Key West International Airport
Aircraft Accident/Incident Report

Key West, Florida 33040
Thursday, November 3, 2011 12:13 EDT

NTSB Narrative Summary Released at Completion of Accident

The pilot-in-command (PIC) stated that he flew the downwind leg at 1,500 feet at 130 knots indicated airspeed and turned onto final approach at 1,000 feet, which he flew at 106 knots. He then touched down 800 feet down the runway at 95 to 100 knots. At touchdown, he extended the speed brakes, and, after traveling another 800 feet, he began to apply wheel braking, but the brake pedals felt “hard” and would not move. He then attempted to apply the emergency brake, but there was no braking action when he pulled it. The airline transport pilot who was in the right seat and acting as the second-in-command reported also trying to apply wheel braking after the PIC was unsuccessful and stated that it did not work. The airplane then overran the runway into the engineered material arresting system. Review of the radar data for the descent and approach portions of the flight indicated that at times the airplane was fast and the approach was unstabilized. However, the touchdown occurred at a reference speed of 103 to 106 knots. Examination of airport security camera images and deceleration values (determined by using time, distance, and velocity calculations) indicated that the airplane’s deceleration was consistent with a lack of braking. Examination of the normal hydraulic braking system and antiskid system did not reveal any malfunctions or failures that would have precluded normal operation of the brakes. Examination of the cockpit revealed that the T-handle for the emergency gear extension system had been activated. This handle is located immediately to the right of the emergency braking handle and was most likely pulled during the incident landing instead of the emergency brake handle. Examination of the emergency braking/landing gear blow-down nitrogen bottle revealed that it was empty; no indication of leakage was discovered, and the witness wire on the landing gear blow-down cable at the nitrogen bottle was intact, indicating that the bottle was most likely empty before the incident flight, since adequate nitrogen should have been available from a properly serviced air bottle even if the landing gear had been extended pneumatically. Review of maintenance records that were provided by the operator nonetheless listed the airplane’s most recent inspection as being completed on September 5, 2011, “in accordance with the instructions and procedures of a current manufacturer’s recommended inspection program.” According to a signed inspection document, 13 phase inspections were completed, including a phase 5 inspection containing 126 separate tasks, comprising inspection of the emergency brake control valve, the brake reservoir, the antiskid components, and the antiskid system, as well as replacement of the antiskid motor/pump filter, operational check of the antiskid brake system, operational check of the emergency brake system, replacement of the brake reservoir air filter, and cleaning of the brake reservoir supply line and system filter. The document also indicated that servicing of the “emergency brake and gear Nitrogen” had been accomplished. The landing checklist in the airplane flight manual cautions that if a “hard brake pedal-no braking condition” is encountered during landing, the pilot should operate the emergency brake system. It also noted that to obtain maximum braking performance from the antiskid system, the pilot must apply continuous maximum effort (no modulation) to the brake pedals. The Pilot’s Abbreviated Checklist also contains emergency procedures for wheel brake failure and antiskid failure. However, examination of the incident airplane revealed that neither of these documents was in the cockpit. Instead, the cockpit contained a double-sided laminated checklist from a training provider titled “Normal Procedures.” No emergency procedures were printed on the checklist and “For Training Purposes Only” appeared at the bottom. Based on the available evidence, it could not be determined that a failure of the normal braking system occurred or that the pilots applied maximum braking effort, as indicated by the airplane manufacturer’s guidance. Further, had the braking system actually failed, the pilots did not apply the emergency brakes, instead activating the landing gear extension handle.

NTSB Probable Cause Narrative

The pilots’ failure to appropriately apply the landing gear wheel brakes after landing, to properly perform the hard brake pedal-no braking condition procedure following the reported brake failure and to apply the emergency brakes. The reason for the reported brake failure could not be determined because postincident examination did not reveal any malfunctions or failures that would have precluded normal operation of the brakes.

Event Information

Type of Event Incident
Event Date 11/3/2011
Event Day of the Week Thursday
Time of Event 1213
Event Time Zone Eastern Daylight Time
Event City Key West
Event State FLORIDA
Event Country --
Zipcode of the event site 33040
Event Date Year 2011
Event Date Month 11
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 243322N
Event Location Longitude 0814534W
Event Location Airport Key West International
Event Location Nearest Airport ID EYW
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 0
Degrees magnetic from airport --
Airport Elevation 3
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1153 Eastern Daylight Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID EYW
Elevation of weather observation facility 3
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 27
Dew Point at event time (in degress fahrenheit) 20
Wind Direction (degrees magnetic) --
Variable Wind Indicator Variable
Wind Speed (knots) 6
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.08
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 5
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 32364
NTSB Notification Source FAA Southern ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Feb 5 2014 9:13AM
User who most recently changed record kenj
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N938D
NTSB Number ERA12IA060
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Minor
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model 550
Aircraft Series Identifier --
Aircraft Serial Number 550-0454
Certified Max Gross Weight 13300
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 2
Cabin Crew Seats --
Passenger Seats 6
Total number of seats on the aircraft 8
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Sep 5 2011 12:00AM
Airframe hours since last inspection 3
Airframe Hours 9900
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type Unknown
Aircraft Owner Name JODA LLC
Aircraft Owner Street Address --
Aircraft Owner City CHESTERFIELD
Aircraft Owner State MO
Aircraft Owner Country USA
Aircraft Owner Zipcode 63017-8531
Operator is an individual? No
Operator Name South Aviation
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Ft. Lauderdale
Operator State FL
Operator Country USA
Operator Zip code 33315
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Business
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code FLL
Departure City Fort Lauderdale
Departure State FL
Departure Country USA
Departure Time 1136
Departure Time Zone EDT
Destination Same as Local Flt crash at destination city
Destination Airport Code EYW
Destination City Key West
Destination State FL
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Feb 5 2014 9:13AM
User who most recently changed record kenj
Since inspection or accident Time of Accident
Event Location Runway Number and Location 09
Runway Length 4801
Runway Width 100
Sight Seeing flight No
Air Medical Flight No
Medical Flight --