wind: gustsEnvironmental issues › Conditions/weather/phenomena · Effect on operationAll aircraft: 1,199 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Hard landingLanding-flare/touchdownAll aircraft: 2,102 casesDefining event

Analysis

The pilot-in-command (PIC) was performing an instrument-landing-system approach and elected to use a flap setting of 30 degrees based on the landing conditions, with an approach speed of 135 knots. The flight crew reported that when the airplane was about 15 to 20 feet above the runway, it encountered windshear, which resulted in a loss of airspeed and a hard landing. The airplane departed the airport about 15 minutes later. After takeoff, when the landing gear was selected to the up position, the nose landing gear door open light remained illuminated and the PIC diverted to another airport, where the airplane landed without incident. Subsequent inspection revealed substantial damage to the nose section of the airplane, which included wrinkling at the forward pressure bulkhead. Data obtained from the airplane's enhanced ground proximity warning system revealed a sink rate warning when the airplane was about 50 feet above the ground. The airplane touched down at an airspeed of about 150 knots. The airplane was certified for normal landings with the flap system at 45 degrees only, and the manufacturer did not provide for a flap setting of 30 degrees except in the event of a flap system malfunction. A weather observation taken at the airport, about the time of the accident, included wind from 120 degrees at 16 knots, gusting to 23 knots, with a visibility of 1 1/4 statute miles in heavy rain and mist and a ceiling of 400 feet broken. The PIC reported that he did not experience any mechanical malfunctions with the airplane during the accident flight.

Factual narrative

On September 27, 2009, about 1550 eastern daylight time, a Bombardier CL-600-2B16, N190MP, was substantially damaged while landing at the Martha's Vineyard Airport (MVY), Vineyard Haven, Massachusetts. The two certificated airline transport pilots and two passengers were not injured. Instrument meteorological conditions prevailed and an instrument flight rules flight plan had been filed for the flight that originated in Denver, Colorado. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The airplane was being flown by the pilot-in-command (PIC) and was cleared for the instrument landing system (ILS) approach to runway 24, a 5,504-foot-long, 100-foot-wide, asphalt runway. The flight crew reported that the landing was performed utilizing a flap setting of 30 degrees based on the landing conditions, with a landing approach speed of 135 knots. The PIC reported that he experienced a left to right crosswind of 24 knots, while the airplane descended on the ILS. The approach was stable, "all the way down to the flare;" however, when airplane was about 15 feet above the runway, "the aircraft suddenly lost airspeed and landed hard." The airplane bounced approximately 15 to 20 feet back into the air, before it contacted the ground, and bounced about 5 to 10 feet. The airplane subsequently landed and rolled out on the runway without further incident. In a written statement, the copilot reported, "…We broke out about 500 feet above the ground. All operations were normal and we had briefed the approach and to be aware of the possibility of windshear due to the conditions. At about 20 feet, the PIC reduced the throttles to idle for the landing flare and just as he did so, there was a loss of about 25 knots of airspeed. The aircraft landed on the main landing gear and bounced. The aircraft then settled on the nose gear and bounced, then landed on the mains…." An airport operations supervisor witnessed the accident and stated that the airplane landed hard, about 1,500 feet down the runway. He further stated that the airplane appeared to be traveling at a high rate of speed, when he observed the airplane's spoilers deploy, with the airplane about 3,000 feet down the runway. The PIC reported that the airplane was visually inspected after the hard landing without any abnormalities noted, and the flight crew departed MVY about 15 minutes later. After takeoff, when landing gear was selected to the up position, the nose landing gear door open light remained illuminated. The PIC elected to divert to Bradley International Airport, Windsor Locks, Connecticut, where the airplane landed without incident. Subsequent inspection of the airplane by a Federal Aviation Administration inspector revealed substantial damage to the nose section of the airplane, which included wrinkling at the forward pressure bulkhead. The airplane was equipped with a cockpit voice recorder (CVR) and an enhanced ground proximity warning system (EGPWS),which were retained for further examination. The airplane was not equipped; nor was it required to be equipped with a flight data recorder (FDR). The CVR was sent to the Safety Board's Vehicle Recorder Laboratory, Washington, DC, for readout. The CVR recorded four channels of audio information for 30 minutes; however, none of the audio was pertinent to the accident. The audio captured was consistent with the CVR being overwritten or recorded over by subsequent events. The EGPWS was downloaded at Honeywell, Inc, Redmond, Washington, under the supervision of an NTSB investigator. Review of the data recorded by the EGPWS revealed a "too low flaps" warning activated when the airplane was about 300 feet above the ground, followed approximately 14 seconds later by a sink rate warning, when the airplane was about 50 feet above the ground. The airplane touched down at airspeed about 150 knots. There were no windshear alerts generated by the EGPWS for the accident flight. The PIC reported 7,220 hours of total flight experience, which included about 710 hours in the same make and model as the accident airplane. He further reported that he did not experience any mechanical malfunctions with the airplane during the accident flight. The airplane operating manual, Supplemental Procedures Section 3, Precautionary Actions, "when windshear activity is known or suspected at arrival…" included the instruction, "Select the minimum flap setting acceptable for the runway length to be used." According to the manufacturer, the airplane was certified for normal landings with the flap system at 45 degrees only, and there was no flight test data to certify the airplane to land with the flap system not at 45 degrees during normal operations. At the time of certification, the airplane was tested for abnormal conditions, including wing flap system malfunctions, with landings at flap settings other than 45 degrees, and corresponding abnormal procedures were published in the airplane flight manual; however, the abnormal procedures and the use of flaps at a setting other than 45 degrees for landing were to be used only in the event of the specific abnormal conditions, and as specified by the appropriate procedure. After the accident, the manufacturer revised the airplane operating manual Supplemental Procedures Section 3, Precautionary Actions, "when windshear activity is known or suspected at arrival…" by deleting the sentence "Select the minimum flap setting acceptable for the runway length to be used." A weather observation taken at MVY, about the time of the accident, reported, wind from 120 degrees at 16 knots, gusting to 23 knots; visibility 1 1/4 statute miles in heavy rain and mist; ceiling 400 feet broken, 900 feet broken, and 1,900 feet overcast; temperature 18 degrees Celsius (C), dew point 17 degrees C; altimeter 29.61 inches of mercury.

Aircraft

Registration
N190MP
Reported as
Bombardier CL-600-2B16
Category
Airplane
Serial number
5161
Airframe hours
7,914
Engines
GE CF-34-3A1, 8,729 lbs thrust, turbo fanGE CF-34-3A1, 8,729 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 18, 2009 · 11 hours before
Departed
APA · Denver, CO
Destination
MVY · Vineyard Haven, MA
Flight plan
IFR
Airport
MVY · Martha's Vineyard, runway 24, 5,504 × 100 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 7, 2009
Seat
Left
Flight hours
7,220 total · 710 in this make and model · 4,632 as pilot in command · 11 in the last 90 days · 8 in the last 30 days · 4 in the last 24 hours
Role
Co-pilot
Age
53
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
September 21, 2009
Seat
Right
Flight hours
8,934 total · 475 in this make and model · 7,543 as pilot in command · 22 in the last 90 days · 20 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
120° at 16 knots, gusting 23
Visibility
1 statute miles
Lowest ceiling
400 ft broken
Temperature
64 °F, dew point 63 °F
Altimeter
29.61 inHg
Observed at
MVY

Docket · 10

The files NTSB released with the investigation on November 23, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.