# NTSB ERA16LA131: Raytheon 400A, N465FL, Rome, GA, March 14, 2016

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Class 3 · Limited · Final report
- Date: March 14, 2016, 15:08 local (19:08 UTC)
- Place: Rome, GA
- Coordinates: 34.353054, -85.151107
- Nearby events: https://openairdocs.org/map.md?lat=34.3531&lon=-85.1511&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: Minor injuries
- Injuries: 1 minor, 1 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Eastern Region Aviation
- Parties: Textron/Beech, FAA-AVP-100, FAA/FSDO, IBT Local 1108, Flight Options
- NTSB case key (mKey): 92847
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA131
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92847/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92847
- Page: https://openairdocs.org/ntsb/ERA16LA131

## Probable cause

The pilots’ failure to use available sources of wind information before landing and recognize cues indicating the presence of the tailwind and conduct a go-around, which resulted in their landing with a significant tailwind and a subsequent runway overrun.

## 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 · Flight crew (probable cause); cases with it: [Raytheon 400A, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7150010), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Wind: high wind](https://openairdocs.org/ntsb-findings/03034055): Environmental issues › Conditions/weather/phenomena · Awareness of condition (probable cause); cases with it: [Raytheon 400A, 1 case](https://openairdocs.org/ntsb-findings/03034055/cases.md?model=7150010), [All aircraft, 112 cases](https://openairdocs.org/ntsb-findings/03034055/cases.md)
- [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Awareness of condition (probable cause); cases with it: [Raytheon 400A, 4 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=7150010), [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.

- [Approach: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Raytheon 400A, 2 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=7150010), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md)
- [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Raytheon 400A, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=7150010), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md)
- [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Raytheon 400A, 4 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7150010), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md)

## Analysis

The pilots of the business jet were conducting a cross-country positioning flight. According to the pilot flying (PF), the flight was uneventful until the landing. While completing the descent checklist and while passing through 18,000 ft mean sea level (msl), the pilot monitoring (PM), received the automated weather report from the destination airport and briefed the PF that the wind was variable at 6 knots, gusting to 17 knots. The PF then programmed the flight management system for a visual approach to runway 7 and briefed the reference speed (Vref) as 107 knots and the go-around speed as 129 knots based on an airplane weight. The PF further reported that he knew the runway was over 4,400 ft long (the runway was 4,495 ft long) and he thought that the airplane needed about 2,900 ft of runway to safely land. During the left descending turn to the base leg of the traffic pattern, the PF overshot the final approach and had to turn back toward the runway centerline as the airplane was being “pushed by the winds.” About 500 ft above ground level (agl), both pilots acknowledged that the approach was “stabilized” while the airspeed was fluctuating between 112 and 115 knots. About 200 ft agl, both pilots noticed that the airplane was beginning to descend and that the airspeed was starting to decrease. The PF added power to maintain the descent rate and airspeed. The PF stated that, after adding power and during the last 200 ft of the approach, the wind was “gusty,” that a left crosswind existed, that the ground speed seemed “very fast,” and that excessive power was required to maintain airspeed. When the airplane was between about 75 and 100 ft agl, the PF asked the PM for the wind information, and the PM responded that the wind was variable at 6 knots, gusting to 17 knots. Both pilots noted that the ground speed was “very fast” but decided to continue the approach. Neither pilot reported seeing the windsock located off the right side of the runway. Review of weather data recorded by the airport’s automated weather observation system revealed that about 3 minutes before the landing, the wind was from 240° at 16 knots, gusting to 26 knots, which would have resulted in a 3- to 5-knot crosswind and 16- to 26-knot tailwind. Assuming these conditions, the airplane’s landing distance would have been about 4,175 ft per the unfactored landing distance performance chart. Tire skid marks were found beginning about 1,000 feet from the approach end of runway 7. The PF stated that the airplane touched down “abruptly at Vref+5 and he applied the brakes while the PM applied the speed brakes. Neither pilot felt the airplane decelerating, so the PF applied harder pressure to the brakes with no effect and subsequently applied full braking pressure. When it was evident that the airplane was going to depart the end of the runway, the PM applied the emergency brakes, at which point he felt some deceleration; however, the airplane overran the end of the runway andtravelled through grass and mud for about 370 feet before stopping. Examination of the airplane revealed that the nose landing gear (NLG) had collapsed, which resulted in the forward fuselage striking the ground and the airframe sustaining substantial damage. Although the pilots reported that they never felt the braking nor antiskid systems working and that they believed that they should have been able to stop the airplane before it departed the runway, postaccident testing of the brake and antiskid systems revealed no evidence of preaccident mechanical malfunctions or failures that would have precluded normal operation, and they functioned as designed. Given the tire skid marks observed on the runway following the accident, as well as the postaccident component examination and testing results, the brakes and antiskid system likely operated nominally during the landing. Based on the available evidence, the pilots failed to recognize performance cues and use available sources of wind information that would have indicated that they were landing in significant tailwind conditions and conduct a go-around. Landing under these conditions significantly increased the amount of runway needed to stop the airplane and resulted in the subsequent runway overrun and the collapse of the NLG.

