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ERA12IA060 · Cessna 550

3 Nov 2011 · Key West, FL, United States

South Aviation Cessna 550 · Incident during landing

From Fort Lauderdale Hollywood International Airport (FLL) to Key West International Airport (EYW)

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Event

NTSB case
ERA12IA060
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Incident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Cessna 550

Aircraft type
Cessna 550
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N938D
Onboard fatalities
Unknown
Route
From Fort Lauderdale Hollywood International Airport (FLL), Fort Lauderdale, FLTo Key West International Airport (EYW), Key West, FL
Aircraft age
About 29 years (built 1982)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Landing · landing roll
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Unknown or undetermined
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Minor

Cause areas

  • Personnel issues › Action/decision
  • Personnel issues › Task performance

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

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.

Probable cause

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record ERA12IA060
Event ID
20111103X34623
Case number
ERA12IA060
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 18f0c6e67825bdd3686a897eaaff48f6e8e702f8d211726838b6eb5ea0b81c0b; retrieved 2026-09-15T16:54:35.372Z.