IAD02FA047

NTSB accident investigation · Beech 400A · Baltimore, MD · May 1, 2002

Accident · No injuriesField investigationFinal report
Date
May 1, 2002, 16:53 local (20:53 UTC)
Place
Baltimore, MD
Injuries
6 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N498CWBeech 400A
Weather
Visual (VMC) · Day
Status
Completed · report September 1, 2004
Report
Approved by Office Director
Parties
Flight Options, Inc., FAA/FSDO, Ratheon Aircraft Company
FAA report
20020501018349A
Case key
54677

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The captain's failure to go around. Factors included the captain's preoccupation with the flight management system, the crew's failure to adhere to company standard operating procedures, and the lack of proper crew coordination.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

OverrunLanding
Go-around - not performedPilot in commandCause
Improper use of equipment/aircraftPilot in commandFactor
Airspeed(vref) - exceededPilot in command
Proper touchdown point - not attainedPilot in command
Procedures/directives - not followedFlightcrewFactor
Crew/group coordination - inadequateFlightcrewFactor
On ground/water collision with objectLanding - roll
Object - approach light/navaid
Object - antenna

Analysis

While on a visual approach, the captain had difficulty with the flight management system. He and the first officer exchanged words about it, and argued as to whether they were cleared for the approach. During that timeframe, with the airplane about 5 miles from the airport, 238 knots and 3,000 feet, the controller also asked the crew if they were "going to be able to get down, " to which the first officer responded, "ah, we're looking." About 30 seconds later, the first officer confirmed that the airport was in sight, and, "we'll be able to get down." After switching over to the tower frequency, the airplane was cleared to land, and about 20 seconds later, the first officer asked the captain, "You gonna be able to make it?" The captain did not respond, but 20 seconds later asked about the runway length, which the first officer gave him. The first officer then told the captain that the airplane was Vref plus forty, and twice said, "There's no way." He then said twice, "Go around." The airplane crossed the landing threshold about 150 feet agl, 166 knots, and the captain landed. The airplane subsequently overran the end of the runway, and went through some lights and antennas. A review of company standard operating procedures revealed that the crew missed numerous required callouts and checklist items, that the captain was trying to program the FMS when the first officer should have been doing it, that the captain should have initiated a go-around when advised that the airplane was not within the "visual approach window," and that after the captain did not respond to the first officer's calls, the first officer should have announced that he was assuming control, and "taken the necessary actions to return the aircraft to a safe flight condition."

Factual narrative

History of flight

On May 1, 2002, at 1653 eastern daylight time, a Beechjet 400A, N498CW, a fractionally-owned and operated airplane managed by Flight Options, Incorporated, was substantially damaged during a landing overrun at Baltimore-Washington International Airport (BWI), Baltimore, Maryland. The two certificated airline transport pilots and the four passengers were not injured. Visual meteorological conditions prevailed, and the airplane was operating on an instrument flight rules flight plan. The executive transport flight originated at Reading Regional/Carl A. Spaatz Field (RDG), Reading, Pennsylvania, and was operated under 14 CFR Part 91.

When interviewed at the scene, the captain stated that the flight from Reading was routine, and that he was at the flight controls during the approach and landing. When the airplane was 6 miles from the airport, he didn't hear that they were cleared for the visual approach. "The FMS [Flight Management System] locked up on me, so I was distracted."

The airplane was on an assigned heading, at an altitude that the captain thought "was higher than...we should be." The captain asked the first officer, "Are we cleared for the visual?" and the first officer reported that they were. The captain then "turned down the runway," but was "fast and...high." The captain lowered the flaps and the landing gear, and said, 'We're high and we're fast, but we'll be okay." The first officer responded, "Hey man, we need to go around," but the airplane was over the threshold and the captain thought they were "okay."

The captain landed the airplane, but didn't know how far down the runway it touched down. The first officer said, "We're not going to make it," but the captain thought they would, and also thought that it was too late to abort the landing, even with full throttle. The airplane subsequently departed the end of the runway, and the captain "just tried to keep it straight."

When asked what the airspeed was when the airplane crossed the runway threshold, the captain responded, "Vref plus 25. Vref was 113 knots, and we were doing about 140."

The captain also noted that when the FMS system malfunctioned, he was "locked out" because both pilots were attempting to program the system simultaneously. He first had to clear his inputs for the first officer to be able to program his side.

When asked about the airplane's performance and handling, the captain stated, "The airplane was fine." The captain also stated that there weren't any mechanical anomalies, but noted that during the system checks prior to the takeoff from Reading, the anti-skid feature of the braking system initially did not test properly, "then there was a delay in the responses on the second test, but it worked satisfactorily." The captain also noted that even if the anti-skid hadn't worked properly, it wouldn't have grounded the airplane. "If it doesn't work, you consult the checklist and increase your landing distances."