## Factual narrative

On March 14, 2016, at 1508 eastern standard time, a Raytheon 400A, N465FL, was substantially damaged when it was involved in an accident at Richard B. Russell Regional Airport (RMG), Rome, Georgia. The two pilots sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. According to the pilot flying (PF), the flight was uneventful until the landing. While completing the descent checklist, and while passing through 18,000 ft mean sea level (msl), the pilot monitoring (PM) received the 1449 Automated Surface Observing System (ASOS) weather at the destination airport and briefed the PF that the wind was variable at 6 knots, gusting to 17 knots. He also noted that he had selected a visual approach to runway 7. The flight was later cleared for the approach by air traffic control. The PF stated that he then programmed the flight management system for a visual approach to runway 7 with a 3-mile final approach leg before he briefed the reference speed (Vref) as 107 knots and the go-around speed as 129 knots based on the airplane’s weight. As the airplane approached the airport between about 2,000 and 2,100 ft msl, the crew entered the downwind leg of the airport traffic pattern for runway 7 at an airspeed of about 200 knots. The PF slowed the airplane to about 170 knots and called for 10° of flaps. The PF mentioned that the airplane’s flightpath was near high terrain, so the PM pressed the “Terrain Inhibit” button to inhibit any possible nuisance alarms. The PF then called for 20° of flaps, started descending from the traffic pattern altitude, and began a left descending turn to the base leg of the traffic pattern with 30° of flaps. The PM stated that the gear down and before landing checklists had been complete abeam the numbers for runway 07. The PF stated that he overshot the final approach and had to turn back toward the final runway centerline as the airplane was “pushed by the winds.” Additionally, the PF described the presence of moderate turbulence during the final approach. About 500 ft above ground level (agl), both pilots acknowledged that the approach was “stabilized” while the airspeed was fluctuating between 112 and 115 knots. When the airplane was about 200 ft agl, both pilots noticed that it was beginning to descend and the airspeed was starting to decrease. The PM told the PF to “add power.” The PF added power, and noted that, during the last 200 ft of the approach, the wind was “gusty,” that a left crosswind existed, that the ground speed seemed “very fast,” and that considerable power was required to maintain airspeed. Between about 75 and 100 ft agl, the PF asked the PM for the wind information, and the PM stated that the wind was variable at 6 knots, gusting to 17 knots. Neither pilot reported seeing the windsock located off the right side of the runway. Both pilots noticed that the ground speed was “very fast,” but they chose to continue the approach. The PF statedthat, when the airplane “abruptly” touched down, it was at an airspeed about 5 knots above Vref and that the airplane was “well within the touchdown zone.” Upon touchdown, the PF applied normal braking while the PM applied the speed brakes. Neither pilot felt the airplane decelerating, so the PF applied harder pressure to the brakes with no effect. Subsequently, the PM said, “max brakes,” and started applying full braking pressure. However, they still did not feel the airplane decelerate or the antiskid system activate. When it was evident that the airplane was going to depart the end of the runway, the PM applied the emergency brakes, at which point, he felt some deceleration. However, the airplane overran the end of the runway, travelled through grass and mud for several hundred feet, and then skidded to a stop. The airplane was manufactured in 2005 and in July 2014, it underwent a supplemental type certificate design change to modify the airplane from a 400A to a 400XT model, which included replacement of the engines, removal of the thrust reversers, and several other avionic, aerodynamic, airframe and cabin interior enhancements. The main landing gear wheels were equipped with hydraulic disc brakes, which could be actuated from either the pilot's or copilot's rudder pedals. The airplane was also equipped with an antiskid system powered through a switch in the cockpit. A review of the operator’s maintenance records revealed that, between December 2014 and March 2016, three discrepancies related to the airplane’s antiskid and brake systems were reported. The discrepancies that were reported included: 1) In December 2014, “no initial braking after landing” for about 3 to 5 seconds, although the braking during taxi operations was reported to “seem normal.” The corrective action included inspection, troubleshooting, and brake bleeding. Air was found in the left brake system and bled out. 2) In December 2015, “on landing the antiskid was cycling on/off excessively,” the airplane “would not slow down,” although the braking during taxi operations was reported to “be normal”. The corrective action noted an operation check with no defects discovered. 3) In January 2016, “antiskid not modulating/braking action poor”. The corrective action included bleeding the brake system and performing a taxi test. No further defects were noted. At 1449, about 20 minutes before the accident, the recorded ASOS weather at RMG included, in part, wind variable at 6 knots, gusting to 17 knots, which is the information the pilots received while passing through 18,000 ft msl during their descent to the airport. At 1505, about 3 minutes before the accident, the reported weather at RMG included, in part, winds from 240° at 16 knots, gusting to 26 knots. Assuming these conditions, a 3- to 5-knot crosswind and 16- to 26-knot tailwind existed about the time of the landing on runway 7. Following the accident, the PF reported that he believed that the airplane needed 2,900 ft ofrunway to safely land. Review of the airplane’s unfactored landing distance performance chart reveal that assuming the weather conditions reported 3 minutes before the accident, and an airplane weight of 12,600 lbs, the landing distance needed was about 4,175 ft. During a postaccident examination of the runway, tire skid marks were found beginning about 1,000 ft from the approach end of the runway 7. The tire marks swerved slightly toward the right about 20 ft right of the centerline and then slightly left toward the centerline and extended to the runway end. Further down the runway, the tire marks became increasingly more pronounced, flattened out, and widened. The tire marks continued and veered left through grass and mud for another 370 ft past the departure end of the runway, where the airplane came to rest (see figure 1). Figure 1 - Overhead view of runway layout showing the approximate measurements of the skid marks and the airplane’s final resting location. Postaccident examination of the airplane revealed that the nose landing gear (NLG) had collapsed, and the forward portion fuselage of the fuselage was substantially damaged. A review of the engines’ full authority digital electronic control data revealed that no faults pertinent to the accident were recorded. The hydraulic brake system was bled, and no gas bubbles were found in the fluid. The antiskid control box was bench tested, and it passed all performed tests. The power brake control valve was bench tested. Plots generated by the left and right and servo modulation tests and power brake valve test showed results outside of the limits for a new production valve. The left tests were repeated, and the results improved. Overall, the plots were consistent with a functioning, in-service valve with no anomalies observed that would not have affected braking or antiskid operations. Fluid samples from the left and right brake ports and pressure port were within acceptable limits. The unit passed all other performed tests. The left wheel speed transducer was bench tested, and it passed all performed tests. The right wheel speed transducer was also bench tested, and it failed the test at the lowest speed setting of 100 Hz. The transducer was then tested at the highest speed setting of 1,200 Hz, and it functioned as expected. The noted anomaly likely would only have impacted braking at speeds below about 10 knots. Overall, examination and testing of the brake and antiskid systems revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation during the landing.

