NTSB CAROL · Event
Event ERA14TA435
Aircraft involved
Probable cause & findings
The pilot’s failure to execute a missed approach after recognizing that the airplane was not aligned with the wet runway, which resulted in a long landing with a tailwind and a subsequent runway overrun.
Factual narrative
On September 13, 2014, about 1340 eastern daylight time, a Cessna T210N, N5132C, nosed over following a landing overrun at the Montgomery County Airpark (GAI), Gaithersburg, Maryland. The commercial pilot and 2 other crew members were not injured. The airplane was substantially damaged. The airplane was registered to the pilot and operated by the U.S. Coast Guard Auxiliary as a public-use flight. Instrument meteorological conditions prevailed at the time which operated on an instrument flight rules clearance. The flight originated about 1130 EDT from the Millville Municipal Airport (MIV), Millville, New Jersey, and was destined for GAI.The pilot stated that the purpose of the flight was to observe boat traffic on several water ways. After takeoff from GAI they flew for about 2.5 hours and then proceeded to MIV and landed uneventfully. The flight departed VFR and flew over Delaware Bay, Chesapeake and Delaware Canals, Chesapeake Bay, and the North part of Chesapeake Bay before proceeding to GAI. While inbound to GAI he obtained Baltimore weather from the XM satellite, and when the flight was 5 miles from GAI, he noted cloud cover. While talking with Potomac Approach Control, he requested IFR clearance, and climbed to either 3,500 or 3,000 feet. While flying in IMC conditions he was vectored towards Frederick, and was cleared for and vectored to intercept the final approach course for the RNAV (GPS) approach. At TIMBE (Final Approach Fix), he extended the landing gear and lowered the flaps to 10 degrees, and continued the approach breaking out at 500 feet. He noticed the flight was 50 to 100 yards left of the runway, and with the runway in sight, he turned to the right in a "gentle" 270 degree turn, maintaining 80 knots. After the completion of the turn he aligned himself with the runway, and lowered the flaps to 40 degrees, maintaining 79 knots. He touched down about 1/2 way down the runway, and after touchdown he kept the flaps at that position and applied the airplane's brakes but they were not effective. The airplane travelled off the end of the runway onto grass and contacted a mound causing the airplane to nose over. He reported there were no injuries and all exited the airplane. The pilot later stated that after getting out of the airplane he noted a 5 to 8 knot tailwind component, and stated that about 10 minutes before starting the approach he was given the wind as 3 to 5 knots but did not recall the direction. He also stated there was standing water on the runway, and it had been previously raining. The pilot reported there was no preimpact mechanical failure or malfunction. The right front seat passenger who is not pilot rated but well acquainted with aviation reported that during the approach, the flight became clear of the clouds at 600 feet with a clear view of the runway, but was "significantly" left of the runway. The pilot executed a go-around and turned to return to runway 14 while maintaining visual contact with the runway, which appeared to be wet. During the descent there appeared to be "choppy wind conditions" with altitude deviations of 50 feet. He indicated the pilot struggled to bring the aircraft to the runway and reported the airplane landed about 1/2 way down the runway. He observed the pilot applying very strong effort on the brakes but the airplane did not appear to slow. The airplane went past the end of the runway at approximately 45 knots, and the nose landing gear collapsed after contacting rising terrain. The airplane then nosed over and came to rest inverted. The rear seat passenger confirmed that when the flight descended below the clouds on the approach the airplane was left of the runway. He reported the pilot went around to the right and landed about 1/4 to 1/3 down the runway. He felt moderate force against his restraint associated with braking, and reported he was surprised by the nose-over. Plotting of the radar data onto a GPS Runway 14 Approach Chart was performed by NTSB personnel. The plot indicated the pilot flew over BEGKA (the intermediate fix) and maintained the final approach course until approaching TIMBE, at which time the airplane flew slightly south of TIMBE. The radar data indicates the flight was not established on the final approach course from before TIMBE to the final radar return which was located southeast of JOXOX; "S" type turns were noted between TIMBE and after JOXOX, which is located 2.3 nautical miles from runway 14. The radar plot and radar data used for the radar plot are