# NTSB ERA11LA345: Cessna 525A, N129SG, Nashville, TN, June 15, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 15, 2011, 17:25 local (22:25 UTC) - Place: Nashville, TN - Coordinates: 36.17361, -86.889167 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.1736&lon=-86.8892&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Landing area overshoot](https://openairdocs.org/ntsb-events/380) - Highest injury: No injuries - Injuries: 5 uninjured - Status: Completed, report January 17, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 80792 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11LA345 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/80792/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=80792 - Page: https://openairdocs.org/ntsb/ERA11LA345 ## Probable cause The pilot-in-command's failure to execute a go-around when the airplane was high and fast on the final approach. ## 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: [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Landing area overshoot](https://openairdocs.org/ntsb-events/380) (defining event); cases with it: [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490); cases with it: [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The pilot-in-command (PIC) was in the left cockpit seat, and a passenger, who possessed a student pilot certificate, was in the right cockpit seat. The PIC was not a certificated flight instructor; however, the student pilot was at the controls for a majority of the flight. During the descent and initial approach, the student pilot allowed the airplane to become high and fast, and the PIC subsequently took over the controls and continued the approach. During the final approach, the ground proximity warning system announced "sink rate" eight times. After touchdown, the antiskid system activated; however, there was insufficient runway remaining on which to stop the airplane. The PIC reported that he neglected to consider the wet runway condition. The airplane overran the runway and struck the instrument landing system antennas before coming to a stop. The PIC reported that there were no mechanical malfunctions or failures during the flight. As a result of the accident, the operator modified its operational procedures to restrict unqualified personnel from the cockpit during flight and initiated a formal risk assessment program. ## Factual narrative On June 15, 2011, about 1725 central daylight time, a Cessna 525A, N129SG, was substantially damaged following a runway overrun at John C. Tune Airport (JWN), Nashville, Tennessee. The certificated airline transport pilot and four passengers were not injured. The airplane was registered to and operated by Deer Horn Aviation LTD under the provisions of 14 Code of Federal Regulations Part 91, as a business flight. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The flight originated from Artesia Municipal Airport (ATS), Artesia, New Mexico, about 1406 mountain daylight time. The pilot-in-command (PIC) reported the following. As the airplane was approaching JWN, one of the owners of the airplane, who held a student pilot certificate, was in the right seat and at the controls. Air traffic control vectored the airplane to the final approach course, and the PIC acquired the airport and cancelled the IFR clearance. He informed the student pilot that the airplane was "high and hot" and he needed to "get down and slow down." The student pilot told the PIC that this "landing is yours" and the PIC assumed the controls. He configured the airplane for landing and "started a steep approach." He considered a go-around, but elected to continue the approach. Approaching the runway, the "sink rate" and "pull up" aural warnings activated on the ground proximity warning system (GPWS). He continued with the approach and the airplane touched down about 1,500 feet down the 5,500 foot long runway. The PIC applied the brakes fully, but the airplane continued down the runway. The PIC reported that he could feel the antiskid braking system working, but he neglected to consider the runway condition, which was wet. The airplane overran the runway and struck the instrument landing system antennas. The PIC applied full left rudder to avoid going down an embankment. The airplane came to rest after turning about 180 degrees. An inspector with the Federal Aviation Administration responded to the accident site and examined the airplane. The left main landing gear was collapsed, and structural damage to the wings was evident. The cockpit voice recorder (CVR) was sent to the NTSB Vehicle Recorders Laboratory for further examination. A review of the CVR recording revealed the following. The recording began at 1521 as the airplane was in cruise climb to flight level 390. The student pilot was at the controls, receiving guidance and instruction from the PIC. During cruise, the pilots discussed various non-pertinent topics, interspersed with operational instruction related to convective activity along the route, avionics, aircraft operating techniques, and the use of weather radar. During the descent into JWN, the student pilot noted how fun it was to deviate around thunderstorms while the PIC explained that the nearby storms were of significant intensity. About 1717, air traffic control assigned an altitude of 3,000 feet and thePIC directed the student pilot to start a descent. The PIC advised the student that the winds may