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NTSB Report

January 12, 2005 · Beech B300 · N350CS

Jacksonville, FL

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
January 12, 2005
Injury Outcomes
No injuries (6 uninjured)
Location
Jacksonville, FL
Aircraft
Beech B300
Tail Number
N350CS
Operator
Cbi
Injuries
None
Aircraft Damage
Substantial
NTSB Number
MIA05LA049

The pilot obtained three preflight weather briefings for the accident flight. The first weather briefing was the evening before the flight, while the last two were obtained the morning of the accident flight. The accident flight departed and ATIS information was obtained when the flight was approximately 30 miles from the destination airport. The ATIS at that time indicated scattered clouds existed at 100 feet with 2 miles visibility. The flight continued and after passing the final approach fix during the ILS approach to runway 32, the tower controller advised the flight crew of an indefinite ceiling of 100 feet with 3/4 mile visibility, with the visibility being supplemented by the ground controller who is a National Weather Service train weather observer, from the previous weather observation taken at 0807. The audible alarm for the ASOS monitor was on at the time of the accident. The ASOS monitor was located due east from the center of the tower cab near the ground control position, while the local control position was located north-northwest from the center of the tower cab. At 0826, a special METAR weather observation was taken indicating the visibility was 1/4 statute mile with fog, and a vertical visibility was 100 feet; the special observation was not provided to the flight crew. At the time the special METAR was taken, the airplane was inside the final approach fix and at an altitude less than 459 feet above ground level. The pilot advised he was flying the airplane at Vref plus 4 knots, and both he and copilot reported the runway environment became visible when the flight was approximately 200 feet agl. During the flare for landing, the flight entered heavy fog. The pilot further reported that he could not determine the point of touchdown; however, while on the ground, the airplane passed the 1000 foot-remaining marker. Full braking and reverse was applied; however, the airplane traveled off the end of the runway onto wet grass and collided with a localizer antenna 557 feet past the departure end of the runway. The pilot further reported there was no preimpact failure or malfunction of the aircraft, aircraft systems, or engines. He also reported that the reason for the overrun was not due to the additional 4 knots, but was due to the fact that while flaring to land with the engines spool down, full flaps extended, and the indicated airspeed below Vmc, fog rolled over the runway severely limiting my view of it. As a result he had to "... feel for the runway" which extended the touchdown point resulting in insufficient runway to stop.

NTSB Probable Cause

The pilot's failure to perform a missed approach after losing sight of the runway and the misjudgment of distance on the runway which resulted in an overrun. A contributing factor was the fog.