## Aircraft

- Registration: [N465FL](https://openairdocs.org/deregistered/N465FL-2024-03-14), registration cancelled 2024-03-14, S/N RK-426, built 2005 (OpenAirDocs)
- Reported make and model: RAYTHEON AIRCRAFT COMPANY 400A (A)
- Registry model: [Raytheon 400A](https://openairdocs.org/model/raytheon-400a) (registry code 7150010) (OpenAirDocs)
- Registry engine: [Williams FJ44-3AP](https://openairdocs.org/engine/williams-fj44-3ap) (registry code 66851, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: RK-426
- Year built: 2005
- Airframe hours: 7061
- Engines: Williams FJ-44-3AP 3050 lbs thrust turbo fan; Williams FJ-44-3AP 3050 lbs thrust turbo fan
- Damage: Substantial damage
- Flight: Positioning, Part 91
- Operator: Flight Options LLC
- Registered owner: Flight Options LLC
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, February 2, 2016
- Departed: JXN, JACKSON, MI
- Destination: RMG, Rome, GA
- Flight plan: IFR
- Airport: RMG, Richard B Russell Regional - J, runway 07, 4,495 × 100 ft, asphalt
- Equipment: Stall warning system, Electronic primary flight display, Electronic multifunction display

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 45; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review November 25, 2015; seat: right; restraint: 4-point; flight hours: 10,393 total, 6,174 in this make and model, 9,638 as pilot in command
- Co-pilot; age 45; injuries: minor; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review November 11, 2015; seat: left; restraint: 4-point; flight hours: 6,036 total, 407 in this make and model, 2,560 as pilot in command

## Weather

- Conditions: Visual (VMC), Day
- Wind: 240° at 16 knots, gusting 26
- Visibility: 10 statute miles
- Lowest ceiling: 4,400 ft broken
- Temperature: 73 °F, dew point 55 °F
- Altimeter: 29.75 inHg
- Observed at: RMG, 1 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 20160314013949A](https://openairdocs.org/incident/20160314013949A), Mar 14, 2016: Raytheon Aircraft Company 400A, Rome, GA, Substantial damage. Aircraft was unable to stop on available runway.

