MIA99FA267

NTSB accident investigation · Learjet 24 · Gainesville, GA · September 26, 1999

Accident · Serious injuriesField investigationFinal report
Date
September 26, 1999, 09:35 local (13:35 UTC)
Place
Gainesville, GA
Injuries
2 serious, 3 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N224SCLearjet 24
Weather
Visual (VMC) · Day
Status
Completed · report March 9, 2001
Report
Approved by Office Director
Case key
47482

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

On this page

Probable cause

The inadequate inspection of the main landing gear brake assemblies, which lead to operation of the aircraft with worn brakes that failed during the landing roll. Contributing factors were the descending terrain, roadway and ditch.

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.

Airframe/component/system failure/malfunctionLanding - roll
Landing gear,normal brake system - worn
Maintenance,inspection - inadequateOther maintenance personnelCause
Landing gear,normal brake system - failure
OverrunLanding - roll
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - drop-off/descending embankmentFactor
Terrain condition - roadway/highwayFactor
Terrain condition - ditchFactor

Analysis

The pilots stated that approach and landing were normal. During landing rollout, about 2,000 feet down the runway, the brakes became ineffective. The aircraft continued to roll off the end of the runway, down an embankment, across a 4 lane road, and came to rest in a drainage ditch. Post-crash examination of the main landing gear brakes showed that 3 out of the 4 brake assemblies were worn beyond allowable limits and all 4 antiskid wheel generators were not producing voltage within the allowable limits. The outboard right main tire had failed during landing roll do to the antiskid becoming inoperative due to the low voltage of the wheel generator. The airplane had received an A-1 through A-6 inspection 2 days before the accident and this was the first flight since the inspection. The A-5 inspection requires inspection of the landing gear brake assemblies for wear, cracks, hydraulic leaks, and release.

Factual narrative

History of flight

On September 26, 1999, about 0935 eastern daylight time, a Learjet 24, N224SC, registered to Dolphin Aviation, Inc., and operated as a Title 14 CFR Part 91 personal flight, overran runway 29 during landing at Lee Gilmer Memorial Airport, Gainesville, Georgia. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The aircraft received substantial damage. The private-rated pilot and one passenger received serious injuries. The commercial-rated copilot and two passengers received minor injuries. The flight originated from Sarasota, Florida, the same day, about 0826.

The pilot stated that the flight was from Sarasota, Florida, to Gainesville, Georgia. Prior to departure, he performed a standard preflight inspection of the aircraft, which included a visual inspection of both the right and left main gear brakes and wheel well. When they were in visual contact with the Lee Gilmer Memorial Airport, the copilot cancelled the instrument flight rules clearance and called the airport UNICOM for local traffic and advisories. After receiving no response, they heard an aircraft announce departure from runway 29. After checking required runway length, the decision was made to use the active runway 29, because the winds favored this runway. They made a normal stabilized approach to runway 29. The Vref speed was 122 and he aimed for touchdown on the end of the runway, in the vicinity of the numbers. After touchdown he applied the brakes and deployed the spoilers. Shortly after applying the brakes, he felt what seemed like a malfunction in the brake system, at which time the brakes became ineffective and the expected decrease in forward motion did not materialize. The aircraft continued moving down the runway and ran off the end.

The copilot stated that the captain made a normal approach and touchdown to Lee Gilmer Memorial Airport. On rollout, 2,000 feet down the runway, the aircraft appeared to stop slowing down. The brakes appeared to become ineffective. The aircraft continued the landing roll off the departure end of the runway. One hundred feet from the end of the runway is a high ravine leading to a four lane highway and then a ditch, which is where the aircraft came to rest.

The passenger seated on the rear bench seat stated that the airplane seemed to be flying low on the downwind leg. From his vantage point, at the very rear of the aircraft, he had a clear view of everything going on in front of the aircraft. The airplane also appeared to be very low in the base leg and final turn and he could not believe how far up the runway they were prior to touchdown. It became apparent, since the forward speed did not significantly decrease that they were not going to stay on the runway. The airplane left the runway at considerable speed, continued across a highway, and seemed to become airborne again as it came to a violent stop, after striking objects, a utility pole among them.

