ERA14TA435

NTSB accident investigation · Cessna T210N · Gaithersburg, MD · September 13, 2014

Accident · No injuriesFinal report
Date
September 13, 2014, 13:40 local (17:40 UTC)
Place
Gaithersburg, MD
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N5132CCessna T210N
Defining event
Landing-landing roll: Runway excursion
Weather
Instrument (IMC) · Day
Status
Completed · report September 24, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20140913016819A
Case key
90071

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 failure to execute a missed approach after recognizing that the airplane was not aligned with the wet runway, which resulted in a long landing with a tailwind and a subsequent runway overrun.

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.

Runway/land/takeoff/taxi surface: wet surfaceEnvironmental issues › Physical environment · Contributed to outcomeCessna T210N: 2 casesAll aircraft: 141 cases
Action: lack of actionPersonnel issues › Action/decision · PilotCessna T210N: 3 casesAll aircraft: 792 casesProbable cause
Wind: tailwindEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna T210N: 3 casesAll aircraft: 594 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.

Analysis

The pilot reported that the flight departed in visual flight rules conditions. While returning to the departure airport, the pilot obtained an instrument flight rules clearance due to instrument meteorological conditions at the destination. He was then vectored to intercept the final approach course for an RNAV (GPS) approach. Radar data indicated that the airplane subsequently flew the final approach course inbound from the intermediate fix to a point slightly south of the final approach fix (FAF). The radar data showed that, beyond the FAF to about 2.3 nautical miles from the runway, the airplane was not established on the final approach course and that it made several "S"-type turns. Witness, pilot, and passenger accounts indicated that the airplane was left of course when it broke out of the clouds. The pilot subsequently executed a right turn while maintaining visual contact with the runway. He then landed the airplane about halfway down the wet runway with about a 7-knot tailwind and 40 degrees of flaps extended. The pilot was unable to stop the airplane, and it overran the end of the runway and impacted rising terrain, which caused the nose landing gear to collapse and the airplane to nose over. The pilot reported no preimpact mechanical failures or malfunctions.

