Primary finding
Probable cause
The pilots’ unstabilized approach and excessive airspeed during approach, which resulted in an insufficient landing distance to stop the airplane before overrunning the runway.
Investigator assessment
Analysis narrative
Following an uneventful flight, the flight crew briefed the arrival to the destination airport and set the calculated landing speeds. The captain and the first officer reported that during final approach, it felt like the airplane was “pushed up” as the wind shifted to a tailwind or updraft before landing near the runway number markings. Upon touchdown, the captain applied the brakes and thought that the initial braking was effective; however, he noticed the airplane was not slowing down. The captain applied maximum braking, and the airplane began to veer to the right; he was able to correct back to the runway centerline, but the airplane subsequently exited the departure end of the runway and traveled down a steep embankment. A pilot-rated passenger reported that throughout the approach to landing, he thought the airplane was high and thought that the excessive altitude continued through and into the base-to-final turn. He added that the bank angle of this turn seemed greater than 45 degrees. Recorded communication from the cockpit voice and data recorder (CVDR) revealed that during the approach to landing, the flight crew performed the landing checks, and the captain noted difficulty judging the approach. About 1 minute later, the recording revealed that the ground warning proximity system reported “five hundred” followed by a “sink rate, pull up” alert about 16 seconds later. Data from the CVDR revealed that about 23 seconds before weight-on-wheels was recorded, the airplane was at an indicated airspeed of about 124 knots and descending. The data showed that this approximate airspeed was maintained until about 3 seconds before weight-on-wheels. The recorded data further showed that the approach speed was set to 120 knots, and the landing reference speed (vREF) was set to 97 knots. Using the reported airplane configuration and the 3.5-knot headwind that was reported at the time of the approach and landing, calculations indicate that the vREF speed should have been about 101 knots indicated airspeed, which would have required a landing distance of about 3,112 feet. Utilizing the same airplane configuration and wind condition with the flight’s reported 124 knot indicated airspeed just before touchdown, the landing distance was calculated to be about 5,624 feet. The intended runway for landing was 5,132-feet long with a 1.9 percent downward slope gradient, and a 123-foot long overrun area. A postaccident examination of the airplane, including the braking system, revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The pilot misjudged the airplane’s speed during the final approach, which resulted in runway overrun.
Source record
Factual narrative
HISTORY OF FLIGHT On May 25, 2011, about 1550 mountain standard time, an Embraer-Empresa Brasileira DE EMB-500 airplane, N244MD, sustained substantial damage during a runway overrun during landing at the Sedona Airport (SEZ), Sedona, Arizona. The captain, who was the flying pilot, and two of the three passengers were not injured. The first officer and one passenger sustained serious injuries. The airplane was registered to a private individual and operated by Superior Air Charter LLC., doing business as Jet Suite Air, Long Beach, California, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The flight originated from San Jose, California, about 1420 Pacific daylight time, with an intended destination of SEZ. Information provided by a Jet Suite representative indicated that the on-demand charter flight originated from San Jose, California, and the purpose of the flight was to transport three passengers to Sedona, Arizona. After arrival in Sedona, the flight was scheduled to depart for Oakland, California, to pick up additional passengers before returning to Los Angeles, California. The captain reported that following an uneventful flight, he briefed the first officer about the arrival to SEZ. About 20 miles from the airport, the flight crew notified air traffic control that they had the airport in sight and subsequently canceled their instrument flight rules (IFR) flight plan and proceeded on a visual approach to the airport. The captain said that the flight overflew the airport and entered a left downwind leg for runway 21 while conducting the descent and approach checklist. The captain stated that when they were established on downwind, the landing checklist was completed and a calculated 99 knot landing reference speed (vREF) was determined. The captain further reported that as he turned base leg at an airspeed of about 120 knots, he thought the airplane was low, and applied slight back pressure on the control yoke to arrest the descent prior to turning final to runway 21. Upon turning final, he thought the airplane was high and reduced the power to idle. The captain stated that as the airplane neared the approach end of the runway, it felt like it was "pushed up" by a wind shift to a tailwind or an updraft and that the airplane touched down firmly near the runway number markings and he immediately applied brakes. During the landing roll, the captain felt that the initial