contained in the NTSB public docket. A witness who was in an airplane near the approach end of runway 14 north of the runway waiting IFR release indicated a right quartering tailwind existed, and reported first observing the airplane when it was left of his position flying in a southerly direction. The witness noted the airplane banked to the right and flew over the runway turning to the north where he lost sight of it. He then noted the airplane flew over his position about 20 seconds later about 200 feet above ground level while in a southerly direction, and flew south of the runway then banked to the left correcting back. The witness estimated that from his vantage point the airplane touched down between 2/3rd's to 3/4 down the runway, followed by seeing the airplane's tail in the air. The witness called on the Potomac Approach control frequency believing it was the common traffic advisory frequency to alert of the accident. A statement from the witness is contained in the NTSB public docket. According to the airport manager, the location where the airplane came to rest was approximately 725 feet past the departure end of the runway. A surface observation weather report taken at GAI at 1335, or about 5 minutes before the accident indicates that the wind was from 290 degrees at 7 knots; no gusts were reported. The pilot reported that the flight departed in visual flight rules conditions. While returning to the departure airport, the pilot obtained an instrument flight rules clearance due to instrument meteorological conditions at the destination. He was then vectored to intercept the final approach course for an RNAV (GPS) approach. Radar data indicated that the airplane subsequently flew the final approach course inbound from the intermediate fix to a point slightly south of the final approach fix (FAF). The radar data showed that, beyond the FAF to about 2.3 nautical miles from the runway, the airplane was not established on the final approach course and that it made several "S"-type turns. Witness, pilot, and passenger accounts indicated that the airplane was left of course when it broke out of the clouds. The pilot subsequently executed a right turn while maintaining visual contact with the runway. He then landed the airplane about halfway down the wet runway with about a 7-knot tailwind and 40 degrees of flaps extended. The pilot was unable to stop the airplane, and it overran the end of the runway and impacted rising terrain, which caused the nose landing gear to collapse and the airplane to nose over. The pilot reported no preimpact mechanical failures or malfunctions. 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).
- — Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Wet-Contributed to outcome
- C Personnel issues-Action/decision-Action-Lack of action-Pilot - C
- — Environmental issues-Conditions/weather/phenomena-Wind-Tailwind-Contributed to outcome
Verbatim from NTSB's published report. Source file
NTSB_2014_ERA14TA435.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 (go-around, imc). 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 2025 · Conference Paper
A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
- Flight Safety Foundation 2024 · FSF / AeroSafety World
Go-Around Safety Forum Findings
Foundation Go-Around Safety Forum technical findings — examines why pilots fail to execute go-arounds when criteria are met (stabilized approach gate not met, energy state out of envelope, traffic con…
- Semantic Scholar 2022 · Article (Journal of Safety Research)
Go-around accidents and general aviation safety.
INTRODUCTION Changes in General Aviation (GA) accident rates, specifically in the go-around phase, are examined by comparing the number of accidents, the proportion of fatal accidents, and the proport…
- Semantic Scholar 2021 · Article (Aerospace)
Classification and Analysis of Go-Arounds in Commercial Aviation Using ADS-B Data
Go-arounds are a necessary aspect of commercial aviation and are conducted after a landing attempt has been aborted. It is necessary to conduct go-arounds in the safest possible manner, as go-arounds …
- NASA NTRS 2021 · Accepted Manuscript (Version with final changes)
Go-Around Criteria Refinement for Transport Category Aircraft
Presently, airline pilots are trained to go around if, when lower than 500 ft above the ground, they are outside of a handful of parameters such as airspeed, position, and rate of descent.
- NASA NTRS 2019 · Conference Paper
Validation of Proposed Go-Around Criteria Under Various Environmental Conditions
This paper evaluates the effects of environmental conditions on touchdown performance under varying approach states and validates proposed go-around criteria developed using data from a previously con…
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