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NTSB investigation record

WPR13FA430

Completed

Cessna 525A· N194SJ

Date
September 30, 2013
Location
Santa Monica, CA
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s failure to adequately decrease the airplane’s ground speed or maintain directional control during the landing roll, which resulted in a runway excursion and collision with an airport sign and structure and a subsequent postcrash fire.

Investigator assessment

Analysis narrative

The private pilot was returning to his home airport; the approach was normal, and the airplane landed within the runway touchdown zone markings and on the runway centerline. About midfield, the airplane started to drift to the right side of the runway, and during the landing roll, the nose pitched up suddenly and dropped back down. The airplane veered off the runway and impacted the 1,000-ft runway distance remaining sign and continued to travel in a right-hand turn until it impacted a hangar. The airplane came to rest inside the hangar, and the damage to the structure caused the roof to collapse onto the airplane. A postaccident fire quickly ensued. The subsequent wreckage examination did not reveal any mechanical anomalies with the airplane's engines, flight controls, steering, or braking system. A video study was conducted using security surveillance video from a fixed-base operator located midfield, and the study established that the airplane was not decelerating as it passed through midfield. Deceleration was detected after the airplane had veered off the runway and onto the parking apron in front of the rows of hangars it eventually impacted. Additionally, video images could not definitively establish that the flaps were deployed during the landing roll. However, the flaps were deployed as the airplane veered off the runway and into the hangar, but it could not be determined to what degree. To obtain maximum braking performance, the flaps should be placed in the "ground flap" position immediately after touchdown. The wreckage examination determined that the flaps were in the "ground flap" position at the time the airplane impacted the hangar. Numerous personal electronic devices that had been onboard the airplane provided images of the passengers and unrestrained pets, including a large dog, with access to the cockpit during the accident flight. Although the unrestrained animals had the potential to create a distraction during the landing roll, there was insufficient information to determine their role in the accident sequence or what caused the delay in the pilot's application of the brakes.

