# NTSB ERA21LA350: Raytheon 390, N351CW, Naples, FL, September 3, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: September 3, 2021, 12:44 local (16:44 UTC) - Place: Naples, FL - Coordinates: 26.150871, -81.77764 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.1509&lon=-81.7776&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: 4 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Textron Aviation - NTSB case key (mKey): 103812 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA350 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103812/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103812 - Page: https://openairdocs.org/ntsb/ERA21LA350 ## Probable cause The pilot was unable to stop the airplane during the landing for reasons which could not be determined, resulting in a runway excursion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Raytheon 390, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7150030), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/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: [Raytheon 390, 2 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7150030), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The pilot stated that the flight was uneventful. During landing, he applied normal braking and the airplane started to slow down. Suddenly the brakes “faded away,” and he was unable to stop the airplane. He further described that he applied full braking pressure and the pedals were operating as they should, but the airplane was not stopping. He added that every few feet the brakes would grab, lock-up for a few feet, and then release. The brakes grabbed several times during the landing roll but were not slowing the airplane down. The airplane overran the end of the runway, and the pilot steered the airplane into the grass and away from a jet blast fence. The anti-skid box, brake valve, anti-skid valve, and both wheel speed transducers were removed and sent to the manufacturer for bench testing. All the components passed the bench tests, and no anomalies were noted. The airplane was not equipped with a flight data recorder. According to automatic dependent surveillance broadcast (ADS-B) data, the airplane landed about 8 knots higher than the Vref speed of 110 knots, with about 4,500 ft of runway remaining. According to the airplane flight manual, the airplane required about 3,000 ft for landing. Based on the available evidence, the reason that the pilot was unable to stop the airplane on the runway could not be determined. ## Factual narrative On September 3, 2021, about 1244 eastern daylight time, a Raytheon Aircraft Company 390, N351CW, was substantially damaged when it was involved in an accident at Naples Municipal Airport (APF), Naples, Florida. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 on-demand flight. According to the pilot, the takeoff and en route portions of the flight were uneventful. During landing, he applied normal braking and the airplane started to slow down. Suddenly the brakes “faded away,” and he was unable to stop the airplane. He further described that he applied full braking pressure and the pedals were operating as they should, but the airplane was not stopping. He added that every few feet the brakes would grab, lock-up for a few feet, and then release. The brakes grabbed several times during the landing roll but were not slowing the airplane down. The airplane overran the end of the runway, and the pilot steered the airplane into the grass and away from a jet blast fence. A Federal Aviation Administration inspector who examined the airplane after the accident observed that the airplane sustained substantial damage to both wings during the runway excursion. The pilot reported the runway surface condition as “damp.” He further stated that it was not raining, there was no standing water on the runway and “If I had to choose between the descriptor of either wet or dry as my only options, I would choose dry.” According to automatic dependent surveillance broadcast (ADS-B) data, the airplane made a normal Vref approach and landed about 8 knots higher than the landing chart for 10,200 lbs about 110 knots. The runway length was 6,600 ft and about 4,500 ft of runway remained for the airplane to stop. The landing chart in the airplane flight manual (AFM) revealed that about 3,000 ft was required for landing on a dry runway, and about 3,750 ft was required for a wet runway. The anti-skid box, brake valve, anti-skid valve, and both wheel speed transducers were removed and sent to the manufacturer for testing. All the components passed the tests, and no anomalies were noted. The airplane was not equipped with a flight data recorder. The cockpit voice recorder was removed and sent the National Transportation Safety Board’s recorders laboratory for download. The airplane was not equipped with thrust reversers. The wind was reported from 150° at 5 knots, at APF, at 1235. ## Aircraft - Registration: [N351CW](https://openairdocs.org/deregistered/N351CW-2023-11-04), registration cancelled 2023-11-04, S/N RB-53 (OpenAirDocs) - Reported make and model: RAYTHEON AIRCRAFT COMPANY 390 - Registry model: [Raytheon 390](https://openairdocs.org/model/raytheon-390) (registry code 7150030) (OpenAirDocs) - Category: Airplane - Serial number: RB-53 - Year built: 2002 - Airframe hours: 3105 - Engines: Williams International FJ44-2A 2300 lbs thrust turbo fan; Williams International FJ44-2A 2300 lbs thrust turbo fan - Damage: Substantial damage - Flight: Business, Part 135 - Operator: Executive Aero Charter Management LLC - Registered owner: PB Air LLC-KMC leasaing LLC-Hanson Enterprises LLC - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, September 2, 2021 - Departed: IND, Indianapolis, IN - Destination: Same as departure - Flight plan: IFR - Airport: APF, Naples Muni, runway 23, 6,600 × 150 ft, asphalt - Equipment: Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Onboard weather, Stall warning system, ADS-B, Angle of attack indicator, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: helicopter, powered-lift; medical: class 1, with waivers/limitations; last flight review May 9, 2021; seat: left; restraint: 4-point; flight hours: 14,413 total, 614 in this make and model, 12,063 as pilot in command, 174 in the last 90 days, 68 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 5 knots - Visibility: 10 statute miles - Temperature: 77 °F, dew point 73 °F - Altimeter: 30.01 inHg - Observed at: APF - METAR: KAPF 031635Z 15005KT 10SM VCTS SCT100 SCT120 25/23 A3001 RMK AO2 RAE33 T02500228 PNO $ ## 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 20210903008689A](https://openairdocs.org/incident/20210903008689A), Sep 3, 2021: Raytheon Aircraft Company 390, Naples, FL, Substantial damage. Aircraft landed in runway 23 and ran off the end of the runway ## Docket (16 files) The files NTSB released with the investigation on August 16, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103812. 44.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13046244&FileExtension=pdf&FileName=Completed%20and%20Signed%20NTSB%20Form%206120.1%20-%20N351CW_Redacted-Rel.pdf - NTSB memorandum for record a�� telephone interview (pilot) (item 2, PDF, 1 page, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13045764&FileExtension=pdf&FileName=Record%20of%20Interview-Rel.pdf - NTSB memorandum for record a�� email correspondence with pilot (item 3, PDF, 1 page, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13143352&FileExtension=pdf&FileName=Memorandom-pilot-Rel.pdf - NTSB memorandum - FAA inspector's statement (item 4, PDF, 1 page, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13133139&FileExtension=pdf&FileName=Memorandom-FAA%20statement-Rel.pdf - Memorandum for record a�� pilot email on runway conditions (item 5, PDF, 1 page, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15897524&FileExtension=pdf&FileName=Memorandom-%20pilot%20runway%20conditions-Rel.pdf - Memorandum for record a�� Textron email on landing distances (item 6, PDF, 1 page, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15897534&FileExtension=pdf&FileName=Memorandom-%20textron%20landing%20distances-Rel.pdf - Antiskid system examination report (item 7, PDF, 6 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15879423&FileExtension=pdf&FileName=Examination%20Short%20Report%20(Premier%20Antiskid%20System)%20v2%20(2)_Redacted-Rel.pdf - AFM performance (excerpt) (item 8, PDF, 1 page, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13132979&FileExtension=pdf&FileName=AFM%20Section%205%20-%20Performance%20exerpt-Rel.pdf - ADS-B data (item 9, CSV, 27.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13124447&FileExtension=csv&FileName=N351CW%20-%20Terr%20-%2011842_20210903143000_Once-Rel.csv - Google earth plot of ADS-B data (item 10, PNG, 6.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13122712&FileExtension=PNG&FileName=Landing%20N351CW-Rel.PNG - Investigative photos (item 11, PDF, 2 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13045774&FileExtension=pdf&FileName=Investigative%20Photo%27s-Rel.pdf - Statement of party representatives to NTSB investigation (item 12, PDF, 1 page, 847 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13135684&FileExtension=pdf&FileName=NTSB%20Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 13, PDF, 1 page, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13260734&FileExtension=pdf&FileName=N351CW%20Release_Redacted-Rel.pdf - Evidence control form (item 14, PDF, 1 page, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13334844&FileExtension=pdf&FileName=Evidence-Control-Form1-Rel.pdf - Cockpit voice recorder (CVR) - specialist's factual report (item 15, PDF, 5 pages, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15961556&FileExtension=pdf&FileName=ERA21LA350_CVR%20Factual%20-%20NewFormat-Rel.pdf - Evidence control form V2 (item 16, PDF, 1 page, 509 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18013312&FileExtension=pdf&FileName=ERA21LA350%20Evidence%20control%20form-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. --- 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.