NYC02FA059

NTSB accident investigation · Mitsubishi MU-300 · Cleveland, OH · February 11, 2002

Accident · No injuriesField investigationFinal report
Date
February 10, 2002, 23:02 local (Feb 11, 2002, 04:02 UTC)
Place
Cleveland, OH
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N541CWMitsubishi MU-300
Weather
Instrument (IMC) · Night/dark
Status
Completed · report February 5, 2004
Report
Approved by Office Director
Parties
FAA, Flight Options
FAA report
20020210005959A
Case key
54189

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 pilot's failure to obtain the proper touch down point on the runway, and the pilot-in-commands failure to initiate a go-round. Factors in the accident were the tailwind condition, the snow-covered runway.

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 - roll
Proper touchdown point - not obtainedCopilot/second pilotCause
Weather condition - tailwindFactor
Acft/equip,inadequate aircraft manuals
Inadequate certification/approvalFaa(organization)
Airport facilities,runway/landing area condition - snow coveredFactor
Go-around - not performedPilot in commandCause
Performance data - not availableManufacturerFactor
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - soft
Gear collapsedLanding - roll

Analysis

As the airplane was descending to the airport, theoilot-in-command (PIC) calculated that the required distance to land on a dry runway would be 2,720 feet. The second-in-command (SIC) stated to the PIC, "all right if I touch down and there's no brakes I'm going around." The ILS Runway 23 approach was in use, and the braking action was reported "poor" by a Hawker Jet, which had landed prior to the accident flight. All runway surfaces were covered with a thin layer of snow. The airplane touched down with about 2,233 feet of runway remaining, of the 5,101-foot long runway. The airplane departed the end of the runway, and proceeded into an overrun grassy area, where the nose landing gear assembly collapsed. The tower controller advised the flightcrew prior to landing that the wind conditions were from 330 degrees at 18 knots. According to the airplane's Pilot's Operating Manual, the estimated landing distance on a dry runway, for the conditions at the time of the accident, was about 2,750 feet. No charts were available in the FAA approved Airplane Flight Manual, to compute a landing distance incorporating a contaminated runway. Review of 14 CFR Part 25.1, which prescribed airworthiness standards for the issue of type certificates, and changes to those certificates, for transport category airplanes, revealed, "For landplanes and amphibians, the landing distance on land must be determined on a level, smooth, dry, hard-surfaced runway." There were no requirements for the applicant to determine landing distances on a wet or contaminated runway. The latest weather recorded at the airport, included winds from 330 degrees at 12 knots, gusts to 22 knots; visibility 3/4 statute mile, light snow; and overcast clouds at 300 feet.

Factual narrative

History of flight

On February 10, 2002, at 2302 eastern standard time, a Mitsubishi MU-300, N541CW, operated by Flight Options Inc., was substantially damaged during an overrun at the Cuyahoga County Airport (CGF), Cleveland, Ohio. The two certificated airline transport pilots were not injured. Night instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the positioning flight that originated from the Palwaukee Municipal Airport (PWK), Chicago, Illinois. The flight was conducted under 14 CFR Part 91.

According to the pilot-in-command (PIC), prior to the accident flight, company dispatch personnel instructed the flightcrew to fly six passengers from Marquette, Michigan, to PWK. Upon arrival at PWK, the PIC called dispatch and was instructed to reposition the airplane to CGF. The PIC proceeded to order fuel and check the current weather in the Cleveland area. The PIC also called the CGF air traffic control tower to inquire about the current weather and any braking action reports that may have been available. The tower controller stated to the PIC that a Cessna Citation had just landed and reported the braking action as fair to good.

The flight departed PWK about 2152, and proceeded eastbound, with the second-in-command (SIC) at the controls. Upon arrival in the Cleveland area, the approach controller advised the flightcrew that the current CGF weather was 300 overcast, visibility 1/2-mile in snow, winds from 320 degrees, variable to 350 degrees at 12-15 knots, gusts to 25 knots. The approach in use was the Runway 23 ILS. The PIC also recalled that he heard the controller state that the Cleveland Hopkins Airport, located about 20 miles west of CGF, was closed due to snow removal, and should reopen in approximately 30 minutes.

While being vectored for the ILS approach, the controller stated that the airplane was "number two" for the approach following a Hawker jet. While the accident airplane was being vectored, it traveled through the final approach course, and had to be re-vectored. The airplane was then given a heading to intercept the final approach course and cleared for the approach. The PIC decided at this point, if the airplane was not stabilized on the approach by 1,900 feet msl, a missed approach would be executed. The airplane was stabilized at 2,000 feet, with the landing gear extended, full flaps, and a "Vref" speed of 106 knots, plus 5 knots. The PIC contacted the tower; advising them that the airplane was on the approach, inbound. The tower controller advised the flightcrew that the runway had been plowed, and that the Hawker had just landed and reported the braking action as "poor." The accident airplane was then cleared to land. The PIC visually identified the runway at 300-400 feet above the decision height, and the landing was continued. The speed of the airplane as it passed over the threshold of the runway was about 106 knots and touchdown occurred within the first 500-600 feet of the runway. Upon touchdown the speed brakes were deployed and maximum braking was applied. The PIC recalled that although there was a firm brake pedal, he could not feel the anti-skid pulsating. Deceleration of the airplane was slow and he soon realized the airplane was not going to stop on the runway, and attempting a go-around was not an option due to the amount of runway remaining. The airplane departed the end of the runway at a speed of 20-30 mph, and proceeded onto a down sloping grass overrun area. During the overrun, the flightcrew elected to shut down the engines. As the airplane was about to come to a stop, the nose gear struck a mound, and the nose landing gear assembly collapsed. The flight crew secured the airplane and exited.