The first officer was also interviewed at the scene, and asked to describe the events prior to and during the flight. He concurred that the flight from Reading was uneventful until the approach for landing. According to the first officer, they were assigned a heading of "210 or 220 at 4,000 feet and we were given direct to the airport. At that time, I was putting the ILS into the FMS at the same time [the captain] was putting in the frequencies."

The crew was also cleared for the visual approach during that same time. The captain continued on the assigned heading and asked, "Are we cleared for the visual?" The first officer responded that they were, and as the airplane turned onto the final approach, he thought they were too high. In addition, the tower controller called and asked if they "could make it." The first officer responded that they could, but it subsequently appeared to him that they couldn't. At 1/4 mile from the runway, he said, "I think we should go around." When the airplane was 1,000 feet down the runway and hadn't touched down yet, he said, "We need to go around."

A couple of seconds later the airplane touched down and the first officer said, "We're not going to make it." At that point, the first officer felt "there was no chance." The thrust reversers were already deployed, and he "popped the speed brakes."

When asked what the airspeed was as the airplane crossed the landing threshold, the first officer responded that he thought it was "Vref (113 knots) plus 40, and coming down at 1,700 feet per minute." When asked where the airplane touched down, he stated, "maybe 50 to 60 percent of the runway remained."

The first officer also stated that he had flown the airplane earlier in the day, and when he landed it on a 5,000-foot runway, it seemed to operate "just fine" and "normally." The first officer further stated that he had flown other Beechjets, and noticed the braking on the accident airplane wasn't as good as others, "but nothing major." On the last leg of flight, "we didn't have any problems at all."

The passengers were interviewed briefly at the scene, and later submitted written statements that were consistent with their original interviews. According to one passenger, the flight was uneventful; however, approaching the airport, he was thinking that the descent was "fairly steep," but since he was usually on large commercial jetliners, he may have been "unused to the normal takeoff and landing patterns of small jets."

The airplane landed "fairly hard, but again not anything unusual." As soon as the airplane touched down, the pilot applied the brakes "at what seemed to be full force." The airplane began to slow, but as the passenger looked forward, through the cockpit window, it was clear that they were going to run out of runway. The passenger told his fellow passengers "we aren't going to make it," and they all braced for an impact.

The airplane then departed the end of the runway, onto the grass, went through some "modest" barriers and a couple of light poles, then over an embankment, and slid down a gentle slope, before finally coming to rest at the bottom of the slope. The passengers and crew then quickly but calmly exited the airplane through the exit door, and moved away from the airplane.

The passenger also noted that the airplane had landed with "maybe 1,000 feet or less to go" and had "little chance to stop due to a lack of rolling space." The amount of time that braking occurred "seemed quite short before we hit the end of the runway, and I estimate we hit the barrier doing maybe 60 mph."

The passenger was not aware of any problems of a mechanical, weather or traffic nature prior to the landing. After the accident, crewmembers were "clearly shaken up (as were we all) but they did not visibly panic, and they got the exit hatch open quickly, and urged us out of the plane. Their behavior after the accident was, in my view, proper and satisfactory." In addition, the cushioned seats and three point lap/shoulder harness system was a safety feature that "worked as designed, and allowed us all to walk away shaken but without visible injury."

A review of air traffic control (ATC) transcripts and radar data revealed that a radar target identified as the accident airplane, callsign Options 498, was 5 miles from the airport, at 3,000 feet above mean sea level (msl), with a groundspeed of 238 knots, when the approach controller asked, "Are you going to be able to get down?"

Forty seconds later, at 16:51:55, the airplane was still at 3,000 feet msl, with a groundspeed of 207 knots, and had closed to within 3 miles of the airport, when the crew received clearance for the visual approach to runway 15L. At 16:52:13, when the airplane was at 2,300 feet, about 2 miles from the airport, with a groundspeed of 190 knots, the crew was cleared to land.

A Safety Board air traffic specialist plotted the last five radar returns for

Aircraft

Registration
N498CW
Reported as
Beech 400A
Category
Airplane
Serial number
RK-108
Airframe hours
2,410
Engines
Pratt & Whitney JT15D-5, 2,965 lbs thrust, turbo fanPratt & Whitney JT15D-5, 2,965 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Executive/Corporate · Part 91
Operator
Flight Options, Inc.
Registered owner
Steven E. Cauley
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 12, 2002 · 61 hours before
Departed
RDG · Reading, PA
Destination
BWI · Baltimore, MD
Flight plan
IFR
Airport
BWI · Baltimore Washington Intl, runway 15L, 5,000 × 100 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
32
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
June 1, 2001
Seat
Left
Toxicology
Performed
Flight hours
3,000 total · 600 in this make and model · 32 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
33
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
3,000 total · 280 in this make and model · 32 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 46 °F
Altimeter
29.84 inHg
Observed at
BWI

Docket · 9

The files NTSB released with the investigation on February 2, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 767 KB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.