# NTSB NYC07LA081: Cessna 500, N511AT, Beverly, MA, March 17, 2007 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 17, 2007, 14:30 local (18:30 UTC) - Place: Beverly, MA - Coordinates: 42.584167, -70.916389 - Nearby events: https://openairdocs.org/map.md?lat=42.5842&lon=-70.9164&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 6 uninjured - Status: Completed, report August 28, 2008 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, FAA/FSDO - NTSB case key (mKey): 65441 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC07LA081 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/65441/pdf - Page: https://openairdocs.org/ntsb/NYC07LA081 ## Probable cause The inadequate guidance and procedures provided by the airplane manufacturer regarding operation of the pneumatic de-icing boots. Also causal was the Federal Aviation Administration's inadequate directives which failed to require manufacturers to direct flightcrews to immediately operate pneumatic deicing boots upon entering icing conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - weather condition - icing conditions - anti-ice/deice system - not used, flightcrew - procedures/directives - inadequate, manufacturer (cause) - procedures/directives - inadequate, faa(other/organization) (cause) - In flight collision with terrain/water, approach - terrain condition - ground ## Analysis During the landing descent in instrument meteorological conditions , the copilot of the Cessna 500 noticed that the windscreen was picking up a trace amount of rime ice. Neither crewmember saw any ice on the wings, and the crew did not activate the deicing boots. The approach seemed normal until reaching approximately 100 feet above ground level, when the crew experienced what the copilot described as a "burble," and the airplane rolled "steeply" to the right. The pilot stated that there was "no buffet and no warning." The crew attempted to recover, but were unsuccessful, and the right wingtip struck the runway overrun area. Postflight inspection revealed "light rime ice" on the wings, horizontal stabilizer, and radome. The airplane was certificated for flight into known icing conditions, but no ice detector, or stall warning system was installed. The Citation 500 was certificated with full span deicing boots on the wing leading edge, but this airplane had been modified with electrically heated anti-ice panels on the inboard wing leading edge. The deicing boots had no automatic or continuous mode. Both pilots had taken Federal Aviation Administration (FAA) approved systems training for the Cessna 500. The pilot stated that he had heard about "ice bridging," at the training provider and his company. The copilot stated that "unless you have 1/4 to 1/2 inch of ice" the boots should not be activated. A review of the Cessna model 560 airplane flight manual (AFM) revealed that like the Cessna 500 operating manual, it advised pilots to wait for ice to build before inflating the pneumatic de-icing boots. Both the study guide and the AFM stated that, "Early activation of the boots may result in ice bridging on the wing." In 1996, the FAA conducted icing evaluations of the Cessna 560. These evaluations resulted in modifications to the stall warning system to increase stick shaker speed in icing conditions, but did not change the procedures for pneumatic de-ice boot operation. In 1997, the Safety Board recommended that, "leading edge deicing boots should be activated as soon as the airplane enters icing conditions because ice bridging is not a concern." A 1997 industry workshop reported that there was no substantiation for the phenomenon of ice bridging. In 1999, the FAA proposed several airworthiness directives (ADs) on 17 airplane models (including Cessna 500, 501, 550, 551, and 560 ) that would have required manufacturers to change the AFMs so that pilots would be required to inflate de-ice boots as soon as ice accumulation began. Cessna Aircraft Company succeeded in convincing the FAA to withdraw the proposed ADs. In December 2002, the FAA issued advisory circular AC 91-74, which stated that there were few, if any, documented cases of ice bridging on modern boot designs. In February 2005, the Safety Board investigated an icing accident involving a Cessna 560, and review of the AFM again revealed guidance that stated that the pneumatic de-icing boots should be activated when ice is 1/4 to 1/2 inch thick. In December 2006, the FAA released a report stating that test results supported "the activation of lifting surfaces" deicers at the first detection of ice formation on the aircraft's lifting surfaces and for the operation of pneumatic deicers in an automatic cycling mode." Although more than 10 years have passed since it was established that ice bridging does not occur, the FAA has not taken any regulatory action, and Cessna Aircraft Company has only removed the references to ice bridging in it's AFMs but, still advises to wait until the ice thickness is 1/4 to 1/2 inch before activating the surface de-ice. Since 1982, the Safety Board has investigated 43 icing occurrences involving turbine-powered airplanes. These events have resulted in 201 deaths and 