# NTSB FTW04FA024: Cessna 550, N418MA, Mineral Wells, TX, November 18, 2003 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: November 18, 2003, 14:10 local (20:10 UTC) - Place: Mineral Wells, TX - Coordinates: 32.781387, -98.059997 - Nearby events: https://openairdocs.org/map.md?lat=32.7814&lon=-98.0600&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 3 uninjured - Status: Completed, report June 30, 2004 - Report: Approved by Office Director - Parties: FAA/FSDO, Cessna Aircraft Company - NTSB case key (mKey): 58358 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW04FA024 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58358/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58358 - Page: https://openairdocs.org/ntsb/FTW04FA024 ## Probable cause The pilot-in-command's failure to maintain control of the airplane while executing a simulated engine failure on final approach. A factor was the windshear. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, approach - faf/outer marker to threshold (ifr) - weather condition - windshear (contributing factor) - Loss of control - in flight, approach - aircraft control - not maintained, pilot in command (cause) - Undershoot, descent - uncontrolled - terrain condition - berm ## Analysis A designated pilot examiner (DPE) was administering a type-rating check ride from the jump seat (located behind co-pilot's seat), and instructed the second-in-command (SIC) (required for the check ride and occupying the front right seat) to reduce the power on one engine to simulate a single engine approach. Approximately 23 seconds later, the airplane began to "drop rapidly." To arrest the descent, both pilots simultaneously applied full power on both engines, and the applicant (occupying the front left seat) increased the airplane's pitch attitude to 12 degrees. However, the airplane continued to descend and touched down short of the landing threshold for the runway. A post-impact fire consumed the airplane. According to the applicant, after takeoff, he demonstrated several maneuvers, and was then provided vectors for a VOR instrument approach. While executing the approach, it was "really bumpy", and they hit a gust of wind, which resulted in him having to correct the airplane's attitude back to straight and level flight. When the airplane was approximately one mile from the end of the runway, he looked outside and saw that he was high on the approach and extended the flaps to 40 degrees. Shortly after, the PIC reduced power on the left engine to simulate a single-engine approach. When the airplane was approximately 1/4 to 1/2-mile from the end of the runway, at 400 feet mean sea level (msl) (about 366 feet above ground level), Vref 110, the airplane began to sink rapidly, and it impacted the ground. The applicant said that he, "never experienced wind shear like that before...and in hindsight it would have been more helpful if they had a better understanding of the wind conditions before they tried to land." Under current FAA regulations, even though the pilot in the right seat (the applicant's flight instructor) acted as the SIC for the purpose of the check ride, the applicant was not type rated in the airplane, and technically, could not be designated as the pilot-in-command (PIC). The instructor was type rated in the airplane; and therefore, was the PIC. ## Factual narrative HISTORY OF FLIGHT On November 18, 2003, approximately 1410 central standard time, a Cessna 550 turbojet, N418MA, was destroyed when it landed short of the runway while attempting to land at Mineral Wells Airport (MWL), near Mineral Wells, Texas. The airline transport pilot, commercial pilot, and the passenger were not injured. The Federal Aviation Administration (FAA) designated pilot examiner (DPE) was seriously injured. The airplane was registered to and operated by a private company. No flight plan was filed for the flight that originated at Meacham International Airport (FTW), Fort Worth, Texas, about 1335. Visual meteorological conditions prevailed for the instructional flight conducted under 14 Code of Federal Regulations Part 91. According to the commercial pilot, he was being administered a check ride to earn a type rating for the airplane. His flight instructor, who was seated in the front right seat, acted as the second-in-command (SIC) for the purpose of the check ride. The DPE sat in the seat located behind the front right seat, and the passenger was seated in the cabin. The DPE, who normally conducted the check ride from the front right seat, said his hip was hurting, and asked the airline transport pilot to act as SIC for the flight, and he agreed. Under current FAA regulations, even though the instructor was acting as the SIC for the purpose of the check ride, the applicant was not type rated in the airplane, and technically, could not be designated as the pilot-in-command (PIC). The instructor was type rated in the airplane; and therefore, was the PIC. For the purpose of this report, the SIC was the commercial rated pilot occupying the left seat, and the PIC was the airline transport pilot (instructor), occupying the right seat. The check ride began with a 1 hour and 15-minute oral examination. After this was completed, the SIC conducted a pre-flight inspection of the airplane. The PIC obtained weather information and informed air traffic control of the intended flight plan, which was to climb to an altitude of 10,500 feet, conduct maneuvers, then execute the VOR RWY 31 approach into Mineral Wells Airport, before returning back to Meacham International Airport. After takeoff, the SIC was asked to demonstrate several maneuvers, including stalls, steep turns, unusual attitude recoveries, and loss of cabin pressurization; after which, the PIC provided vectors to Mineral Wells for the VOR RWY 31 instrument approach. The SIC said that while executing the approach, it was "really bumpy" and they hit a gust of wind, which resulted in him having to correct the airplane's attitude back to straight and level flight. When the airplane was approximately 1-mile from the end of the runway, the SIC looked outside and saw that he was high on the approach and extended the flaps to 40 degrees. Shortly after, the PIC reduced power on the left engine to simulate a single-engine approach and stated it would be a touch and go landing. When the airplane was approximately 1/4 to 1/2-mile from the end of the runway, while descending through 400 feet mean sea level (msl) (about 366 feet above ground level), Vref 110, the airplane began to "dive" and "drop rapidly." Both pilots simultaneously applied full power on both engines, and the SIC increased the airplane's pitch attitude to 12 degrees. However, the airplane continued to descend and touched down short of the runway. It then veered left and slid before it came to an abrupt stop onto a berm located to the left of the runway. The SIC said the airplane hit the ground so hard that the gear had sheered from the