National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Las Vegas, NV

Accident Number:

WPR13LA310

Date & Time:

07/05/2013, 1845 PDT

Registration:

XBRSC

Aircraft:

ROCKWELL NA-265-65

Aircraft Damage:

Substantial

Defining Event:

Loss of control on ground

Injuries:

6 None

Flight Conducted Under:

Part 91: General Aviation - Personal

Analysis

The pilots reported that, during the approach, the main hydraulic system lost pressure. They selected the auxiliary hydraulic system “on,” continued the approach, and extended the landing gear using the emergency landing gear extension procedures. During the landing roll, about two-thirds down the runway, the pilots noticed that the brakes were not working normally and then turned onto a taxiway to clear the runway. The captain reported that, once on the taxiway, he was unable to stop or steer the airplane as it proceeded across a parallel runway and into an adjacent field where it subsequently struck a metal beam.

A postaccident examination of the airplane revealed brake system continuity with the cockpit controls. The tires, brake assemblies, and brake pads were intact and undamaged. The hydraulic lines from the hydraulic pump to the wheel brakes were intact. No hydraulic fluid was observed leaking on the exterior or interior portions of the airplane. The hydraulic fluid reservoir was found about 1/4 full. Further, testing of the two hydraulic pumps revealed that they were both functional, and no mechanical failures or anomalies that would have precluded normal operation were noted.

The airplane’s hydraulic system failure emergency procedures state that, if hydraulic pressure is lost, the electrically driven hydraulic pump should be reset and that, if the hydraulic pressure was not restored, that the primary hydraulic system should be disengaged and the landing gear should be lowered using the emergency landing gear extension procedures. After the gear is extended, the auxiliary hydraulic system should be selected “on” for landing. However, the pilots stated that they did not attempt to reset the electric hydraulic pump and that they performed the emergency landing gear extension procedures with the auxiliary hydraulic pump engaged. It is likely that the pilots’ failure to select the auxiliary hydraulic system “off” before extending the landing gear caused the hydraulic pressure in the auxiliary system to dissipate, which left only the emergency brake accumulator available for braking during the landing. The number of emergency brake applications that can be made by the pilots depends on the accumulator charge, which may be depleted in a very short time.

The airplane’s emergency braking procedures state that, as soon as the airplane is safely stopped, the pilots should request towing assistance. However, the pilots did not stop the airplane on the runway despite having about 3,900 ft of runway remaining; instead, they turned off the runway at an intersection, which resulted in a loss of directional control.

 

 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilots’ failure to follow the airplane manufacturer’s emergency procedures for a hydraulic system failure and emergency braking, which resulted in the loss of braking action upon landing and the subsequent loss of directional control while turning off the runway. Contributing to the accident was the loss of hydraulic pressure for reasons that could not be determined because postaccident testing and examination of the hydraulic system revealed no mechanical failures or anomalies that would have precluded normal operation.

 

Findings

Aircraft

Surface speed/braking - Not attained/maintained (Cause)

Directional control - Not attained/maintained (Cause)

Personnel issues

Aircraft control - Flight crew (Cause)

Use of policy/procedure - Flight crew (Cause)

Use of equip/system - Flight crew (Cause)

Environmental issues

Object/animal/substance - Contributed to outcome

Not determined

Not determined - Unknown/Not determined (Factor)

Factual Information

On July 5, 2013, about 1845 Pacific daylight time, a Rockwell International Corporation NA-265-65, Mexican registered XB-RSC, sustained substantial damage following a reported loss of control while taxiing at the McCarran International Airport (LAS) Las Vegas, Nevada. The airplane was registered to and operated by Eseasa Contrucciones, S. A. de C. V., under the provisions of Title 14 Code of Federal Regulations Part 91. The captain, first officer, and four passengers were not injured. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the personal flight which originated from Brownsville, Texas about 1755, central daylight time.

The pilots reported that about 20 miles from the airport, the main hydraulic system lost pressure. They selected the auxiliary hydraulic system and continued the approach. During the landing roll, about two thirds down the runway, the pilots noticed that the brakes were not working normally and turned onto a taxiway to clear the runway. Once on the taxiway, the captain reported he was unable to stop or steer the airplane as it proceeded across a parallel runway and then into an adjacent grass field where it subsequently struck a metal beam located within a drainage area.

Examination of the airplane wreckage by a Federal Aviation Administration Inspector revealed that the left wing was substantially damaged. The airplane was recovered to a secure storage facility for further examination.

A review of the airplane's emergency procedures for Hydraulic Pressure or Hydraulic Caution Light On, revealed that the electrically driven hydraulic pump should be reset and if the hydraulic pressure does not return to normal, to select the hydraulic pump to "off," and use the emergency gear lowering procedures to extend the landing gear. After the gear is emergency extended, the hydraulic auxiliary pump should be selected "on" for landing. The flight crew stated that they did not attempt to reset the hydraulic pump and accomplished the emergency landing gear extension procedures with the auxiliary hydraulic pump engaged.

Upon landing, the flight crew stated that they activated the emergency brake switch on the runway. The airplane's emergency procedures state when using emergency braking, as soon as the airplane is brought safely to a stop, that the flight crews should request towing assistance. The procedures also state that the number of brake applications available to the crew is dependent on the accumulator charge and may be depleted in a very short time. The landing runway was 10,525 feet in length, 150 feet wide, and had a 0.9 % uphill gradient. The flight crew did not bring the airplane to complete stop on the runway but taxied off the runway at an intersection, with about 3,900 feet of runway remaining.

