NTSB CAROL · Event
Event CEN19LA090
Aircraft involved
Probable cause & findings
The flight crew's decision to continue an unstable approach under conditions that exceeded the airplane's landing performance capabilities, which resulted in a runway overrun and impact with terrain.
Factual narrative
HISTORY OF FLIGHTOn February 11, 2019, about 1007 eastern standard time, a Beech 400A airplane, N750TA, was substantially damaged when it was involved in an accident near Richmond, Indiana. The two pilots and one passenger were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The captain stated that he reviewed the flight plan the night before and discussed with the first officer the possibility of having to cancel the flight due to weather conditions. He recalled that the cloud ceiling was 100 ft above ground level (agl) and visibility was 1/2 mile with fog and mist. He reviewed the NOTAMs and he did not recall any concerning runway conditions. The captain and first officer conducted a preflight inspection of the airplane and checked the weather several times on the morning of the flight. The captain reported that the weather conditions were improving, and he did not recall seeing any new NOTAMs regarding runway conditions. The flight departed Waukesha County Airport (UES), Waukesha, Wisconsin, about 0917; throughout the flight, the crew continued to monitor the weather conditions at the destination. the captain stated that the reported conditions included 1.5 miles visibility, a cloud ceiling of 1,500 ft agl, wind from 090° at 4 kts, with fog and mist. The crew discussed the approach to runway 24 and the 4-knot quartering tailwind. During the approach, the first officer advised the captain that the airplane was high on final; the captain requested that the first officer configure the airplane for landing. The captain reported that, as the destination, Richmond Municipal Airport (RID), Richmond, Indiana, came into view during the approach, the runway appeared to have a "very light coating of snow on it." The captain elected to land and apply full thrust reversers and braking. After touchdown, the captain asked the first officer about the spoilers, and the first officer confirmed that the spoilers were deployed. A few seconds later, the captain thought that the airplane was not slowing much and advised the first officer that the airplane was going to go off the end of the runway. The airplane continued off the end of the runway and across a road. Data recorded by the airplane's G5000 avionics system showed that the airplane touched down about 10:06:58 at 129 kts and came to a stop about 10:07:25. The captain reported no mechanical malfunctions of the airplane during the flight; however, he stated that the engines were not visibly damaged, and that they shut down uncommanded after the airplane came to rest. After the accident, the captain used his iPad to review the NOTAMs again. At that time, he saw that the airport was closed and that the runway condition codes were “3-3-3”, i.e., braking deceleration is noticeably reduced for the wheel braking effort applier or direction control is noticeably reduced for each third of the runway. AIRCRAFT INFORMATIONThe operator, Stein's Aircraft Services, LLC, was a 19-year-old company that started as an aircraft management company and had grown into two full-service fixed base operators managing 15 corporate aircraft and 1 joint Part 135 and Part 91 aircraft. The operator employed about 15 full-time pilots and had an additional 6 pilots on contract. All Stein full-time pilots were trained at simulator training vendors. The contract pilots were also simulator trained and their currency verified. The operator reported that their normal procedures were to schedule the pilots more than 24 hours prior to their assigned flights and pilots to show about an hour or more before the flight. The day prior to a trip, lead pilots were required to preflight and discuss the trips and responsibilities with the other flight crew members. A Flight Risk Assessment Tool (FRAT) was required by the company for all legs of the trip and the risks had to be met to dispatch aircraft. The FRAT was required to be updated within 12 hours of the flight. The operator reported that the FRAT was not updated within the 12-hour time slot required for approval. After the accident, the operator emphasized the importance of good cockpit resource management (CRM) and restated that pilots "can and have the ability to cancel or change their trip." Additionally, the operator emphasized to the current simulator training vendor to pay close attention to CRM during training sessions. The airplane flight manual supplement for operation on wet or contaminated runways, in part, stated:
INTRODUCTION TO PERFORMANCE