## Docket (18 files)

The files NTSB released with the investigation on March 23, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92847. 47.0 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 634 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=3672930&FileExtension=pdf&FileName=Operator%206120%20Accident%20Report_Redacted-Rel.pdf
- Pilots statements (item 2, PDF, 7 pages, 14.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10084933&FileExtension=pdf&FileName=PIlots%20Statements_Redacted-Rel.pdf
- Memorandum for record_pilot monitoring/non flying (right seat) (item 3, PDF, 2 pages, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11775755&FileExtension=pdf&FileName=Memorandum%20for%20Record-Pilot%20Monitoring%20Email%20Account%20of%20Accident-Rel.pdf
- Memo for record-flight crew interview (item 4, PDF, 1 page, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11926622&FileExtension=pdf&FileName=Memorandum%20for%20Record-Flight%20Crew%20Interview-Rel.pdf
- AS-30 weather email (ouo) (item 5, PDF, 7 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10118163&FileExtension=pdf&FileName=Weather%20Report-Rel.pdf
- Landing distance performance chart (item 6, PDF, 1 page, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10120768&FileExtension=pdf&FileName=Landing%20Performance%20Chart-Rel.pdf
- Systems group chairman's factual report (item 7, PDF, 8 pages, 543 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4712524&FileExtension=pdf&FileName=ERA16LA131%20System%20Factual_Final-Rel.pdf
- Maintenance hours and due list report (item 8, PDF, 5 pages, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10120090&FileExtension=pdf&FileName=N465FL%20Maintenance%20Hours%20and%20Due%20List_Redacted-Rel.pdf
- Excerpt - brake/anti-skid 18 month history report (item 9, XLSX, 628 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11774379&FileExtension=xlsx&FileName=Nextant%20fleet%2018%20mos%20history%20report%20ATA%2032-Rel.xlsx
- Maintenance_30 days of maintenance records and discrepancies (item 10, PDF, 68 pages, 18.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10119487&FileExtension=pdf&FileName=Last%2030%20Days%20of%20Maintenance%20Records%20and%20Discrepancies_Redacted-Rel.pdf
- Maintenance_a&b check excerpt for landing gear and brakes (item 11, PDF, 3 pages, 622 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10120366&FileExtension=pdf&FileName=Excerpt%20of%20A%20and%20B%20Maintenance%20Inspection%20Check%20for%20Landing%20Gear%20and%20Brakes_Redacted-Rel.pdf
- Summary email of component testing at manufacturer (item 12, PDF, 1 page, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10109241&FileExtension=pdf&FileName=Summary%20Email%20of%20Component%20Testing%20at%20Crane_Redacted-Rel.pdf
- Descent and approach checklist (item 13, PDF, 1 page, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10109080&FileExtension=pdf&FileName=Checklist-Rel.pdf
- Flight operations manual excerpt_stabilized approach & go-around (item 14, PDF, 2 pages, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11770331&FileExtension=pdf&FileName=Flight%20Operations%20Manual%20Excerpt_Stabilized%20Approach%20and%20Go-Around-Rel.pdf
- Runway layout with measurements and graphics (item 15, PDF, 1 page, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11769490&FileExtension=pdf&FileName=Runway%20Layout%20with%20Measurements%20and%20Graphics-Rel.pdf
- Airport overview diagram (item 16, PDF, 1 page, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10118509&FileExtension=pdf&FileName=Airport%20Overview%20Runway%20Diagram-Rel.pdf
- Photo array_accident site and damage (item 17, PDF, 8 pages, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10123010&FileExtension=pdf&FileName=Photographs%20of%20Accident%20Site%20and%20Damage-Rel.pdf
- Statement of party representatives to NTSB investigation (item 18, PDF, 17 pages, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10118720&FileExtension=pdf&FileName=Party%20Forms%20Master%20Signed%20Copies_Redacted-Rel.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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