According to the SIC, who was flying the airplane from the left seat, the PIC had called the tower while they were on the ground at PWK, and stated that a Cessna Citation pilot reported the braking action at CGF as "good." As the flight arrived in the Cleveland area, the controller vectored the airplane for the ILS approach because airport personnel were plowing the runway, and that they were number two for the approach behind a Hawker. The SIC stated that the vector was poor, and that he flew through the localizer course. The airplane was then re-vectored back and became established on the approach at 2,000 feet msl. The flightcrew was then instructed to contact the tower, where they were cleared to land. To the SIC's best recollection, the flightcrew was never given the braking action by the tower controller. The airplane "broke out" about 200-300 feet above the decision height, with the runway in sight, and straight ahead. As the airplane crossed the "numbers," the speed was at "ref," and touchdown occurred about 500-600 feet down the runway. The SIC applied maximum braking and the airplane began to slide to the right. The SIC straightened out the airplane and both flightcrew members felt that there was no antiskid. At that time the SIC determined that there was insufficient remaining runway to abort the landing, and committed himself in trying to slow the airplane down. The airplane then departed the end of the runway, at 30-40 mph, and proceeded into an overrun grassy area. The SIC did recall that the nose gear collapsed prior to the airplane coming to a complete stop.

An airport employee, who was plowing snow on the airport, stated that he was advised by the control tower that two airplanes were inbound, and he was instructed to remain clear of the runway. The employee positioned the plow truck to taxiway intersection A8 and stopped. After the first airplane landed, which was the Hawker, the pilot reported to the control tower that the braking action was poor. When the second airplane arrived, which was the MU-300, the employee observed it touchdown between A5 and A6 taxiway intersections. The employee then noticed that the airplane was not slowing down, and crossed the A8 taxiway intersection at a high rate of speed. The airplane then departed the end of the runway and came to rest in the grass.

A Federal Aviation Administration (FAA) inspector interviewed the CGF tower controller on February 13, 2002. The controller stated that he visually observed the accident airplane as it flew over the threshold of runway 23, and that it "looked like a normal landing, within the first 600 feet or so." When the tower controller was re-interviewed on February 17, 2002, by the FAA inspector, he stated, "I saw the plane come over the numbers at the normal height so it looked like a normal landing." When asked if he observed the airplane touchdown on the runway, the tower controller stated, "No, I did see it next go by really fast at A-6."

Excerpts of the cockpit voice recorder (CVR) transcript revealed the following:

At 2233:19, as the airplane was descending to the CGF airport, the flightcrew began a discussion regarding the runway length available at CGF. The PIC calculated that the runway required to land would be 2,720 feet. The SIC queried if that number was for a dry runway, which the PIC confirmed.

At 2233:48, the PIC stated, "so even if you add half... thirteen... ah that's four thousand so. County's fifty one hundred feet." The SIC replied, "all right if I touch down and there's no brakes I'm going around." The PIC stated, "what's that?" which the SIC replied, "I said if I touch down and I have no brakes like we're skidding on ice and we go."

At 2257:12, the PIC advised the approach controller that the airplane had just flown though the localizer. The approach controller replied, "Options five forty one my mistake turn right heading two seven zero intercept the localizer." About 22 seconds later, the approach controller advised the flight crew, "...you're five from KROOK. maintain three thousand 'til established on the localizer. cleared for the ILS two three at County."

At 2258:15,

Aircraft

Registration
N541CW
Reported as
Mitsubishi MU-300
Category
Airplane
Serial number
SA-004
Airframe hours
7,457
Engines
Pratt & Whitney JT 15D-4D, 2,500 lbs thrust, turbo fanPratt & Whitney JT 15D-4D, 2,500 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
Flight Options Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 16, 2002
Departed
PWK · Chicago, IL
Destination
CGF
Flight plan
IFR
Airport
CGF · Cuyahoga County Airport, runway 23, 5,101 × 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
None
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
January 26, 2002
Seat
Right
Flight hours
12,478 total · 2,000 in this make and model · 11,200 as pilot in command · 88 in the last 90 days · 25 in the last 30 days · 2 in the last 24 hours
Role
Co-pilot
Age
33
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
May 24, 2001
Seat
Left
Flight hours
3,899 total · 326 in this make and model · 1,500 as pilot in command · 152 in the last 90 days · 30 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
330° at 12 knots, gusting 22
Visibility
0.75 statute miles
Lowest ceiling
300 ft overcast
Temperature
28 °F, dew point 28 °F
Altimeter
29.87 inHg
Observed at
CGF

Docket · 21

The files NTSB released with the investigation on December 5, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 MB 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.