Runway Overrun During Landing Pinnacle Airlines Flight ..., Schemes and Mind Maps of Aviation

Download Runway Overrun During Landing Pinnacle Airlines Flight ... and more Schemes and Mind Maps Aviation in PDF only on Docsity!

aviation

Runway Overrun During Landing

Pinnacle Airlines Flight 4712

Bombardier/Canadair Regional Jet CL600-2B19, N8905F

Traverse City, Michigan

April 12, 2007

ACCIDENT REPORT

NTSB/AAR-08/

PB2008-

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO- 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314- Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2008-910402 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605- The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. National Transportation Safety Board. 2008. Runway Overrun During Landing, Pinnacle Airlines, Inc., Flight 4712, Bombardier/Canadair Regional Jet CL600-2B19, N8905F, Traverse City, Michigan, April 12, 2007****. Aircraft Accident Report NTSB/AAR-08/02. Washington, DC.

Abstract: This report explains the accident involving a Bombardier/Canadair Regional Jet

CL-600-2B19, N8905F, operated by Pinnacle Airlines, Inc., which ran off the departure end of

runway 28 after landing at Cherry Capital Airport, Traverse City, Michigan. The safety issues

discussed in this report include the pilots’ actions and decision-making during the approach,

landing, and landing roll; pilot fatigue and line check airman duty time regulations; weather and

field condition information and ground operations personnel communications; and criteria for

runway closures in snow and ice conditions. Safety recommendations concerning these issues

are addressed to the Federal Aviation Administration.

Accident Report

iii

C ontents

Abbreviations and Acronyms ....................................................................................... v

Accident Report

v

AbbreviAtions And ACronyms AC advisory circular ACARS aircraft communications addressing and reporting system AFD airport facility directory agl above ground level AIM Aeronautical Information Manual ALPA Airline Pilots Association ARC aviation rulemaking committee ARFF aircraft rescue and firefighting ARTCC air route traffic control center ASAP aviation safety action program ASOS automated surface observing system ATC air traffic control ATCT air traffic control tower ATIS automatic terminal information service °C degrees Celsius

Abbreviations and Acronyms

Accident Report

vi

CAMI Civil Aerospace Medical Institute CDT central daylight time CFM company flight manual CFR Code of Federal Regulations cg center of gravity CLE Cleveland-Hopkins International Airport CRJ Bombardier/Canadair Regional Jet CTAF common traffic advisory frequency CVR cockpit voice recorder DOT Department of Transportation DSM Des Moines International Airport DTW Detroit Metropolitan Wayne County Airport °F degrees Fahrenheit FAA Federal Aviation Administration FCTM flight crew training manual FDR flight data recorder FLIR forward-looking infrared device

Abbreviations and Acronyms

Accident Report

viii

NWA Northwest Airlines NWS National Weather Service OE operating experience OpSpec operations specification POI principal operations inspector RVR runway visual range S/N serial number SAFO safety alert for operators SOC system operations control SPECI special weather observation TAF terminal aerodrome forecast TR thrust reverser TVC Cherry Capital Airport Vapp approach landing speed (Vref + 5 knots) Vref reference landing speed WSFO National Weather Service forecast office

Accident Report

ix exeCutive summAry On April 12, 2007, about 0043 eastern daylight time, a Bombardier/Canadair Regional Jet (CRJ) CL600-2B19, N8905F, operated as Pinnacle Airlines flight 4712, ran off the departure end of runway 28 after landing at Cherry Capital Airport (TVC), Traverse City, Michigan. There were no injuries among the 49 passengers (including 3 lap-held infants) and 3 crewmembers, and the aircraft was substantially damaged. Weather was

reported as snowing. The airplane was being operated under the provisions of 14 Code of

Federal Regulations Part 121 and had departed from Minneapolis-St. Paul International

(Wold-Chamberlain) Airport, Minneapolis, Minnesota, about 2153 central daylight time. Instrument meteorological conditions prevailed at the time of the accident flight, which operated on an instrument flight rules flight plan. The National Transportation Safety Board determines that the probable cause of this accident was the pilots’ decision to land at TVC without performing a landing distance assessment, which was required by company policy because of runway contamination initially reported by TVC ground operations personnel and continuing reports of deteriorating weather and runway conditions during the approach. This poor decision- making likely reflected the effects of fatigue produced by a long, demanding duty day, and, for the captain, the duties associated with check airman functions. Contributing to the accident were 1) the Federal Aviation Administration pilot flight and duty time regulations that permitted the pilots’ long, demanding duty day and 2) the TVC operations supervisor’s use of ambiguous and unspecific radio phraseology in providing runway braking information. The safety issues discussed in this report include the pilots’ actions and decision-making during the approach, landing, and landing roll; pilot fatigue and line check airman duty time regulations; weather and field condition information and ground operations personnel communications; and criteria for runway closures in snow and ice conditions.

