WPR13LA310

NTSB accident investigation · Rockwell NA-265-65 · Las Vegas, NV · July 6, 2013

Accident · No injuriesLimited investigationFinal report
Date
July 5, 2013, 18:45 local (Jul 6, 2013, 01:45 UTC)
Place
Las Vegas, NV
Injuries
6 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
XBRSCRockwell NA-265-65
Defining event
Taxi-from runway: Loss of control on ground
Weather
Visual (VMC) · Dusk
Status
Completed · report November 19, 2015
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Sabreliner Aviation LLC, Federal Aviation Administration
Case key
87393

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 pilots’ failure to follow the airplane manufacturer’s emergency procedures for a hydraulic system failure and emergency braking, which resulted in the loss of braking action upon landing and the subsequent loss of directional control while turning off the runway. Contributing to the accident was the loss of hydraulic pressure for reasons that could not be determined because postaccident testing and examination of the hydraulic system revealed no mechanical failures or anomalies that would have precluded normal operation.

Findings · 7

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Flight crewAll aircraft: 9,295 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Flight crewAll aircraft: 191 casesProbable cause
Performance/control parameters: surface speed/brakingAircraft › Aircraft oper/perf/capability · Not attained/maintainedAll aircraft: 238 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedAll aircraft: 3,958 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Flight crewAll aircraft: 1,391 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedAll aircraft: 2,247 casesProbable cause
Object/animal/substanceEnvironmental issues › Physical environment · Contributed to outcomeAll aircraft: 224 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilots reported that, during the approach, the main hydraulic system lost pressure. They selected the auxiliary hydraulic system "on," continued the approach, and extended the landing gear using the emergency landing gear extension procedures. During the landing roll, about two-thirds down the runway, the pilots noticed that the brakes were not working normally and then turned onto a taxiway to clear the runway. The captain reported that, once on the taxiway, he was unable to stop or steer the airplane as it proceeded across a parallel runway and into an adjacent field where it subsequently struck a metal beam. A postaccident examination of the airplane revealed brake system continuity with the cockpit controls. The tires, brake assemblies, and brake pads were intact and undamaged. The hydraulic lines from the hydraulic pump to the wheel brakes were intact. No hydraulic fluid was observed leaking on the exterior or interior portions of the airplane. The hydraulic fluid reservoir was found about 1/4 full. Further, testing of the two hydraulic pumps revealed that they were both functional, and no mechanical failures or anomalies that would have precluded normal operation were noted. The airplane's hydraulic system failure emergency procedures state that, if hydraulic pressure is lost, the electrically driven hydraulic pump should be reset and that, if the hydraulic pressure was not restored, that the primary hydraulic system should be disengaged and the landing gear should be lowered using the emergency landing gear extension procedures. After the gear is extended, the auxiliary hydraulic system should be selected "on" for landing. However, the pilots stated that they did not attempt to reset the electric hydraulic pump and that they performed the emergency landing gear extension procedures with the auxiliary hydraulic pump engaged. It is likely that the pilots' failure to select the auxiliary hydraulic system "off" before extending the landing gear caused the hydraulic pressure in the auxiliary system to dissipate, which left only the emergency brake accumulator available for braking during the landing. The number of emergency brake applications that can be made by the pilots depends on the accumulator charge, which may be depleted in a very short time. The airplane's emergency braking procedures state that, as soon as the airplane is safely stopped, the pilots should request towing assistance. However, the pilots did not stop the airplane on the runway despite having about 3,900 ft of runway remaining; instead, they turned off the runway at an intersection, which resulted in a loss of directional control.