The passenger seated on the left side of the aircraft just aft of the cabin door stated that the airplane was about 2.5 miles out from the runway at about 1,000 feet on the downwind leg. The airplane was turned onto final approach about 3 miles from the runway. The touchdown was firm and he is positive the airplane touched down about 1/3 down the runway. Touchdown was left main gear first, then right main gear, then nose gear. He looked out the right passenger window and saw the airplane was moving past hangars and airplanes at a very high rate of speed. He briefly remembers the brakes being applied and his father, who was seated on the rear bench seat, stating that they were going off the end of the runway. He observed the intersection with the other runway go by and the runway markers flash by. At this point the copilot told them to hold on , that they were going off the end of the runway, and that there was a hill. He felt a strain on his seat belt and encountered a negative G effect. The airplane then "slammed" onto and crossed a highway. The main landing gear made a loud crack and snapped off as the airplane hit the curb on the far side of the highway. He remembered the crushing and bending noise of the fuselage as the airplane slammed onto the ground and cut down a utility pole with its lines dropping on top of the airplane.

A witness stated he was working at the front desk of the fixed-base operator, located to the west of runway 4-22 and north of runway 11-29. He observed N224SC rolling out after landing on runway 29. The airplane appeared to be traveling at higher than normal speed and shortly thereafter, he saw smoke trailing from both main landing gear. He observed the airplane go off the end of the runway and disappear over a grassy slope, in a cloud of dust.

Personnel information

Records from the Federal Aviation Administration, Airman Certification Branch, Oklahoma City, Oklahoma, show the pilot holds a private pilot certificate with airplane single engine land, airplane multiengine land, and instrument airplane ratings, and type ratings for Cessna 500 and Learjet. The certificate was last issued on August 26, 1994, when the Learjet type rating was added. The pilot holds a FAA Class 3 medical certificate, issued on March 12, 1998, with the restriction that the pilot must wear correcting lenses while exercising the privileges of the certificate. The pilot reported on the NTSB Pilot/Operator Aircraft Accident Report that he received a biennial flight review on June 4, 1999, in a Beech Baron. Documents the pilot supplied to NTSB show he received a 12/24 month pilot proficiency check in the Learjet on February 18, 1999. The pilot reported he has 4,800 total flight hours, with 600 flight hours in the Learjet. He reported he flew 22 total flight hours in the last 90 days, and 8 total flight hours in the last 30 days, all in the Learjet.

Records from the Federal Aviation Administration, Airman Certification Branch, Oklahoma City, Oklahoma, show the copilot holds a commercial pilot certificate with airplane single engine land, airplane multiengine land, airplane single engine sea, and instrument airplane ratings, and a type rating for Learjet. The certificate was last issued on October 3, 1993, when the Learjet type rating was added. The copilot holds a FAA Class 2 medical certificate, issued on September 22, 1999, with the restriction that the pilot must wear correcting lenses while exercising the privileges of the certificate. Documents the copilot supplied to NTSB show he received a biennial flight review and instrument proficiency check on May 2, 1999, and he completed a second in command proficiency check in the Learjet model 25B on June 6, 1999. The copilot reported he has 6,675 total flight hours, with 675 flight hours in the Learjet. He reported he flew 0 total flight hours in the last 90 days and last 30 days. AIRCRAFT INFORMATION

The aircraft was a Learjet model 24, serial number 100. Records show that at the time of the accident the aircraft had accumulated 12,868 total flight hours and 12,805 cycles. The aircraft was last inspected on September 24, 1999, 1 flight hour before the accident. This inspection was a Phase A-1 through A-6, 300 hour inspection. Phase A-5 calls for inspection of the landing gear brake assemblies for wear, cracks, hydraulic leaks, and release. This item on the inspection was signed off by a mechanic on September 20, 1999. The item was not signed off by an inspector.

At the time of the accident the aircraft was displaying FAA registration number N224SC. Documents in the aircraft showed this registration number was assigned to the aircraft on March 11, 1999, and the FAA Certificate of Aircraft Registration reflected this registration number. The FAA Standard Airworthiness Certificate, last issued on April 1, 1998, reflected the previous FAA registration number, N427LJ.

Meteorological information

The Lee Gilmer Memorial Airp

Aircraft

Registration
N224SC
Reported as
Learjet 24
Category
Airplane
Serial number
100
Airframe hours
12,869
Engine
GE CJ610-4, 2,850 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Dolphin Aviation, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · September 24, 1999 · 2 hours before
Departed
SRQ · Sarasota, FL
Destination
GVL
Flight plan
IFR
Airport
GVL · Lee Gilmer Memorial, runway 29, 4,001 × 100 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
61
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
4,830 total · 580 in this make and model · 4,830 as pilot in command · 25 in the last 90 days · 8 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 61 °F
Altimeter
30.00 inHg
Observed at
GVL, 1 nm away