Factual Information

Accident Report

2 to TVC was routine. The captain/check airman was the flying pilot and was overseeing the first officer’s initial operating experience (OE)^2 ; the first officer performed the duties of the monitoring pilot. The CVR recorded several instances during the accident flight in which the pilots indicated that they were tired. For example, the CVR recorded the following statements on the captain’s channel: 1) about 2332:12, “yeah, just tired. Too late for this…;” 2) about 2341:53, “aw I’m tired dude, just (expletive) worn out;” and 3) about 0018:43 “…a wet dog ready to go to sleep tonight dude.” Additionally, about 0020:41, the CVR recorded the first officer stating, “jeez, I’m tired.” Further, several yawns were recorded on the captain’s channel (about 2340:00, 0001:06, 0004:00, and 0009:47). Because the TVC ATCT had closed at 2200 the night of the accident (consistent with its normal operations), the captain briefed the first officer regarding landing at TVC at night, after the tower closed, in snowy windy weather conditions. Records indicate that the Pinnacle dispatch personnel who were providing flight-following services for the accident flight occasionally provided the pilots with updated TVC weather information during earlier portions of the flight. Specifically, the aircraft communications addressing and reporting system (ACARS) log showed that about 2354, dispatch personnel sent weather updates to the accident airplane indicating IFR conditions with restricted visibility in light snow. After reviewing the weather information (about 2357), the captain made a public address statement advising the passengers that the winds at TVC were “dying down significantly…so it looks like we’re gonna have no problems gettin’ in this evening.” About 0010, the pilots listened to the TVC automated surface observation system (ASOS) for updated airport weather information, which indicated, in part, that winds were out of 040º at 7 knots and visibility of 1 1/2 miles in light snow. About 0021, the MSP Air Route Traffic Control Center (ARTCC) controller confirmed that the accident pilots had received the current TVC weather and began to issue radar vectors for the instrument landing system (ILS) approach to runway 28 at TVC.^3 About 0025, the captain sent a message to dispatch indicating that the TVC weather looked good for the approach, citing winds out of 040 degrees at 8 knots. Company dispatch personnel responded, stating, “[w]e show that too, looks like we should be good.” The weather data subsequently recorded by the TVC’s ASOS showed that the conditions at TVC began to deteriorate rapidly after 0025, with visibility of 1/2 mile in moderate snow, sky obscured, and vertical visibility of 400 feet. The pilots did not listen to the ASOS again as they continued to follow air traffic control (ATC)-provided radar vectors for the ILS approach to TVC; however, they did obtain information regarding runway conditions from TVC airport operations personnel. For example, beginning about 0025, the CVR recorded a radio conversation between the captain and the TVC airport (^2) The first officer was hired by Pinnacle on January 3, 2007, and successfully completed his CRJ ground training and proficiency check in February and March 2007, respectively. For additional information, see section 1.5.2. (^3) The ILS approach to runway 28, with minimums of a 200-foot decision height and 1/2-mile visibility, was the only precision approach at TVC. Nonprecision approaches, with higher minimum requirements, were available to runway 36 (which was closed). Only circling approaches (which were also nonprecision approaches with higher minimum requirements) were available to runway 10.

