# NTSB ERA22LA123: Britten-Norman BN-2A-9, N821RR, Culebra, PR, February 15, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: February 15, 2022, 09:55 local (13:55 UTC) - Place: Culebra, PR · runway 13 - Coordinates: 18.313276, -65.304068 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=18.3133&lon=-65.3041&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Hard landing](https://openairdocs.org/ntsb-events/092) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 104644 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA123 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104644/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104644 - Page: https://openairdocs.org/ntsb/ERA22LA123 ## Probable cause The flight crew’s failure to arrest the descent rate during the non-standard approach, which resulted in a hard landing and failure of the right-wing structure. Contributing was the flight instructor’s selection of a challenging approach for initial training. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: landing flare](https://openairdocs.org/ntsb-findings/01062041): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Britten-Norman BN-2A-9, 1 case](https://openairdocs.org/ntsb-findings/01062041/cases.md?model=1520210), [All aircraft, 1,285 cases](https://openairdocs.org/ntsb-findings/01062041/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Flight crew; cases with it: [Britten-Norman BN-2A-9, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1520210), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Britten-Norman BN-2A-9, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1520210), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: unnecessary action](https://openairdocs.org/ntsb-findings/02041045): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Britten-Norman BN-2A-9, 1 case](https://openairdocs.org/ntsb-findings/02041045/cases.md?model=1520210), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/02041045/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092) (defining event); cases with it: [Britten-Norman BN-2A-9, 1 case](https://openairdocs.org/ntsb-events/092/sequence.md?model=1520210), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) - [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Britten-Norman BN-2A-9, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=1520210), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing: Aircraft structural failure](https://openairdocs.org/ntsb-events/337); cases with it: [Britten-Norman BN-2A-9, 1 case](https://openairdocs.org/ntsb-events/337/sequence.md?model=1520210), [All aircraft, 290 cases](https://openairdocs.org/ntsb-events/337/sequence.md) ## Analysis The pilot was receiving flight training as a new hire, and the accident occurred during his first flight in the airplane and the first landing. The pilot stated the approach was flown at the upper end of the allowable approach speed, and about 100 ft above the normal glidepath. During the landing, all three of the airplane’s landing gear touched down at the same time, the airplane immediately veered right, and continued off the right side of the runway. The airplane sustained substantial damage to the right-wing structure. The flight instructor chose an airport with a challenging approach that required a special training program prior to the first landing. The approach procedure requires a left 40° turn then rolling wings level just before touchdown. It is likely that the airplane’s descent rate during landing exceeded the airplane’s capability, which resulted in a hard landing and failure of the right-wing structure. ## Factual narrative On February 15, 2022, about 0955 Atlantic standard time, a Britten-Norman BN-2A-9 airplane, N821RR, was substantially damaged when it was involved in an accident at Benjamin Rivera Noriega Airport (CPX), near Isla de Culebra, Puerto Rico. The pilot receiving instruction, flight instructor, and pilot-rated passenger were not injured. The airplane was operated by Air Flamenco conducted as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the pilot, he had recently retired from flying large transport-category airplanes. He was recently hired by Air Flamenco and had received some ground school training on the BN-2A-9, the company mission, routes, and destinations. The accident occurred on the first landing of his first flight, and it was his first ever landing at the accident airport. The pilot stated that he entered a left downwind for landing on runway 13, and the estimated wind conditions were 090° at 15 to 16 knots. The instructor advised him that his aiming point should be the grass area that preceded the landing threshold. The approach was flown about 80 knots and about 100 ft above the normal flightpath. The pilot reported that the wind was not a factor. After touchdown the airplane “leaned to the right” and veered off the right side of the runway. In an interview with a Federal Aviation Administration (FAA) aviation safety inspector, the flight instructor confirmed this was the first flight with the pilot. Air Flamenco considered CPX a “special airport” because of the short runway and challenging runway environment and company pilots who flew there participated in a “special” training program. Typically, pilots would have completed the other phases of flight training and additional training specific to CPX before landing at CPX for the first time. The instructor described a stabilized approach at 70 knots. He said the pilot made a three-point, flat landing (all three of the airplane’s landing gear contacting the runway at the same time), and the airplane turned right almost immediately. When asked, the instructor said it was not a hard landing. In the company flight log for the accident flight, he reported the airplane “experienced strong wind conditions sliding the aircraft off of the runway.” In another company incident report, the instructor stated that because it’s free castering, the nosewheel turned 90° to the right at touchdown, causing the aircraft to drift right of the runway and “making it very hard to regain directional control.” The commercial pilot seated in the back stated it was not a hard landing, but it was “harder than anything he had experienced before at that airport.” The FAA inspector who responded to the accident site photographed witness marks on the runway, in the grass apron along the wreckage path, and the wreckage itself. The inspector described and his photographs illustrated witness marks consistent with propeller strikes and orange paint transfer marks on the runway. The rightpropeller blades displayed tip curling and the orange-painted wingtip displayed impact damage, scraping, and asphalt transfer. The distance between the scars on the runway were consistent with the distance between the