The contaminated runway performance assumes that any dry snow, wet snow, slush or standing water is a uniform depth and density, does not exceed 0.5 inch in depth…. Runway Contaminated by Standing Water, Slush or Loose Snow A runway is considered to be contaminated when more than 25% of the runway surface area (whether in isolated areas or not) within the required length and width being used, is covered by surface water more than 3 mm (0.125 inch) deep, or by slush or loose snow equivalent to more than 3 mm (0.125 inch) of water. METEOROLOGICAL INFORMATIONAt 0955, the recorded weather at RID included wind from 080° at 4 kts; visibility 1/2 statute mile; fog; scattered clouds at 300 ft agl, overcast clouds at 1,500 ft agl; temperature 0°C; dew point 0°C; altimeter 30.12 inches of mercury. At 1015, the recorded weather at RID included wind from 080° at 4 kts; visibility 1 statute mile; mist; scattered clouds at 300 ft agl, overcast clouds at 1,500 ft agl; temperature 0°C; dew point 0°C; altimeter 30.13 inches of mercury. AIRPORT INFORMATIONThe operator, Stein's Aircraft Services, LLC, was a 19-year-old company that started as an aircraft management company and had grown into two full-service fixed base operators managing 15 corporate aircraft and 1 joint Part 135 and Part 91 aircraft. The operator employed about 15 full-time pilots and had an additional 6 pilots on contract. All Stein full-time pilots were trained at simulator training vendors. The contract pilots were also simulator trained and their currency verified. The operator reported that their normal procedures were to schedule the pilots more than 24 hours prior to their assigned flights and pilots to show about an hour or more before the flight. The day prior to a trip, lead pilots were required to preflight and discuss the trips and responsibilities with the other flight crew members. A Flight Risk Assessment Tool (FRAT) was required by the company for all legs of the trip and the risks had to be met to dispatch aircraft. The FRAT was required to be updated within 12 hours of the flight. The operator reported that the FRAT was not updated within the 12-hour time slot required for approval. After the accident, the operator emphasized the importance of good cockpit resource management (CRM) and restated that pilots "can and have the ability to cancel or change their trip." Additionally, the operator emphasized to the current simulator training vendor to pay close attention to CRM during training sessions. The airplane flight manual supplement for operation on wet or contaminated runways, in part, stated:
INTRODUCTION TO PERFORMANCE
The contaminated runway performance assumes that any dry snow, wet snow, slush or standing water is a uniform depth and density, does not exceed 0.5 inch in depth…. Runway Contaminated by Standing Water, Slush or Loose Snow A runway is considered to be contaminated when more than 25% of the runway surface area (whether in isolated areas or not) within the required length and width being used, is covered by surface water more than 3 mm (0.125 inch) deep, or by slush or loose snow equivalent to more than 3 mm (0.125 inch) of water. WRECKAGE AND IMPACT INFORMATIONLinear witness marks in the snow consistent with the landing gear started about halfway down runway 24, near the intersection with runway 15/33, continued down the remaining runway, through a localizer antenna array, and ended at the wreckage site. The nose landing gear (NLG) collapsed and deformed the fuselage and structure behind the NLG. The throttle quadrant was abeam this structure. No other damage was found that would have precluded normal operation of the airplane. ADDITIONAL INFORMATIONPerformance Information An NTSB airplane performance study indicated that the airplane crossed the runway threshold at a speed of 150 knots and touched down 3,100 ft beyond the threshold of the runway at 125 knots. About 4 seconds after touchdown, the thrust reversers were deployed. The airplane traveled beyond the end of the runway and came to rest about 750 ft beyond the runway. According to the pilot checklist, the airplane's landing reference speed (Vref) was between 110 and 114 knots. The airplane flight manual indicated that, for a dry runway with calm wind, the airplane's stopping distance was between about 3,234 ft and about 3,546 ft. For wet or compacted snow, the stopping distance was 5,300 ft. Landing distance calculations do not account for thrust reverser deployment. AIDS TO NAVIGATIONThe captain's report indicated that instrument landing system for runway 24 was out of service. However, the airport was serviced by an area navigation (RNAV) GPS approach to runway 24. The RNAV (GPS) approach to runway 24 began at the PEWEZ waypoint, which was the published initial fix. A 4 nm holding pattern was collocated