braking was effective; however, he noticed the airplane was not slowing down, and applied maximum brakes. The captain stated that during maximum brake application, the airplane began to veer to the right three times. He said that each time, he was able to steer the airplane back to the runway centerline, however, during the third time, the right main landing gear exited the runway surface; he steered the airplane back onto the runway surface; however, the airplane subsequently exited the departure end of the runway and traveled down an embankment. The captain added that during the landing roll, he felt a loss of braking effectiveness from the left side that he corresponded with the antiskid system actuating. The captain could not recall the exact speed of the airplane at the time of touchdown, but recalled that the airplane was at about 120 knots during final approach and was slowing at the time of the landing. The first officer reported that following an uneventful flight, air traffic control kept the airplane at 11,000 feet mean sea level (msl) until they had established visual contact with the airport. He recalled that when the flight was about 6 to 8 miles from SEZ, they informed air traffic control they had the airport in sight and subsequently canceled their IFR clearance. The first officer stated that the airplane was already slowed and that they extended the landing gear and lowered the flaps to the number one flap setting in order to descend. The first officer said that they entered the airport traffic pattern for runway 21 on a left crosswind prior to turning left downwind. After the airplane was established on the left downwind, a number two flap setting (26-degree deflection) was selected. The first officer further stated that the base leg and final approach was normal, noting the approach speed was 120 knots. During final approach to landing, the first officer felt the "wind pushing the airplane" followed by a firm landing around the 1,000-foot runway markers. In a written statement, an airline transport pilot rated passenger seated in the left aft forward facing seat reported that they had an uneventful flight until the approach segment started. The passenger said that he started monitoring the flight closer when the pilot lowered the landing gear before they entered the airport traffic pattern. The passenger said that while looking out the window, he noted that the airplane seemed high. Shortly after this he could see the runway from a distance and assumed they would be landing on runway 3 since the runway had better terrain clearance and was uphill. The passenger further reported that as the approach to landing began, he noticed that the flight was going to land on runway 21. As the flight started on the downwind leg, he thought the flight was high and felt that the excessive altitude continued through and into the base to final turn. The passenger stated that the bank angle of the base leg to final turn seemed greater than 45 degrees and that he was uncomfortable with the steep angle on the final approach. The passenger said that as the flight continued the descent on final and crossed high over the threshold, he thought the flight crew would initiate a go-around, however, the flight continued the approach to touchdown. The passenger stated that the flight continued the landing roll and started to swerve both left and right. He said that this continued to get worse as the airplane progressed down the runway. He added that in addition to the lateral movement, the airplane banked severely in both directions. A witness, located in the airport terminal building, reported that he had received a landing request from the accident airplane on the common traffic advisory frequency. The witness responded to the landing request with the current automated weather observing system (AWOS) and informed the pilots that runway 3 was the uphill runway. The witness said that he attempted to transmit this information twice with no response. He further stated that he then observed the accident airplane land within the touchdown area on runway 21 and "fish tail" on the runway at a "high rate of speed" until it exited the departure end of the runway. The witness further reported that he observed the airplane strike a chain link fence and continue out of sight down an embankment. PERSONNEL INFORMATION The captain, who was the flying pilot, age 62, held an airline transport pilot certificate with airplane multi-engine land ratings, and a commercial pilot certificate with an airplane single-engine landing rating. The captain also held multiple type ratings in various transport category aircraft. A first-class airman medical certificate was issued to the pilot on March 10, 2011, with no limitations stated. Review of company training records revealed that the captain underwent his most recent CFR Part 135 proficiency check for the accident make/model airplane on March 8, 2011. Company records showed that at the time of the accident, the captain had accumulated 23,970 hours of total flight time, of which 570 hours were in the accident make/model airplane, 51 hours in the previous 30 days, and 2 hours within the previous 24 hours. The first officer, who was the non-flying, age 32, held an airline transport pilot certificate with an airplane multi-engine land rating, and a commerc