LAX06FA211

NTSB accident investigation · Cessna 560 · Upland, CA · June 25, 2006

Accident · FatalField investigationFinal report
Date
June 24, 2006, 22:26 local (Jun 25, 2006, 05:26 UTC)
Place
Upland, CA
Injuries
1 fatal, 2 serious
Damage
Destroyed
Phase of flight
Landing
Aircraft
N486SBCessna 560
Weather
Visual (VMC) · Night
Status
Completed · report July 25, 2007
Report
Approved by Office Director
Parties
National Transportation Safety Board, Cessna Aircraft Company, Crane Aerospace, Federal Aviation Administration, Pratt and Whitney Canada
FAA report
20060624011949A
Case key
63971

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 pilot's unstabilized approach to the runway and failure to obtain the proper touchdown point, which resulted in a runway overrun.

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
ContinuedPilot in commandCause
Light condition - night
Touchdown - incorrectPilot in commandCause
On ground/water collision with objectLanding
Terrain condition - drop-off/descending embankment
Object - fence
Terrain condition - rough/uneven
On ground/water encounter with terrain/waterLanding
Terrain condition - drop-off/descending embankment
Terrain condition - rough/uneven

Analysis

The airplane touched down at night about 1,400 feet down the 3,864-foot runway and overran the runway surface, coming to rest about 851 feet beyond the departure end. The pilot was operating the airplane using a single-pilot waiver that he obtained two months prior to the accident. The airplane was certified by the Federal Aviation Administration with a flight crew of two. The pilot was returning from a personal event with his family, and landing at his home airport when the accident occurred. Witnesses stated that the pilot’s approach into the airport was not consistent with previous approaches in which the airplane would touch down directly on the runway numbers. They also stated that they heard the thrust reversers deploy, and then return to the stowed position. The airplane flight manual states that once the thrust reversers have been deployed, a pilot should not attempt to restow the thrust reversers and take off. Two sink rate warnings were issued during the approach to landing which should have alerted the pilot of the unstabilized approach. Performance calculations showed that the airplane would have required an additional 765 to 2,217 feet of runway for a full stop landing.

Factual narrative

1.1 History of the Flight

On June 24, 2006, at 2226 Pacific daylight time, a Cessna 560, N486SB, collided with obstacles and terrain following a runway overrun at Cable Airport, Upland, California. The airplane was registered to Aero Charter Services, Incorporated and the commercial pilot (the president of Aero Charter Services, Incorporated) was operating the airplane under the provisions of 14 CFR Part 91 using a single-pilot waiver. The pilot and two passengers sustained serious injuries; the airplane was destroyed. Night visual meteorological conditions prevailed and the pilot canceled his instrument flight rules clearance at 2221 when he reported obtaining visual contact with Cable Airport. The pilot departed from Montgomery Field, San Diego, California, at 2200, and was landing at his destination when the accident occurred. One of the passengers later succumbed to her injuries.

According to friends of the pilot, the pilot, his wife, and his daughter, were attending a personal event in San Diego. They were returning to their home-based airport when the accident occurred. The pilot had been based at the airport for about 2 years.

1.1.1 Witness Information

A witness, who was a pilot and airplane builder, was standing at the Experimental Aircraft Association (EAA) chapter hangar located on the northeast side of the airport, when the airplane landed on runway 24. He noted a 5 to 7 knot tailwind from the east. When the accident airplane touched down, the airplane was approximately 1,000 to 1,300 feet down the 3,864-foot runway. He heard the engines spool up and then it was quiet. The landing approach was not consistent with landings that the witness had previously seen the pilot of N486SB conduct. Normally when the pilot would land the airplane, he would touch down directly onto the numbers of the runway.

Additional witnesses were sitting in their home, which was located in a rock quarry plant at the end of runway 24. They heard the airplane and looked out the window. As it passed by four big hangar doors, they could hear the thrust reversers and the airplane kept rolling off the end of the runway. The witness stated, "It appeared like the pilot wanted to climb the airplane." They then witnessed flames shooting up from the accident area. The witnesses noted that it appeared the airplane did not have the runway distance it needed to land.

Another witness, reported that he did not see the airplane coming into land. He could hear the airplane and it sounded as if it were taking off. He then heard the sound of "reverse thrust" prior to the airplane powering up again. As the airplane came into view from behind a building, it was low to the ground and climbing. When it was about 20 to 40 yards above ground level, the witness heard the thrust reversers again and the airplane nosed down into the ground where it impacted an embankment and exploded into flames.

An additional witness, who was a police officer, reported that he did not see the airplane but heard it fly over his house. He had heard the airplane fly over many times in the past and was familiar with his approach. As the airplane came over his house, it sounded lower than normal like the engines were spooled down. Normally, about 20 to 25 seconds later he hears the sound of the thrust reversers but he did not hear them deploy.