propeller spinner and the wingtip. The right main landing gear was mounted to the aft portion of the right engine. The right wing was twisted downward and the aft portion of the right wing was deformed upward at the wing root, which resulted in substantial damage to the right wing. After the accident, there was some discussion between the flight crew and company mechanics about the nosewheel free-castering system. Postaccident examination of the airplane at the airport by the FAA revealed no evidence of preimpact mechanical anomalies with the nosewheel that would have prevented normal operation. A detailed examination of the wing revealed the right half of the wing was deformed aft and the leading edge was twisted down. The right wing lower spar cap was deformed upward. The forward spar cap was bent aft. The rear spar upper and lower spar caps were deformed upward significantly. The rear spar upper and lower caps were deformed down and aft. The right wing front and rear spars, ribs, and stringers were damaged. There were abrasions present on the lower portion of the right wing tip, and yellow paint transfers were observed on the runway surface. There was no appreciable corrosion noted in any of the interior or exterior areas of the wing examined, or on the fuselage structure. All the fracture surfaces examined had a dull, grainy appearance consistent with overstress separation The approach into CPX involves some maneuvering prior to touchdown due to terrain west of the airport. The initial approach begins at 800 ft mean sea level (msl) and 80 kts over Flamenco Lagoon northwest of the airport on a heading aligned about 40° right of runway heading. While over Flamenco Lagoon, the instructions call for flaps at 56°, completion of the before landing checklist, and maintaining a positive rate of descent. The approach continues the same heading to a descent to 400 feet msl to a saddle in the terrain located about 2,000 ft northwest of the runway 13 threshold. The approach necessitates a continued descent to the runway from the saddle while making a left 40° turn to align with the runway. Just before touchdown the airplane must roll right from the left turn to a wings level attitude. The recommended speed remains 80 knots for the final approach and the instructions warn not to overshoot the runway. The note in the training materials states “If you do not land in the first 1,300 feet of RWY 13 or you are above 80 kts, a go-around procedure must be executed. Turbulence may be experienced when the wind is from the north.” Britten-Norman Aircraft Limited provided information on the certification landing loads for the airplane. They stated that the rear spar web would be expected to fracture first followed by bending of the upper and lowerspar caps near the location noted on the accident airplane under a hard landing condition that exceeded the design limit load by about 20% to 50%. They noted that typical hard landing events that do not exceed the design limits would result in damage to the lower part of the nacelle where the lower main landing gear mount point is located and the upper wing skin above the main landing gear. ## Aircraft - Registration: [N821RR](https://openairdocs.org/aircraft/N821RR), registered now, S/N 338, built 1973 (OpenAirDocs) - Reported make and model: BRITTEN-NORMAN BN-2A-9 - Registry model: [Britten-Norman BN-2A-9](https://openairdocs.org/model/britten-norman-bn-2a-9) (registry code 1520210) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 338 - Year built: 1973 - Airframe hours: 2864.2 - Engines: Lycoming O-540-E4C5 260 horsepower reciprocating; Lycoming O-540-E4C5 260 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Air Charter Inc DBA, doing business as Air Flamenco - Registered owner: Air Charter Inc DBA - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, January 27, 2022 - Departed: TJIG, San Juan, PR - Destination: Same as departure - Airport: CPX, Benjamin Rivera Noriega, runway 13, 2,600 × 60 ft, asphalt - Equipment: ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review July 22, 2021; seat: left; restraint: lap only; flight hours: 16,550 total, 0 in this make and model, 7,346 as pilot in command - Flight instructor; age 48; injuries: none; commercial, flight instructor, airline transport; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review November 15, 2021; seat: right; restraint: lap only; flight hours: 6,000 total, 5,000 in this make and model, 5,700 as pilot in command, 44 in the last 90 days, 12 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft overcast - Temperature: 81 °F, dew point 73 °F - Altimeter: 30.16 inHg - Observed at: JNR, 20 nm away - METAR: TJNR 151353Z AUTO 05009KT 10SM OVC100 27/23 A3016 RMK AO2 SLP212 T02720228 ## 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 20220215000979A](https://openairdocs.org/incident/20220215000979A), Feb 15, 2022: Britten-Norman BN-2A-9, Culebra, PR, Substantial damage. On February 15, 2022, at 0950 local time(east), N821RR Britten Norman BN2A aircraft, serial number 338[privacy data omitted]were conducting a flight from… ## Docket (8 files) The files NTSB released with the investigation on June 28, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104644. 14.4 MB in all. - Airworthiness group chair's factual report (item 1, PDF, 9 pages, 4 photos, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15023195&FileExtension=pdf&FileName=ERA22LA123%20AW%20Factual-Rel.pdf - Airworthiness group chair's factual report attachment 1 - cpx training materials (item 2, PDF, 5 pages, 4 photos, 654 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15023205&FileExtension=pdf&FileName=ERA22LA123%20AW%20Attachment%201-CPX%20Profiles-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 3, PDF, 11 pages, 5.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15078416&FileExtension=pdf&FileName=6120%20Pilot_Operator%20Aircraft%20Accident_Incident%20Report_Redacted-Rel.pdf - Pilot's statement (item 4, PDF, 9 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15085345&FileExtension=pdf&FileName=Pilot%20statements_Redacted-Rel.pdf - FAA inspector's statement (item 5, PDF, 1 page, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15086167&FileExtension=pdf&FileName=MFR%20FAA-Rel.pdf - Manufacturer submission (item 6, PDF, 1 page, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15085794&FileExtension=pdf&FileName=MFR%20Britten-Norman-Rel.pdf - Operator training manual (item 7, PDF, 7 pages, 520 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15124323&FileExtension=pdf&FileName=Air%20Charter%20Training%20Manual%20Rev.%2028%20oficial-Rel.pdf - Photos (item 8, PDF, 7 pages, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15085870&FileExtension=pdf&FileName=Photos-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.