# NTSB ERA19TA133: Cessna 650, N220CM, Sanford, FL, March 14, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Final report - Date: March 13, 2019, 22:15 local (Mar 14, 2019, 02:15 UTC) - Place: Sanford, FL - Coordinates: 28.776945, -81.235 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.7769&lon=-81.2350&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi-from runway: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 99149 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19TA133 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99149/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99149 - Page: https://openairdocs.org/ntsb/ERA19TA133 ## Probable cause The pilot's failure to keep the airplane on the taxiway while taxiing at night. Contributing to the accident was a miscommunication between the flight crewmembers about the position of the airplane. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 650, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2076802), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Communication (personnel): interpretation/understanding](https://openairdocs.org/ntsb-findings/02063530): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Cessna 650, 1 case](https://openairdocs.org/ntsb-findings/02063530/cases.md?model=2076802), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/02063530/cases.md) - [Performance/control parameters: heading/course](https://openairdocs.org/ntsb-findings/01062047): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 650, 1 case](https://openairdocs.org/ntsb-findings/01062047/cases.md?model=2076802), [All aircraft, 82 cases](https://openairdocs.org/ntsb-findings/01062047/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi-from runway: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Cessna 650, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=2076802), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Taxi-from runway: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 650, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=2076802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot stated that after landing the airplane at night, the taxiway that he normally used was occupied, so he taxied toward the ramp via an alternate taxiway. As he approached the ramp, there were four or five airplanes on the ramp, and the pilot asked the copilot if the area was clear on the right side. The pilot was referring to the ground path, but the copilot thought he was referring to the other airplanes. When the copilot replied that they were clear, the pilot turned right. The airplane then exited the taxiway onto grass and the nosewheel struck concrete, which resulted in substantial damage to the fuselage structure above the nose landing gear. The pilot reported that there were no preimpact mechanical malfunctions with the airplane. ## Factual narrative On March 14, 2019, about 2215 eastern daylight time, a Cessna 650, N220CM, was substantially damaged during taxi at Orlando Sanford International Airport (SFB), Orlando, Florida. The two airline transport pilots and two passengers were not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight that departed Yeager Airport (CRW), Charleston, West Virginia, about 2100. The pilot stated that after landing, the taxiway that he normally used had an airplane on it, so he taxied toward the ramp via an alternate taxiway. As he approached the ramp, there were four or five airplanes on the ramp and the pilot asked the copilot if the area was clear on the right side. The pilot was referring to the ground and the copilot thought he was referring to the other airplanes. When the copilot replied that they were clear, the pilot turned right. The airplane then exited the taxiway on to grass and the nosewheel struck concrete before the airplane came to rest. The pilot added that there were no preimpact mechanical malfunctions with the airplane. Examination of the airplane by a Federal Aviation Administration inspector revealed damage to the structure above the nose landing gear and the pressure bulkhead. ## Aircraft - Registration: [N220CM](https://openairdocs.org/deregistered/N220CM-2021-07-03), registration cancelled 2021-07-03, S/N 650-0160, built 1988 (OpenAirDocs) - Reported make and model: Cessna 650 (No Series) - Registry model: [Cessna 650](https://openairdocs.org/model/cessna-650) (registry code 2076802) (OpenAirDocs) - Registry engine: [Garrett TFE731 series](https://openairdocs.org/engine/garrett-tfe731-series) (registry code 29001, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 650-0160 - Year built: 1988 - Airframe hours: 9655 - Engines: Honeywell TFE-731 turbo fan; Honeywell TFE-731 turbo fan - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Rp Sales And Leasing Inc - Registered owner: Rp Sales And Leasing Inc - Airworthiness certificate: Standard, Transport - Departed: CRW, Charleston, WV - Destination: SFB, Sanford, FL - Flight plan: IFR - Airport: SFB, Orlando Sanford International - Equipment: Data recorder, Auto-pilot, Angle of attack indicator, Stall warning system, Satellite tracking device, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 83; injuries: none; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review March 2, 2019; seat: left; restraint: 3-point; flight hours: 30,000 total, 4,000 in this make and model, 29,000 as pilot in command, 75 in the last 90 days, 30 in the last 30 days, 6 in the last 24 hours - Co-pilot; age 69; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 4, 2019; seat: right; restraint: 3-point; flight hours: 4,353 total, 261 in this make and model, 3,640 as pilot in command, 86 in the last 90 days, 31 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 110° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 61 °F - Altimeter: 30.13 inHg - Observed at: SFB ## 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 20190314001369A](https://openairdocs.org/incident/20190314001369A), Mar 14, 2019: Cessna 650, Sanford, FL, Substantial damage. Sanford airport operations reported that on March 14, 2019 at approximately 10:15 pm aircraft N220CM was taxing from runway 9L to the ramp via taxiway bravo… ## Docket (2 files) The files NTSB released with the investigation on April 15, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99149. 2.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471891&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photo Array (item 2, .PDF, 3 photos, 636 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471892&FileExtension=.PDF&FileName=Photo%20Array-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.