Factual Information

Accident Report

3 operations supervisor regarding the runway condition and ongoing snow removal operations. The airport operations supervisor indicated that he had “multiple pieces of [snow removal] equipment” on runway 28 and that he was “running numbers for you as we speak.” The captain indicated that they would be landing in about 13 minutes. According to the CVR, about 0026:56, the airport operations supervisor radioed the pilots, advising that the braking action on runway 28 was “40 plus,”^4 with “thin wet snow [over] patchy thin ice…give us about [5 to 8] minutes to clear the runway…when you’re ready to land.” About 0029:10, the CVR recorded the captain stating, “there’s snow removal on the field yet they’re showing forty or better sounds like a contaminated… runway to me.” During the next 4+ minutes, the CVR recorded additional conversation between the pilots, TVC operations, and MSP ARTCC personnel regarding the status of the snow removal equipment on the runway and the timing of the approach. About 0032:16 (about 6 minutes before the captain’s estimated arrival time), the airport operations supervisor contacted the pilots to indicate that the last snow plow was off the runway. The captain responded, advising that the accident flight would be turning inbound and requesting additional airport traffic advisories if applicable. About 0033, the captain advised the MSP ARTCC controller that the TVC runway was clear of snow removal equipment; the controller advised him that it would “be about another…2 minutes ‘til I get you out far enough to turn you back onto the ILS.” The pilots then discussed the length of the landing runway, and, about 0033:46, the captain stated, “…and at night it’ll feel short too...with contaminant…more than likely.” About 0034, the airport operations supervisor contacted the accident pilots again regarding their proximity to the airport. The captain replied that they expected an inbound turn clearance from the controller in about 1 minute, and the airport operations supervisor responded, “okay, roger that…it’s comin’ down pretty good here so ahhh (guess) I’ll see you on the ground here.” About 1 minute later, the airport operations supervisor queried the pilots about their progress, indicating “it’s comin’ down pretty good guys, just to give you a heads up.” About 7 seconds later (about 0035:42), the controller issued the first of a series of heading changes, vectoring the accident pilots towards the approach to runway 28. About 0036:19, the captain commented to the first officer, “…says it’s comin’ down good, which means its snowing…and we probably won’t see the runway, so be ready for the missed [approach].” About 1 minute later, the airport operations supervisor contacted the pilots, stating “I need to know if [you] guys are gonna be landing soon ‘cause I gotta… this is fillin’ in pretty quick down here…so, ah, how far are you guys out?” The captain replied that they were intercepting the approach course inbound and anticipated landing in “4 1/2, 5 minutes at the most.” According to the CVR, at 0038:03.2, the airport operations supervisor stated, “…I don’t know what the ah conditions [are] like…the runway, but I’m gonna call braking (^4) The “40 plus” braking report was based on the runway coefficient of friction values (.40+) obtained by ground personnel using an electronic recording decelerometer. Federal Aviation Administration guidance indicates that an airplane’s braking performance starts to deteriorate and directional control begins to be less responsive at MU values of .40 or less.

Factual Information

Accident Report

5 the approach threshold of runway 28 at an airspeed of about 148 knots^7 and touched down on the runway about 2,400 feet from the threshold at an airspeed of 123 knots. The FDR data showed that the brakes were applied and the spoilers deployed immediately after the airplane touched down and that the thrust reversers were fully deployed within 4 seconds after touchdown. FDR information further showed that the thrust reversers were deployed and stowed twice during the landing roll. The first deployment occurred when the airplane was about 3,000 feet from the departure end of the runway, and the second deployment occurred when the airplane was about 1,100 feet from the departure end of the runway. The airplane ran off the end of runway 28 at a ground speed of about 47 knots, on a heading of about 254°. It came to a stop on a heading of about 250°, about 100 feet west of the end of the 200-foot-long, 190-foot-wide blast pad pavement located off the end of runway 28. 1.2 Injuries to Persons Table 1. Injury chart. Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 0 0 0 0 0 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 2 1 49 0 52 Total 2 1 49 0 52 Note: Title 14 CFR 830.2 defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours, starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface. A minor injury is any injury that does not qualify as a fatal or serious injury. 1.3 Damage to Airplane The airplane had substantial, but repairable, damage, primarily to the forward lower fuselage, including the nose gear well area. 1.4 Other Damage No other damage was reported. (^7) Based on the airplane’s estimated landing weight of 46,473 pounds, the pilots decided to use the more conservative landing card information, which indicated a landing reference speed (Vref) of 142 knots (with up to 5 knots added for gusty winds) for a landing weight of 47,000 pounds.