airplane and the wings were damaged. After the airplane came to a sudden stop, the SIC saw that the PIC was "dazed" and that the DPE had been thrown to the back of the airplane. A post impact fire started to consume the left side and rear of the airplane. All four occupants exited the airplane in less than 10 seconds. The SIC added that he had received all of his flight instruction in the airplane from the PIC, but the flight instruction did not include a simulated engine-out on short final approach. The SIC also added that he had, "never experienced wind shear like that before...and in hindsight it would have been more helpful if they had a better understanding of the wind conditions before they tried to land." According to the PIC, he said that the DPE asked him if he would sit in the front right seat during the check ride, and he agreed. While the DPE was administering the oral exam to the SIC, the PIC called Mineral Wells Airport and obtained the current weather conditions. He also calculated the airplane's Vref speed, which was 108 knots. Once airborne, the SIC demonstrated maneuvers, and then the PIC vectored him for the VOR RWY 31 approach at Mineral Wells Airport. The PIC stated that when the airplane was over the Millsap VORTAC, which was 4 nautical miles from the end of the runway, the DPE instructed him to reduce power on the left engine. Seconds after the left power lever was reduced to flight idle, the PIC said, "the aircraft sank," and the DPE instructed him to bring the power up on both engines. As power was being restored to the left engine, the SIC rotated the airplane upward to about 15 degrees. He did not recall the airplane's indicated airspeed. Prior to impact, a downdraft moved the airplane to the left of the runway centerline, and the airplane landed short of the runway. When it came to rest, the left wing and aft section of the airplane caught on fire. According to the DPE, he said that he administered the check ride from the "jump seat", which on this airplane, was the seat behind the co-pilot's seat. During segments of the flight, he left his seat and stood between the two pilot seats and observed. The DPE said the flight was normal until they were established on the VOR RWY 31 approach. When the airplane was on the procedure turn inbound (about 6 nautical miles from the end of the runway), he instructed the PIC to "retard the left throttle simulating a single engine approach." One hundred feet prior to the minimum descent altitude (MDA), he instructed the PIC to restore power to the left engine and continue with a normal landing. The airspeed was 110 knots, two knots above Vref. At that time, the DPE returned to the jump seat and attached his safety belt. He said, "I felt the airplane sinking rapidly and turned around and yelled, max power, pull the nose up to go-around. I then checked my safety belt because my buckle did not seem tight and the aircraft hit the ground. Evidently, my buckle was not securely fastened, for I was tossed around the airplane like a ping-pong ball." The DPE said that once the airplane came to rest, the passenger kicked the door open, and the post-impact fire began to rapidly consume the airplane. A cockpit voice recorder (CVR) was removed from the airplane and sent to the Safety Board's audio laboratory in Washington DC. A CVR Group convened on December 3-4, 2003. Participants included the FAA, Cessna Aircraft Company, and the operator. A timed transcript of the recording was produced. The recording began at 1339:31 as the crew discussed frequencies and prepared for takeoff. At 1342:34, a controller at Meacham International Airport cleared the airplane for takeoff. After conducting several maneuvers, the crew began the VOR RWY 31 approach into Mineral Wells at 1400:45. While on final approach, at 1409:35, the DPE said, "and you just lost your engine." Two seconds later, the PIC stated, "all right your left engine's dead." At 1409:43, the SIC confirmed that the landing gear was down. Nine seconds later, the PIC said, "airspeed" several times, followed by the DPE saying, "push'em both up." At 1410:00, the sound of an impact was heard and the recording ended. The accident occurred during the hours of daylight approximately 32 degrees, 46 minutes north ## Aircraft - Registration: N418MA (not matched to a registry record) - Reported make and model: Cessna 550 - Category: Airplane - Serial number: 550-0144 - Engines: Pratt & Whitney JT15-D4 2500 lbs thrust turbo fan; Pratt & Whitney JT15-D4 2500 lbs thrust turbo fan - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Registered owner: Haalo, Ltd. - Airworthiness certificate: Standard, Normal - Departed: FTW, Fort Worth, TX - Destination: MWL, Mineral Wells, TX - Airport: MWL, Mineral Wells Airport, runway 31, 6,000 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: none; airline transport; airplane ratings: single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: right; flight hours: 16,500 total, 500 in this make and model - Co-pilot; age 44; injuries: none; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 25 knots, gusting 30 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 37 °F - Altimeter: 29.80 inHg - Observed at: MWL ## 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 20031118032719A](https://openairdocs.org/incident/20031118032719A), Nov 18, 2003: Cessna 550, Mineral Wells, TX, Destroyed. (-23) On November 18, 2003, at approximately 2:10 pm CST, a Cessna CE-550-550 turbojet aircraft, N418MA, owned by haalo ltd., 400 schroeder, waco, TX 76710 was… ## Docket (7 files) The files NTSB released with the investigation on April 29, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58358. 1.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 - Pilot in Command (item 1, .PDF, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451430&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2%20-%20Pilot%20in%20Command-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 - Second in Command (item 2, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451431&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2%20-%20Second%20in%20Command-Master.PDF - DPE Statement (item 3, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451432&FileExtension=.PDF&FileName=DPE%20Statement-Master.PDF - PIC and SIC Record of Conversation (item 4, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451433&FileExtension=.PDF&FileName=PIC%20and%20SIC%20Record%20of%20Conversation-Master.PDF - Photo 1 - Aerial view of accident site (item 5, .PDF, 591 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40210829&FileExtension=.PDF&FileName=Photo%201%20-%20Aerial%20view%20of%20accident%20site-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451434&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 7, .PDF, 378 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211389&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-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.