16 serious injuries. In the past 4 years, the Safety Board has issued 18 recommendations and one Safety Alert related to icing. As of June 2008, actions to reduce dangers to aircraft flying in icing conditions remain on the Safety Board's 10 Most Wanted List. The Safety Board has classified the FAA response to this issue as "Unacceptable." ## Factual narrative HISTORY OF FLIGHT On March 17, 2007, about 1430 eastern daylight time, a Cessna 500, N511AT, operated by Air Trek, Inc., was substantially damaged during landing at Beverly Municipal Airport (BVY), Beverly, Massachusetts. None of the four crewmembers or two passengers were injured. Instrument meteorological conditions prevailed and an instrument flight rules flight plan had been filed for the flight, which originated at Charlotte County Airport (PGD), Punta Gorda, Florida at approximately 1100. The air ambulance flight was conducted under 14 Code of Federal Regulations (CFR) Part 135. During the descent into BVY, the flight crew was given, information 'Hotel' by air traffic control (ATC); with wind at 310 degrees at 8 knots, visibility 1 statute mile, a 500 foot overcast sky with mist, and good ground braking action. The given approach at BVY was the RNAV 16, circle-to-land Runway 34. According to the flight crew, they advised ATC that their general operations manual (GOM) prohibited circling approaches with ceilings less then 1500 feet, and requested the GPS RUNWAY 16 approach at BVY. Reference speed was set to 97 knots. After passing the initial approach fix they entered the clouds at 3,500 feet mean sea level (msl), turned on the anti-ice system, and noticed that there was "quite a bit of wind" which they had to compensate for. Moments later, the copilot noticed that they were picking up a trace amount of rime ice on the windscreen; however, since neither pilot saw any ice on the wings, the deicing boots were never activated. As they neared the final approach fix (FAF), they "added a notch" of approach flaps, and then added full flaps when they crossed the FAF. At 600 feet msl, they acquired the field and the precision approach path indicator (PAPI). Once established on the PAPI, speed was V-ref +10 (107 knots), and the approach to landing seemed normal until reaching approximately 100 feet above ground level. At this point, the flight crew experienced what the copilot described as a "burble," and the airplane rolled "steeply" to the right. The pilot stated that there was "no buffet and no warning." They attempted to roll wings level, and added power to arrest the sink, but were unsuccessful and the right wingtip struck the surface of the runway-overrun area. After landing and taxiing to the ramp, the flight crew conducted a post flight inspection of the airplane. They noted that the right wing was bent upward about 10 degrees, and "Light rime ice" was present on the leading edges of the wings, horizontal stabilizer, and radome. According to a customer service agent, after the airplane came to a stop on the airport ramp area, he also observed an accumulation of ice on the leading edges and nose of the airplane. He described it as a rime ice strip, about two inches top to bottom, covering the entire leading edge from wing tip to wing root. The white of the ice was "highly visible," although, he could see the wing's rubber boot through the ice in some areas, and estimated that approximately 90 to 95% of the wing boot was covered by the two-inch strip. On the nose of the aircraft he also witnessed a solid coverage of ice approximately 10-15 inches in diameter that was about 1/16 to 1/8 of an inch thick. Upon exiting the aircraft, he also observed the flight crew immediately go the right wing to inspect it and asked them, "What happened?" They replied, that they believed they had encountered "wind shear," when they came across the tree line on the approach to runway 16, and, "it was like the bottom just fell out on us." The ATC tower controller also witnessed the event and stated that the airplane appeared to touchdown hard and on its right wing. When he asked the pilot if everything was all right, the pilot replied, "I believe so," and stated that they had experienced a wind shear on final. The ATC controller said he queried the crew of a Canadair Challenger that landed on runway 16 just after the mishap, if they had experienced any wind shear and they said they had not. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with multiple ratings including airplane multi-engine land, and a CE-500 type rating. According to records provided by Air Trek, the pilot had a total flight experience of 4,950 hours, with 3,200 hours in the accident airplane make and model. His most recent FAA first-class medical certificate was issued on October 25, 2006. The copilot held an airline transport pilot certificate with multiple ratings including airplane multi-engine land and a B-737 type rating. According to records provided by Air Trek, he had a total flight experience of 25,982 hours, with 24.8 hours in the accident airplane make and model. His most recent FAA first-class medical certificate was issued on August 22, 2006. AIRCRAFT INFORMATION The airplane