Source record

Factual narrative

HISTORY OF FLIGHT On September 29, 2013, at 1820 Pacific daylight time, a Cessna 525A Citation, N194SJ, veered off the right side of runway 21 and collided with a hangar at the Santa Monica Municipal Airport (SMO), Santa Monica, California. The private pilot and three passengers were fatally injured, and the airplane was destroyed by a post-crash fire. The airplane was registered to CREX-MML LLC, and operated by the pilot under the provision of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight originated from Hailey, Idaho, about 1614. Witnesses reported observing the airplane make a normal approach and landing, on centerline and within the runway touchdown zone markings. The airplane started to drift to the right side of the runway during the roll out, the nose pitched up suddenly and dropped back down, then the airplane veered off the runway, and impacted the 1,000-foot runway distance remaining sign. It continued to travel in a right-hand turn, and impacted a hangar structural post with the right wing. The airplane came to rest inside the hangar, and the damage to the hangar structure caused the roof to collapse onto the airplane. A post-accident fire quickly ensued. On-scene examination of the wreckage and runway revealed that there was no airplane debris on the runway. The three landing gear tires were inflated and exhibited no unusual wear patterns. The Federal Aviation Administration (FAA) control tower local controller reported that the pilot did not express over the radio any problems prior to or during the landing. PERSONNEL INFORMATION The pilot, age 63, held a private pilot certificate with ratings for airplane single & multiengine land, and instrument airplane, issued March 27, 2004, and a third-class medical certificate issued May 21, 2012, with the limitation that he must wear corrective lenses. The pilot's current logbook was not located. An examination of copies from the pilot's previous logbook showed the last entry was dated June 5-7, 2009, and totaled his flight time as 3,463.1 hours, with 1,236.2 hours in the Cessna 525A. On the pilot's May 21, 2012, application for his FAA medical certificate he reported 3,500 hours total time, and 125 hours within the previous 6 months. The pilot had logbook endorsements from Flight Safety International, Orlando, Florida, for flight reviews and proficiency checks dated January 19, 2002, November 2, 2002, November, 15, 2003, June 4, 2004, March 2, 2005, March 22, 2006, March 21, 2007, and March 31, 2008. Training records provided by Flight Safety showed that he had completed the Citation Jet (CE525) 61.58 Recurrent PIC training on February, 27, 2013. The person occupying the right seat in the cockpit was a non-pilot rated passenger. AIRCRAFT INFORMATION The low wing, six-seat, retractable landing gear, business jet, serial number 525A0194, was manufactured in 2003, and was based at the Santa Monica Airport. It was powered by two Williams International FJ44-2C engines, each capable of producing 2,400 pounds of static thrust at sea level. A review of the maintenance records revealed that the most recent maintenance was performed on September 7, 2013, and included hydrostatic test of the fire extinguisher bottles, battery functional check, pitot-static system check, transponder calibration check, visual corrosion inspections on the landing gear and horizontal/vertical stabilizer spars, and a generator control unit wire bundle service bulletin. The records showed that as of September 7, the total airframe hours were 1,932.8. Total time on the number one engine (SN 126257) was 1,932.8 hours with 1,561 cycles, and the total time on the number two engine (SN 126256) was 1,932.8 hours with 1,561 cycles. Total landings were 1,561. The aircraft was not equipped with a flight data recorder or a cockpit voice recorder. Flap Position & Speed Brakes The flap system description from the Cessna 525 Operating Manual states: "The trailing edge flaps are electrically controlled and hydraulically actuated by the main hydraulic system. Normal flap travel is from 0 to 35 degrees and any intermediate position can be selected. A mechanical detent is installed at the takeoff and approach (15 degrees) position of the flap lever. The full flap position (35 degrees) is reached by pushing down on the flap lever when passing through the takeoff and approach detent." "The flaps have an additional position called GROUND FLAPS (60 degrees) which provides additional drag during the landing roll." The speed brake system description from the Operating Manual states: "The speed brakes are installed on the upper and lower surfaces of each wing to permit rapid rates of descent, rapid deceleration, and to spoil lift during landing roll. The speed brakes are electrically controlled and hydraulically actuated by a switch located on the throttle quadrant and may be selected to the fully extended or fully retracted positions. When the speed brakes are fully extended a white SPD BRK EXTEND annunciator will illuminate to remind the pilot of the deployed status of the speed brakes. The angular travel for the upper speed brake panels is 49 degrees, +2 or -2 degrees and the lower panels travel 68 degrees, +2 or -2 degrees. The lower speed brake panels close with the upper panel. The speed brakes will also automatically deploy when GROUND FLAPS position or selected on the flap handle." Brake System The brake system description from the Operating Manual states: "An independent power brake and anti-skid system is used for wheel braking. The closed center hydraulic system is comprised of an independent power pack assembly (pump, electric motor, and filter), accumulator and reservoir which provides pressurized hydraulic fluid to the brake metering valve and anti-skid valve. A hand-controllable pneumatic emergency brake valve is provided in the event of a power brake failure. Pneumatic pressure is transmitted to the brakes though a shuttle valve integral to each brake assembly." "The brake metering valve regulated a maximum of 1,000 psi +50/-20 psi to the brakes based upon pilot/copilot input to the left and right rudder pedals. RPM transducers at each wheel sense the onset of a skid and transmit information to the anti-skid control box. The anti-skid control box reduces brake pressure by sending electronic inputs to the anti-skid valve. Pressure to the brake metering valve is controlled by mechanical input through a bellcrank and push-rod system from either the pilot or the copilot's rudder pedals. A manually operated parking brake valve allows the pilot to increase the brake pressure while the brake is set, and provide thermal relief at 1,200 psi. After thermal relief, pressure will drop to no less than 600 psi, and the pilot or copilot must restore full brake pressure prior to advancing both engines to take-off power." "Pneumatic pressure from the emergency air bottle is available as a backup to the normal system." METEOROLOGICAL INFORMATION Recorded weather data from the Santa Monica Airport automated surface observation system (ASOS elevation 177 feet) at 1824 showed the wind was from 240 degrees at 4 knots, visibility was 10 statute miles with clear sky, temperature was 21 degrees C and dew point 12 degrees C, and the altimeter was 29.97 inHg. Sun position was calculated using the National Oceanic and Atmospheric Administration (NOAA) solar position calculator. The Los Angeles location of 34 degrees, 3 minutes, 0 seconds latitude, and 118 degrees, 13 minutes, 59 seconds longitude was used for the solar position calculation on September 29, 2013, at 1820 PDT. The solar azimuth was calculated to be 264.33 degrees, and solar elevation was 3.59 degrees above the horizon. This position placed the Sun near horizon level, about 54 degrees to the right of the centerline

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