1.2 Performance Information

The airplane was equipped with a Honeywell enhanced ground proximity warning system (EGPWS) unit. The unit does not record event times or dates, but tracks the duration of an event and each leg. The flight history was downloaded from the EGPWS unit at Honeywell, Redmond, Washington, on July 31, 2006, with the National Transportation Safety Board (NTSB) investigator and representatives from Honeywell present. The accident flight was identified as the last recorded event in the unit.

1.2.1 Performance Study

An NTSB performance engineer completed a performance study using data obtained from the Honeywell EGPWS, the Cockpit Voice Recorder (CVR), reported atmospheric data, and airplane data from Cessna's airplane flight manual. The results of the study indicated that the airplane approached runway 24 for landing, above the 4-degree visual glide slope indicator. During the approach, the data showed two periods of sink rate warnings, and then about 11 seconds after the last warning the data indicated that the airplane touched down about 1,400 feet beyond the runway 24 displaced threshold. The published total landing length of runway 24 is 3,707 feet. Landing distance calculations revealed that the distance required for a full stop landing after touchdown was between 3,072 and 4,524 feet for the given conditions. According to the engineer, the accident flight needed an additional 765 to 2,217 feet of runway for a full stop landing.

During the approach, two sink rate warnings were issued; one was issued about 1,500 feet horizontally from the threshold and the other was issued about 700 feet horizontally from the threshold. The engineer further reported that the sound of touchdown occurred about 11 seconds after the last sink rate warning, placing the airplane at a minimum, about 1,400 feet past the runway 24 displaced threshold.

1.3 Cockpit Voice Recorder Information

A Fairchild Model A200S 2-hour solid-state CVR (serial number unidentifiable) was delivered to the audio laboratory of the National Transportation Safety Board on June 27, 2006. The event was captured near the end of the recording. A CVR Group was not convened.

The CVR engineer indicated that at 2221:35, the pilot radioed that he was on the vhf-omnidirectional range (VOR) approach into Cable and would be entering the downwind for runway 24. He canceled his instrument clearance and at 2223:03, the pilot radioed that he was established on the downwind leg for Cable Airport. At 2224:26 the pilot indicated that he was turning base. At 2224:50, there was a sound consistent with six radio on-off key clicks being performed in rapid succession. At 2224:56, the pilot called again stating that he was turning base. A series of messages related to minimums and sink rate were heard and at 2225:51, the sound of touchdown was heard. The recording ended at 2226:10.

1.4 Pilot Information

The pilot held a commercial pilot certificate with ratings to fly single- and multi-engine airplanes under instrument conditions. The pilot held a second-class medical certificate that was issued on September 9, 2005. It contained the restriction that the pilot must wear lenses for distant and possess glasses for near vision. On the application, the pilot reported a total flight time of 2,700 hours.

The pilot attended training at CAE Simuflight, in Fort Worth, Texas. On April 18, 2006, the pilot obtained a single pilot certification by Federal Aviation Administration exemption to operate the Cessna Citation CE-560-Ultra, CE-560-Encore aircraft. The certification was valid through April of 2007.

The pilot's attorney submitted the completed National Transportation Safety Board (NTSB) form 6120.1/2, the Pilot Operator Report, on behalf of the pilot. On the form a total flight time of 2,951 flight hours was reported, with 268 hours in the accident make/model airplane. A total of 50 hours of night flight time was recorded. No flight times were reported for the past 90 and 30 days. The pilot indicated on the form that he could not recall the circumstances that led to the accident.

1.5 Airplane Information

The airplane was a Cessna 560 Citation manufactured in 2001 and was certified by the FAA requiring a two-person flight crew. It was equipped with two model PW535A Pratt and Whitney Canada engines. Federal Aviation Administration records show that the airplane was purchased by Aero Charter Services, Incorporated on August 5, 2005.

On June 24, the airplane was fueled with 500 gallons of Jet A at Crown Air, located

Aircraft

Registration
N486SB
Reported as
Cessna 560
Category
Airplane
Serial number
560-0580
Airframe hours
2,513
Engine
Pratt & Whitney Canada PC535A, 3,361 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · May 1, 2006 · 30 hours before
Departed
MYF · San Diego, CA
Destination
CCB · Upland, CA
Flight plan
IFR
Airport
CCB · Cable Airport, runway 24, 3,864 × 75 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
April 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
2,951 total · 268 in this make and model

Weather

Conditions
Visual (VMC) · Night
Wind
Calm
Visibility
7 statute miles
Lowest ceiling
20,000 ft broken
Temperature
72 °F, dew point 61 °F
Altimeter
29.95 inHg
Observed at
KONT, 6 nm away

FAA reports on this event · 1

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