with this waypoint and was depicted with a block altitude between 2,700 and 6,000 ft. The final approach course was 238°. On crossing UYOKO, pilots established themselves on the 068-degree course and remained at or above 2,700 ft until reaching the final approach fix, the WANKU waypoint, which after crossing; pilots could descend to at or above 1,820 ft until crossing the NINRE waypoint, located 2.7 nm from the end of the runway. On crossing NINRE, pilots could continue their descent to the published minimum descent altitude of 1,320 ft, if the airplane is I-NAV equipped, which is 384 ft above the runway elevation. The weather minimums to fly the straight-in approach were 400 ft ceiling and 1 mile visibility. The flight crew was approaching the destination airport on an instrument flight rules cross-country flight in instrument meteorological conditions. The captain stated that, after visually acquiring the runway environment during the approach, he saw that the runway "had a very light coating of snow," but he chose to continue the approach and apply full thrust reversers and braking after touchdown. The cockpit voice recorder revealed that the first officer advised the captain that the airplane was high while on final approach. The airplane crossed the runway threshold at 150 knots, touched down about 3,100 ft along the 5,502-ft-long runway at 125 knots, continued down the remaining runway, through an antenna array, and across a road before coming to rest about 750 ft beyond the paved surface. The airplane's landing approach reference speed (Vref) was between 110 and 114 knots. On a dry runway with calm wind conditions, the airplane required between about 3,200 ft and 3,500 ft runway stopping distance after touchdown; on a runway contaminated with wet or compacted snow, this distance increased to 5,300 ft. Although the captain reported that the engines shut down without his input following the accident, images from the accident site showed that the nose landing gear collapsed, deforming the surrounding structure, which included the area of the throttle quadrant. It is likely that the collapsed structure impacted the throttle quadrant and resulted in the engine shutdown. The captain reported that there were no other mechanical malfunctions or anomalies with the airplane. The captain and first officer conducted a preflight inspection of the airplane and checked the weather several times on the morning of the flight. The captain reported that the weather conditions were improving, and he did not recall seeing any new NOTAMs regarding runway conditions. The pilots' decision to continue the unstable approach and landing to the snow-covered runway despite that the distance available was inadequate resulted in the runway overrun; however, given the airplane's excessive approach speed and touchdown point over halfway down the runway, it is likely that the crew would have been unable to stop the airplane on the remaining runway even if it had been uncontaminated. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Personnel issues-Task performance-Use of equip/info-(general)-Flight crew - C
- C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Capability exceeded - C
- — Environmental issues-Conditions/weather/phenomena-Wind-Tailwind-Effect on operation
- — Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Snow/slush/ice covered surface-Effect on operation
Verbatim from NTSB's published report. Source file
NTSB_2019_CEN19LA090.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (crm). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- NASA NTRS 2019 · Abstract
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- Embry-Riddle Scholarly Commons 2017 · Journal article (IJAAA)
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- NASA NTRS 2026 · Technical Memorandum (TM)
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- arXiv 2025 · arXiv preprint
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- Semantic Scholar 2024 · Article (BMC Medical Education)
Augmented reality visualization for ultrasound-guided interventions: a pilot randomized crossover trial to assess trainee performance and cognitive load
Augmented reality (AR) technology involving head-mounted displays (HMD) represents a significant innovation in medical education, particularly for training in guided invasive procedures.
- NASA NTRS 2023 · Technical Memorandum (TM)
Safety Case for Small Uncrewed Aircraft Systems (sUAS) Beyond Visual Line of Sight (BVLOS) Operations at NASA Langley Research Center
This Technical Memorandum (TM) is written to provide for dissemination of the methods and safety considerations for operations of small Uncrewed Aerial Systems (sUAS) Beyond Visual Line-of-Sight (BVLO…
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