Factual narrative

On September 13, 2014, about 1340 eastern daylight time, a Cessna T210N, N5132C, nosed over following a landing overrun at the Montgomery County Airpark (GAI), Gaithersburg, Maryland. The commercial pilot and 2 other crew members were not injured. The airplane was substantially damaged. The airplane was registered to the pilot and operated by the U.S. Coast Guard Auxiliary as a public-use flight. Instrument meteorological conditions prevailed at the time which operated on an instrument flight rules clearance. The flight originated about 1130 EDT from the Millville Municipal Airport (MIV), Millville, New Jersey, and was destined for GAI.The pilot stated that the purpose of the flight was to observe boat traffic on several water ways. After takeoff from GAI they flew for about 2.5 hours and then proceeded to MIV and landed uneventfully. The flight departed VFR and flew over Delaware Bay, Chesapeake and Delaware Canals, Chesapeake Bay, and the North part of Chesapeake Bay before proceeding to GAI. While inbound to GAI he obtained Baltimore weather from the XM satellite, and when the flight was 5 miles from GAI, he noted cloud cover. While talking with Potomac Approach Control, he requested IFR clearance, and climbed to either 3,500 or 3,000 feet. While flying in IMC conditions he was vectored towards Frederick, and was cleared for and vectored to intercept the final approach course for the RNAV (GPS) approach. At TIMBE (Final Approach Fix), he extended the landing gear and lowered the flaps to 10 degrees, and continued the approach breaking out at 500 feet. He noticed the flight was 50 to 100 yards left of the runway, and with the runway in sight, he turned to the right in a "gentle" 270 degree turn, maintaining 80 knots. After the completion of the turn he aligned himself with the runway, and lowered the flaps to 40 degrees, maintaining 79 knots. He touched down about 1/2 way down the runway, and after touchdown he kept the flaps at that position and applied the airplane's brakes but they were not effective. The airplane travelled off the end of the runway onto grass and contacted a mound causing the airplane to nose over. He reported there were no injuries and all exited the airplane. The pilot later stated that after getting out of the airplane he noted a 5 to 8 knot tailwind component, and stated that about 10 minutes before starting the approach he was given the wind as 3 to 5 knots but did not recall the direction. He also stated there was standing water on the runway, and it had been previously raining. The pilot reported there was no preimpact mechanical failure or malfunction. The right front seat passenger who is not pilot rated but well acquainted with aviation reported that during the approach, the flight became clear of the clouds at 600 feet with a clear view of the runway, but was "significantly" left of the runway. The pilot executed a go-around and turned to return to runway 14 while maintaining visual contact with the runway,which appeared to be wet. During the descent there appeared to be "choppy wind conditions" with altitude deviations of 50 feet. He indicated the pilot struggled to bring the aircraft to the runway and reported the airplane landed about 1/2 way down the runway. He observed the pilot applying very strong effort on the brakes but the airplane did not appear to slow. The airplane went past the end of the runway at approximately 45 knots, and the nose landing gear collapsed after contacting rising terrain. The airplane then nosed over and came to rest inverted. The rear seat passenger confirmed that when the flight descended below the clouds on the approach the airplane was left of the runway. He reported the pilot went around to the right and landed about 1/4 to 1/3 down the runway. He felt moderate force against his restraint associated with braking, and reported he was surprised by the nose-over. Plotting of the radar data onto a GPS Runway 14 Approach Chart was performed by NTSB personnel. The plot indicated the pilot flew over BEGKA (the intermediate fix) and maintained the final approach course until approaching TIMBE, at which time the airplane flew slightly south of TIMBE. The radar data indicates the flight was not established on the final approach course from before TIMBE to the final radar return which was located southeast of JOXOX; "S" type turns were noted between TIMBE and after JOXOX, which is located 2.3 nautical miles from runway 14. The radar plot and radar data used for the radar plot are contained in the NTSB public docket. A witness who was in an airplane near the approach end of runway 14 north of the runway waiting IFR release indicated a right quartering tailwind existed, and reported first observing the airplane when it was left of his position flying in a southerly direction. The witness noted the airplane banked to the right and flew over the runway turning to the north where he lost sight of it. He then noted the airplane flew over his position about 20 seconds later about 200 feet above ground level while in a southerly direction, and flew south of the runway then banked to the left correcting back. The witness estimated that from his vantage point the airplane touched down between 2/3rd's to 3/4 down the runway, followed by seeing the airplane's tail in the air. The witness called on the Potomac Approach control frequency believing it was the common traffic advisory frequency to alert of the accident. A statement from the witness is contained in the NTSB public docket. According to the airport manager, the location where the airplane came to rest was approximately 725 feet past the departure end of the runway. A surface observation weather report taken at GAI at 1335, or about 5 minutes before the accident indicates that the wind was from 290 degrees at 7 knots; no gusts were reported.

Aircraft

Registration
N5132C
Reported as
Cessna T210N
Category
Airplane
Serial number
21063708
Built
1979
Airframe hours
5,606
Engine
Teledyne Continental TSIO-520-R, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Public aircraft - federal · Public use
Operator
USCG District 5
Registered owner
Bernard A Heckman Md Pa
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 14, 2014
Departed
MIV · Millville, NJ
Destination
GAI · Gaithersburg, MD
Flight plan
IFR
Airport
GAI · Montgomery County Airpark, runway 14, 4,202 × 75 ft, asphalt
Equipment
Onboard weather, Electronic primary flight display, Electronic multifunction display, Auto-pilot

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
77
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
April 25, 2013
Seat
Left
Restraint
3-point
Flight hours
6,940 total · 6,880 as pilot in command · 40 in the last 90 days · 20 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
290° at 7 knots
Visibility
4 statute miles
Lowest ceiling
400 ft overcast
Temperature
63 °F, dew point 61 °F
Altimeter
30.17 inHg
Observed at
GAI

Docket · 11

The files NTSB released with the investigation on August 26, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.1 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.

Other investigations on N5132C · 1

Matched to the same aircraft by N-number and date.