be gusty and that he had the student’s "back." About 1721, after ATC assigned a 170 degree heading and cleared the aircraft for the instrument landing system (ILS) runway 20 approach, the PIC noted that the localizer was not being received. He then realized that he had entered the incorrect frequency into the radio. The airplane subsequently flew through the localizer course, and ATC issued a vector to re-intercept the course. At 1722, the PIC noted that the airplane was on course, reported that the runway was in sight, and cancelled the IFR flight plan with ATC. At 1723, the PIC noted that the aircraft was "real high," and the student pilot should get the plane down. The student pilot acknowledged, and then asked the PIC if he wanted to take the landing. The PIC responded that he would take the controls. The PIC then advised on the common traffic advisory frequency that the airplane was on a straight-in approach to runway 20 at JWN. At 1724, the GPWS announced "sink rate sink rate," followed by a radio altimeter annunciation of "five hundred." From this point until touchdown, the GPWS repeated "pull up" eight times, as the PIC stated, "Don’t worry about it." During the landing roll, the student pilot and the PIC began making animated expressions of concern, commencing at 1724:56 and continuing until the end of the recording. The PIC reported that he was not a certified flight instructor. He also reported that there were no mechanical malfunctions or failures with the airplane during the accident flight. JWN was equipped with an Automated Weather Observing System (AWOS); however, at the time of the accident, wind, temperature, and dew point information were not available. The 1711 weather at Nashville International Airport (BNA) located 9 miles east of JWN, included the following: winds from 180 degrees at 6 knots, 6 miles visibility, light rain and thunderstorms, scattered clouds at 4,500 feet, scattered cumulonimbus clouds at 6,000 feet, broken clouds at 11,000 feet, overcast clouds at 25,000 feet, temperature 19 degrees Celsius, dew point 18 degrees Celsius, and altimeter 29.78 inches of mercury. Thunderstorms began at 1701 and rain began at 1701. There was occasional lightning in the area. As a result of the accident, the operator modified its operational procedures to restrict unqualified personnel from the cockpit during flight. Also, a formal risk assessment program was initiated. ## Aircraft - Registration: N129SG (not matched to a registry record) - Reported make and model: CESSNA 525A - Category: Airplane - Serial number: 525A0129 - Airframe hours: 3224 - Engines: WILLIAMS FJ 44 SERIES 1900 lbs thrust turbo fan; WILLIAMS FJ 44 SERIES 2400 lbs thrust turbo fan - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Deer Horn Aviation Ltd Co - Registered owner: Deer Horn Aviation Ltd Co - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, December 7, 2010, 116 hours before - Departed: ATS, Artesia, NM - Destination: JWN, Nashville, TN - Flight plan: IFR - Airport: JWN, John C. Tune, runway 20, 5,500 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane, helicopter; medical: class 1, with waivers/limitations; last flight review March 31, 2011; seat: left; flight hours: 13,488 total, 670 in this make and model, 11,099 as pilot in command, 100 in the last 90 days, 28 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 180° at 6 knots - Visibility: 6 statute miles - Lowest ceiling: 11,000 ft broken - Temperature: 66 °F, dew point 64 °F - Altimeter: 29.78 inHg - Observed at: BNA, 11 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 20110615011269A](https://openairdocs.org/incident/20110615011269A), Jun 15, 2011: Cessna 525A, Nashville, TN, Substantial damage. On final approach 5 miles out for runway 20, the airspeed of the aircraft was 200 KTS and the aircraft was above glide path. The person in the right seat, who… ## Docket (6 files) The files NTSB released with the investigation on November 30, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=80792. 6.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353583&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Photo 1: Tire Marks in Grass at Runway 20 Departure End (FAA Photo) (item 2, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353586&FileExtension=.PDF&FileName=Photo%201%3A%20Tire%20Marks%20in%20Grass%20at%20Runway%2020%20Departure%20End%20(FAA%20Photo)-Master.PDF - Photo 2: Aircraft in Grass at Runway 20 Departure End (FAA Photo) (item 3, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353587&FileExtension=.PDF&FileName=Photo%202%3A%20Aircraft%20in%20Grass%20at%20Runway%2020%20Departure%20End%20(FAA%20Photo)-Master.PDF - Photo 3: Aircraft in Grass, Left Side, with Wing Damage (FAA Photo) (item 4, .PDF, 983 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353588&FileExtension=.PDF&FileName=Photo%203%3A%20Aircraft%20in%20Grass,%20Left%20Side,%20with%20Wing%20Damage%20(FAA%20Photo)-Master.PDF - Photo 4: Left Wing Structural Damage (FAA Photo) (item 5, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353589&FileExtension=.PDF&FileName=Photo%204%3A%20Left%20Wing%20Structural%20Damage%20(FAA%20Photo)-Master.PDF - Cockpit Voice Recorder 12 - Specialist's Factual Report (item 6, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358828&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Specialist%27s%20Factual%20Report-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.