A postaccident examination of the airplane, revealed brake system continuity with the cockpit controls. The tires, brake assemblies, and brake pads were intact and undamaged. The hydraulic lines from the hydraulic pump to the wheel brakes were intact. No hydraulic fluid was observed leaking on the exterior or interior portions of the airplane. Further, the external portions of the brake assemblies were not contaminated with hydraulic fluid. The hydraulic reservoir quantity was observed low in fluid and about ¼ full. According to the airplane's maintenance manual, the reservoir maximum capacity was two gallons. The reservoir fluid was observed to be dark red/brown in color and had a musky burnt scent. A sample of the reservoir hydraulic fluid was sent to the National Transportation Safety Board Materials (NTSB) laboratory for analysis.

The analysis of the hydraulic fluid revealed that the acid level was degraded beyond the normal range expected for this type of fluid but not to a critical level. Reference the Material Laboratory Factual Report in the public docket for additional information.

The two hydraulic pumps were removed and sent to their respective manufacturer for a functional check. Examination and functional checks of both hydraulic pumps revealed that they operated normally. No mechanical failures or anomalies that would preclude normal operation were noted.

The airplane's cockpit voice recorder (CVR) was sent to the NTSB Vehicle Recorder Division for readout. The recording of the accident flight was not present and consistent with the CVR being inoperative prior to the accident.

 

History of Flight

Approach

Sys/Comp malf/fail (non-power)

Taxi-from runway

Loss of control on ground (Defining event)

Collision with terr/obj (non-CFIT)

 

 

Pilot Information

Certificate:

Commercial

Age:

61

Airplane Rating(s):

Multi-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

Seatbelt, Shoulder harness

Instrument Rating(s):

Airplane

Second Pilot Present:

Yes

Instructor Rating(s):

None

Toxicology Performed:

No

Medical Certification:

Unknown With Waivers/Limitations

Last FAA Medical Exam:

02/13/2013

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

10/10/2012

Flight Time:

7400 hours (Total, all aircraft), 2100 hours (Total, this make and model), 7100 hours (Pilot In Command, all aircraft), 75 hours (Last 90 days, all aircraft), 25 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

 

 

Co-Pilot Information

Certificate:

Commercial

Age:

39

Airplane Rating(s):

Multi-engine Land

Seat Occupied:

Right

Other Aircraft Rating(s):

None

Restraint Used:

Seatbelt, Shoulder harness

Instrument Rating(s):

Airplane

Second Pilot Present:

Yes

Instructor Rating(s):

None

Toxicology Performed:

No

Medical Certification:

Unknown Without Waivers/Limitations

Last FAA Medical Exam:

05/10/2012

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

10/10/2012

Flight Time:

1939 hours (Total, all aircraft), 788 hours (Total, this make and model), 75 hours (Last 90 days, all aircraft), 25 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

ROCKWELL

Registration:

XBRSC

Model/Series:

NA-265-65

Aircraft Category:

Airplane

Year of Manufacture:

 

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

465-55

Landing Gear Type:

Retractable - Tricycle

Seats:

10

Date/Type of Last Inspection:

 Unknown

Certified Max Gross Wt.:

24000 lbs

Time Since Last Inspection:

 

Engines:

2 Turbo Fan

Airframe Total Time:

9940 Hours at time of accident

Engine Manufacturer:

Garrett

ELT:

Installed, activated, did not aid in locating accident

Engine Model/Series:

TFE-731-3R-1D

Registered Owner:

Eseasa Contrucciones S.A. de C.V.

Rated Power:

3700 lbs

Operator:

Eseasa Contrucciones S.A. de C.V.

Operating Certificate(s) Held:

None

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Dusk

Observation Facility, Elevation:

KLAS, 2181 ft msl

Distance from Accident Site:

0 Nautical Miles

Observation Time:

1856 PDT

Direction from Accident Site:

Lowest Cloud Condition:

Few / 11000 ft agl

Visibility

10 Miles

Lowest Ceiling:

Broken / 25000 ft agl

Visibility (RVR):

 

Wind Speed/Gusts:

17 knots / 23 knots

Turbulence Type Forecast/Actual:

/ None

Wind Direction:

180°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

29.53 inches Hg

Temperature/Dew Point:

38°C / 5°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

Brownsville, TX (BRO)

Type of Flight Plan Filed:

IFR

Destination:

Las Vegas, NV (LAS)

Type of Clearance:

IFR

Departure Time:

1755 CDT

Type of Airspace:

Class B

 

Airport Information

Airport:

McCarran International Airport (LAS)

Runway Surface Type:

Concrete

Airport Elevation:

2181 ft

Runway Surface Condition:

Dry

Runway Used:

25L

IFR Approach:

ILS

Runway Length/Width:

10526 ft / 150 ft

VFR Approach/Landing:

Full Stop

 

Wreckage and Impact Information

Crew Injuries:

2 None

Aircraft Damage:

Substantial

Passenger Injuries:

4 None

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

6 None

Latitude, Longitude:

36.074722, -115.151389 (est)

 


 


Administrative Information

Investigator In Charge (IIC):

Albert P Nixon

Report Date:

11/19/2015

Additional Participating Persons:

Gary Rucker; Federal Aviation Administration; Las Vegas, NV

John Mecalo; Sabreliner Aviation LLC; Perryville, MO

Publish Date:

05/18/2016

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=87393