Factual narrative

On July 5, 2013, about 1845 Pacific daylight time, a Rockwell International Corporation NA-265-65, Mexican registered XB-RSC, sustained substantial damage following a reported loss of control while taxiing at the McCarran International Airport (LAS) Las Vegas, Nevada. The airplane was registered to and operated by Eseasa Contrucciones, S. A. de C. V., under the provisions of Title 14 Code of Federal Regulations Part 91. The captain, first officer, and four passengers were not injured. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the personal flight which originated from Brownsville, Texas about 1755, central daylight time. The pilots reported that about 20 miles from the airport, the main hydraulic system lost pressure. They selected the auxiliary hydraulic system and continued the approach. During the landing roll, about two thirds down the runway, the pilots noticed that the brakes were not working normally and turned onto a taxiway to clear the runway. Once on the taxiway, the captain reported he was unable to stop or steer the airplane as it proceeded across a parallel runway and then into an adjacent grass field where it subsequently struck a metal beam located within a drainage area. Examination of the airplane wreckage by a Federal Aviation Administration Inspector revealed that the left wing was substantially damaged. The airplane was recovered to a secure storage facility for further examination. A review of the airplane's emergency procedures for Hydraulic Pressure or Hydraulic Caution Light On, revealed that the electrically driven hydraulic pump should be reset and if the hydraulic pressure does not return to normal, to select the hydraulic pump to "off," and use the emergency gear lowering procedures to extend the landing gear. After the gear is emergency extended, the hydraulic auxiliary pump should be selected "on" for landing. The flight crew stated that they did not attempt to reset the hydraulic pump and accomplished the emergency landing gear extension procedures with the auxiliary hydraulic pump engaged. Upon landing, the flight crew stated that they activated the emergency brake switch on the runway. The airplane's emergency procedures state when using emergency braking, as soon as the airplane is brought safely to a stop, that the flight crews should request towing assistance. The procedures also state that the number of brake applications available to the crew is dependent on the accumulator charge and may be depleted in a very short time. The landing runway was 10,525 feet in length, 150 feet wide, and had a 0.9 % uphill gradient. The flight crew did not bring the airplane to complete stop on the runway but taxied off the runway at an intersection, with about 3,900 feet of runway remaining. A postaccident examination of the airplane, revealed brake system continuity with the cockpit controls. The tires, brake assemblies, and brake pads were intact and undamaged.The hydraulic lines from the hydraulic pump to the wheel brakes were intact. No hydraulic fluid was observed leaking on the exterior or interior portions of the airplane. Further, the external portions of the brake assemblies were not contaminated with hydraulic fluid. The hydraulic reservoir quantity was observed low in fluid and about ¼ full. According to the airplane's maintenance manual, the reservoir maximum capacity was two gallons. The reservoir fluid was observed to be dark red/brown in color and had a musky burnt scent. A sample of the reservoir hydraulic fluid was sent to the National Transportation Safety Board Materials (NTSB) laboratory for analysis. The analysis of the hydraulic fluid revealed that the acid level was degraded beyond the normal range expected for this type of fluid but not to a critical level. Reference the Material Laboratory Factual Report in the public docket for additional information. The two hydraulic pumps were removed and sent to their respective manufacturer for a functional check. Examination and functional checks of both hydraulic pumps revealed that they operated normally. No mechanical failures or anomalies that would preclude normal operation were noted. The airplane's cockpit voice recorder (CVR) was sent to the NTSB Vehicle Recorder Division for readout. The recording of the accident flight was not present and consistent with the CVR being inoperative prior to the accident.

Aircraft

Registration
XBRSC
Reported as
Rockwell NA-265-65
Category
Airplane
Serial number
465-55
Airframe hours
9,940
Engines
Garrett TFE-731-3R-1D, 3,700 lbs thrust, turbo fanGarrett TFE-731-3R-1D, 3,700 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Eseasa Contrucciones S.A. de C.V.
Registered owner
Eseasa Contrucciones S.A. de C.V.
Airworthiness certificate
Standard, Normal
Departed
BRO · Brownsville, TX
Destination
LAS · Las Vegas, NV
Flight plan
IFR
Airport
LAS · McCarran International Airport, runway 25L, 10,526 × 150 ft, concrete
Equipment
Auto-pilot, Stall warning system

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Unknown, With waivers/limitations
Last flight review
October 10, 2012
Seat
Left
Restraint
3-point
Flight hours
7,400 total · 2,100 in this make and model · 7,100 as pilot in command · 75 in the last 90 days · 25 in the last 30 days · 4 in the last 24 hours
Role
Co-pilot
Age
39
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Unknown, Without waivers/limitations
Last flight review
October 10, 2012
Seat
Right
Restraint
3-point
Flight hours
1,939 total · 788 in this make and model · 75 in the last 90 days · 25 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
180° at 17 knots, gusting 23
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
100 °F, dew point 41 °F
Altimeter
29.53 inHg
Observed at
KLAS

Docket · 11

The files NTSB released with the investigation on October 21, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.0 MB in all.