was manufactured in 1974, and had been modified with a Sierra Industries Incorporated, Citation Eagle (wing) modification. This modification had been originally developed by Advanced Systems Technology Incorporated (ASTEC) and was originally marketed as the "ASTEC EAGLE." The owner purchased the airplane on October 2, 1997. The most recent continuous airworthiness inspection was completed on February 28, 2007. At the time of the accident, the airplane had accumulated 22,015 total hours of operation. No recorders were installed. METEOROLOGICAL INFORMATION A weather observation taken about 11 minutes after the accident, included; wind at 300 degrees at 7 knots, visibility 10 miles, ceiling overcast at 500 feet, temperature 30 degrees Fahrenheit, dew point 28 degrees Fahrenheit, and an altimeter setting of 29.44 inches of mercury. AIRPORT INFORMATION BVY had two runways, oriented in a 09/27 and 16/34 configuration. Runway 16 was asphalt, and in good condition. It was equipped with a 4-light PAPI, a medium intensity approach light system, medium intensity runway edge lights, and non-precision markings. The total length of the runway was 5,001 feet, and its width was 100 feet. WRECKAGE AND IMPACT INFORMATION Post accident examination of the accident site and airplane by a Federal Aviation Administration (FAA) inspector revealed that, ground scars and impact signatures, which corresponded with the right wing striking the paved surface, existed approximately 100 ft before the displaced threshold. The upper wing skin of the right wing/fuel tank had been breached, exposing the main spar. The spar was broken and the outboard portion of the right wing and aileron had been bent in an upward direction at an approximate 10-degree angle, seven feet inboard of the wingtip. No preimpact mechanical malfunctions were discovered. TESTS AND RESEARCH Warning Systems According to the airplane manufacturer, an AOA system was optional, and no ice detector, or stall warning system was installed. Stall warning was achieved aerodynamically, aided by stall strips on the inboard section of each wing. The strips would disrupt the airflow over the wing causing that area to stall first and accentuate the pre-stall buffet. This would alert the pilot of the impending stall by aerodynamic buffeting which would occur at "approximately VS1 +12 in the clean (flaps up) configuration, and VSO + 5 in the landing configuration." Eagle Wing Modification According to 14 CFR Part 25.1419, if an airplane manufacturer seeks certification for flight in icing conditions, the airplane must be able to safely operate in the continuous maximum and intermittent maximum icing conditions of appendix C. As part of the supplemental type certificate for the ASTEC Eagle wing modification (STC SA645NW), additional icing tests and analysis were required by the FAA to demonstrate that the anti-icing performance of the Eagle system met those requirements, and that it's anti-icing performance was equivalent to, or higher than, the level ## Aircraft - Registration: [N511AT](https://openairdocs.org/deregistered/N511AT-2012-11-01), registration cancelled 2012-11-01, S/N 500-0166, built 1974 (OpenAirDocs) - Reported make and model: Cessna 500 - Registry model: [Cessna 500](https://openairdocs.org/model/cessna-500) (registry code 2076602) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada JT15D-1 series](https://openairdocs.org/engine/pratt-whitney-canada-jt15d-1-series) (registry code 52060, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 500 0166 - Airframe hours: 22015 - Engines: Pratt & Whitney JT15D-1A 2200 lbs thrust turbo jet; Pratt & Whitney JT15D-1A 2200 lbs thrust turbo jet - Damage: Substantial damage - Flight: Part 135 - Operator: Air Trek Inc. - Registered owner: Air Ambulance by Air Trek Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, February 1, 2007 - Departed: PGD, Punta Gorda, FL - Destination: BVY, Beverly, MA - Flight plan: IFR - Airport: BVY, Beverly Municipal Airport, runway 16, 5,001 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; commercial, flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review January 1, 2007; seat: left; flight hours: 4,950 total, 3,200 in this make and model, 4,500 as pilot in command, 370 in the last 90 days, 100 in the last 30 days, 10 in the last 24 hours - Co-pilot; age 60; injuries: none; commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review January 1, 2007; seat: right; flight hours: 25,982 total, 25 in this make and model, 22,238 as pilot in command, 105 in the last 90 days, 46 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 300° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 500 ft overcast - Temperature: 30 °F, dew point 28 °F - Altimeter: 29.44 inHg - Observed at: BVY ## 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 20070317003099A](https://openairdocs.org/incident/20070317003099A), Mar 17, 2007: Cessna 500CESSNA, Beverly, MA, Substantial damage. (-23) On an IFR GPS approach with a 500 ft ceiling to rwy 16 bvy aircraft landed hard and appeared to go sideways on the runway, tower asked PIC if everything… 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.