# NTSB ERA14TA435: Cessna T210N, N5132C, Gaithersburg, MD, September 13, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Final report - Date: September 13, 2014, 13:40 local (17:40 UTC) - Place: Gaithersburg, MD - Coordinates: 39.163612, -77.158058 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.1636&lon=-77.1581&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report September 24, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 90071 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14TA435 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90071/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90071 - Page: https://openairdocs.org/ntsb/ERA14TA435 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Runway/land/takeoff/taxi surface: wet surface](https://openairdocs.org/ntsb-findings/03023010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna T210N, 2 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md?model=2073456), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna T210N, 3 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2073456), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Cessna T210N, 3 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=2073456), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Cessna T210N, 12 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2073456), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna T210N, 5 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073456), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N5132C-2023-12-21), registration cancelled 2023-12-21, S/N 21063708 (OpenAirDocs) - Reported make and model: CESSNA T210N - Registry model: [Cessna T210N](https://openairdocs.org/model/cessna-t210n) (registry code 2073456) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21063708 - Year built: 1979 - Airframe hours: 5606 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 77; injuries: none; 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 ## 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 20140913016819A](https://openairdocs.org/incident/20140913016819A), Sep 13, 2014: Cessna T210N, Gaithersburg, MD, Substantial damage. On September 13, 2014, [privacy data omitted] piloted aircraft N5132C, a Cessna 210 from millville, n.j. enroute to Gaithersburg airpark, Gaithersburg,… ## Other investigations on N5132C (1) 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. - [NTSB ERA22LA415](https://openairdocs.org/ntsb/ERA22LA415), Aug 25, 2022: Cessna T210N (N5132C), Georgetown, DE, substantial damage. Probable cause: The pilot's failure to extend the landing gear before landing. Contributing to the accident was an inoperative landing gear warning horn. ## Docket (11 files) The files NTSB released with the investigation on August 26, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90071. 15.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431158&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Weather Report and Record (item 2, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431159&FileExtension=.PDF&FileName=Weather%20Report%20and%20Record-Master.PDF - Witness Statement (item 3, .PDF, 596 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431160&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Radar Plot Onto GPS Approach Chart (item 4, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431161&FileExtension=.PDF&FileName=Radar%20Plot%20Onto%20GPS%20Approach%20Chart-Master.PDF - Radar Data Used for Radar Plot (item 5, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431162&FileExtension=.PDF&FileName=Radar%20Data%20Used%20for%20Radar%20Plot-Master.PDF - Record of Conversation (item 6, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431163&FileExtension=.PDF&FileName=Record%20of%20Conversation-Redacted.PDF - Statement from Rear Seat Occupant (item 7, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431164&FileExtension=.PDF&FileName=Statement%20from%20Rear%20Seat%20Occupant-Redacted.PDF - Statement from Right Front Seat Occupant (item 8, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431165&FileExtension=.PDF&FileName=Statement%20from%20Right%20Front%20Seat%20Occupant-Redacted.PDF - GPS Runway 14 Approach Chart (item 9, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431166&FileExtension=.PDF&FileName=GPS%20Runway%2014%20Approach%20Chart-Master.PDF - Photo 1 - Airplane Where It Came To Rest (Photo Courtesy of FAA) (item 10, .PDF, 6.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431167&FileExtension=.PDF&FileName=Photo%201%20-%20Airplane%20Where%20It%20Came%20To%20Rest%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Skid Marks (Photo Courtesy of FAA) (item 11, .PDF, 5.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431168&FileExtension=.PDF&FileName=Photo%202%20-%20Skid%20Marks%20(Photo%20Courtesy%20of%20FAA)-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.