Full Narrative

On January 12, 2005, about 0828 eastern standard time, a Raytheon Aircraft Company B300, N350CS, registered to SRAIR, LLC, and operated by CBI, Inc., ran off the end of runway 32 and collided with a localizer antenna while landing at Craig Municipal Airport, Jacksonville, Florida. Instrument meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed for the 14 CFR Part 91 corporate flight from Witham Field Airport, Stuart, Florida, to Craig Municipal Airport. The airplane was substantially damaged and there were no injuries to the airline transport-rated pilot, commercial-rated copilot, or four passengers. The flight originated about 0730, from Witham Field Airport. The pilot stated to the NTSB investigator-in-charge (NTSB-IIC) that he obtained three preflight weather briefings for the accident flight; none of the weather briefings indicated the flight would not be possible. The first occurred the evening before, and the last two were obtained the morning of the accident flight. The accident flight departed and when the flight was within 30 miles from the destination airport, they obtained the automated terminal information service (ATIS) which was indicating scattered clouds at 100 feet and 2 miles visibility. The flight continued and only after passing the final approach fix, the tower controller advised the flight of an indefinite ceiling of 100 feet with 3/4 mile visibility. The pilot reported to the NTSB that he was flying the airplane at Vref plus 4 knots, the runway became in sight at approximately 200 feet above ground level (agl), and he was not sure of the point of touchdown. He initially reported in writing to the FAA that they, "landed long and entered a fog bank and could only see 200 to 300 feet." While on the ground, the airplane passed the 1,000 foot remaining marker and full braking and reverse propellers was applied. He was unable to stop the airplane which traveled off the runway onto wet grass then collided with the localizer antenna. He stated there were no discrepancies with the airplane, its systems, or the engines. He later stated to the NTSB that the reason for the overrun was not due to the additional 4 knots, but was due to the fact that while flaring to land with the engines spool down, full flaps extended, and the indicated airspeed below Vmc, fog rolled over the runway severely limiting my view of it. As a result he had to "... feel for the runway" which extended the touchdown point resulting in insufficient runway to stop. The copilot reported that the runway lights and threshold became in sight when the flight was approximately 200 feet agl, however, heavy fog was entered during the flare for landing. National Transportation Safety Board review of the certified voice tape from the Craig Municipal Airport (KCRG) air traffic control tower (ATCT) for the times 0823 through 0833, revealed one of the flightcrew members advised the tower controller that the flight was intercepting the ILS to runway 32. The local controller cleared the flight to land and advised the flightcrew of a Cessna Caravan that broke out of IMC conditions at minimums approximately 20 minutes earlier; the communication was acknowledged by one of the flightcrew members. According to air traffic control information provided by the manager of the KCRG ATCT, at 0825:02, the local controller advised the flightcrew that the visibility was 3/4 of a mile and the vertical visibility was 100 feet, which was acknowledged. The next communication from the flightcrew was to inform the tower controller that they had ran off the end of the runway and needed to be towed. An Automated Surface Observation System (ASOS) report taken at 0826, indicates that the wind was calm, the visibility was 1/4 statute mile in fog, the vertical visibility was 100 feet, the temperature and dew point were 15° and 14° Celsius, respectively, and altimeter setting was 30.19 inHg; the local controller did not provide the special observation to the flight crew. Radar data showed at the time the observation was taken, the flight was inside the final approach fix and at an altitude less than 459 feet agl. The KCRG ATCT tower manager reported that by the time the ground controller notified the local controller of the 1/4 mile visibility (reported in special METAR at 0826), the accident airplane had already landed. The previous special METAR observation taken at 0807, indicates the wind was calm, the visibility was 2 statute miles in mist, overcast clouds existed at 100 feet, the temperature and dew point were each 13°C, and the altimeter setting was 30.19 inHg. The KCRG ATCT Manager further reported the ground controller who is a National Weather Service trained weather observer supplemented the report of the 2 mile visibility noted in the 0807 observation, and changed it to 3/4 mile which was reported to the flight crew. National Transportation Safety Board review of recorded radar data revealed that from 0822:48, to 0824:02, the airplane was flown at 1,900 feet mean sea level (msl). The next radar target at 0824:07, indicated the airplane was at 1,800 feet msl. The radar data further indicated that between 0824:07, and 0825:48 (last radar contact and approximately 12 seconds before 0826 METAR), the airplane descended to 500 feet msl. The hexagon shaped tower cab of the KCRG ATCT contains an ASOS monitor located due east from the center of the tower cab near the ground control position, while the local control position in the tower cab is located north-northwest from the center of the tower cab. The KCRG ATCT Manager reported the audible alarm for the ASOS monitor was on at the time of the accident. Review of the instrument approach procedure for the ILS approach to runway 32 revealed the airplane is to maintain 1,900 feet msl until reaching the ADERR intersection which is the glide slope intercept/final approach fix location. The minimums for a straight-in ILS approach for runway 32 for all category aircraft are 200 feet agl and 1/2 mile visibility. Examination of the runway by the FAA-IIC revealed skid marks were located on the runway beginning approximately 600 feet before the departure end of the runway. The airport manager reported that the localizer antenna was located 557 feet past the departure end of runway 32. The cockpit voice recorder (CVR) was initially retained by the NTSB for readout; however, a transcription of communications recorded by the CVR was not prepared. The airplane minus the retained cockpit with recorder was released to the pilot, Gary Phillips, on March 2, 2005. The retained cockpit with recorder was also released to Gary Phillips on March 9, 2005.

Flight

Event TypeAccident
Event Time08:28 EST
Nearest AirportCraig Municipal Airport (0nm)
Runway32
Runway Length3998 ft
Runway Width100 ft
Flight Plan FiledIFR
Flight Plan ActivatedYes
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBeech B300
Tail NumberN350CS
Aircraft CategoryAir
DamageSubstantial
OperatorCbi
Operating RulePart 91
Engines2
Engine TypeTurboprop
Engine DetailsPratt & Whitney Canada · PT6A-60A · Turboprop · 1050
Seats11

People & Injuries

Injury SummaryNo injuries (6 uninjured)
Fatal0
Serious0
Minor0
Uninjured6
Total6
Crew 1Age 63 · Second Class · None
Crew 2Age 33 · Second Class · None

Conditions

ConditionsIMC
LightDaylight
WindCalm
Visibility0.2 sm
CeilingVertical visibility 100 ft
Temperature / Dew Point59 / 57
Altimeter30.19 inHg
Observation Time13:26
Weather SourceWFAC

Appendix: Source Data