Factual Information

Accident Report

6 1.5 Personnel Information 1.5.1 The Captain The captain, age 27, was hired as a first officer by Pinnacle on May 11, 2001. He was upgraded to captain in April 2004 and to line check airman status in August 2006. The captain held a multiengine airline transport pilot certificate with a type rating in the CRJ. The captain held a first-class Federal Aviation Administration (FAA) airman medical certificate, dated February 14, 2007, with the limitation that he “must wear corrective lenses.” During postaccident interviews, the captain stated that he was wearing contact lenses at the time of the accident. The captain told investigators that he started flying in 1997, received his private pilot certificate in 1998, and his commercial pilot certificate, flight instructor certificates, instrument rating, and multiengine rating in 1999. He stated that he worked as a flight instructor at Henderson State University, Henderson, Arkansas, for about 2 years and also flew under contract with Arkansas Game and Fish Commission before he was hired by Pinnacle. According to the captain’s Pinnacle employment and flight records, he had flown about 5,600 hours total flight time, including about 4,200 hours in CRJs, of which about 2,500 hours were flown as CRJ captain. He had flown about 220, 54, 28, and 8 hours in the 90, 30, and 7 days and 24 hours, respectively, before the accident. Company records showed that the captain obtained his initial CRJ type rating in March 2004. His most recent line check occurred in April 2006, and his most recent CRJ proficiency check and recurrent ground training occurred in March 2007. A search of FAA records revealed no accident or incident history or enforcement actions for the captain. A search of the National Driver Register found no record of driver’s license suspension or revocation. The captain was based at Memphis International Airport (MEM), Memphis, Tennessee, and commuted from his home near Pensacola, Florida. He was married, and, 6 months before the accident, his wife had given birth to their first child. According to the captain, his personal and financial situations changed with the birth of his son and his wife quitting work. The captain characterized his health as good and indicated that there were no major health changes during the previous 6 months. The captain stated that when he was home without work demands, he typically went to bed about 2130 and awakened about 0730. However, he further stated that when he was home his sleep could be interrupted because he tried to provide relief for his wife during the night by responding when his son awakened. About 2040 on April 6, the captain and the first officer completed a 2-day OE training trip.^8 The captain commuted home from Minneapolis to Pensacola on April 7. He (^8) The captain told investigators that he initially tried to find another check airman to conduct the first officer’s OE because the accident pilots were personal friends. However, no other check airman was available. The captain stated that he attempted to perform the OE with the same strictness he would for any other candidate.

Factual Information

Accident Report

8 Company pilots who had flown with the captain^9 described him as professional, knowledgeable, approachable, and polite. The accident first officer described the captain as a good pilot with strong teaching abilities and a willingness to help. 1.5.2 The First Officer The first officer, age 28, was hired as a first officer by Pinnacle on January 3, 2007. He held a commercial pilot certificate with a single-engine rating, issued in April 2000, a flight instructor certificate issued in July 2001, and a commercial pilot certificate with a multiengine rating issued in March 2002. Between April 2001 and his hire date with Pinnacle, the first officer was employed in various flight instructor and 14 CFR Part 135 freight and charter pilot positions. The first officer held a first-class FAA airman medical certificate, dated November 3, 2006, with the limitation that he “must wear corrective lenses.” During postaccident interviews, the first officer stated that he was wearing glasses at the time of the accident. According to the first officer’s Pinnacle employment and flight records, he had flown about 2,600 hours total flight time, including 22 hours in CRJs. He had flown about 22, 22, 15, and 8 hours in the 90, 30, and 7 days, and 24 hours, respectively, before the accident. Company records showed that the first officer obtained his initial CRJ ground training and proficiency check in February and March 2007, respectively,

and was accomplishing his OE training at the time of the accident.^10 A search of FAA

records revealed no accident or incident history or enforcement actions for the first officer.

A search of the National Driver Register found no record of driver’s license suspension or

revocation.

The first officer was based at MEM and resided in the area, having relocated from California after he was hired by Pinnacle. The first officer was single and told investigators that his personal situation had changed when his mother died in November 2006. He reported that his financial situation had also changed and that he was having difficulty paying his bills because he was in training and earning a low starting salary at Pinnacle. The first officer characterized his health as good and indicated that there were no major health changes during the previous 6 months. The first officer told investigators that, when he did not have work demands, he typically went to bed about 2200 and awakened about 0800; however, he described his schedule as “crazy” and indicated that he sometimes slept until noon. After the captain and the accident first officer completed their 2-day OE training trip on April 6, the first officer was off duty for several days, during which he visited relatives in San Diego, California. The first officer stated he went to bed about 2200 on April 9 and awakened between 0400 and 0430 on April 10 to catch a flight to MSP. The first officer told investigators that he arrived at MSP about midday, drank juice at an airport (^9) Five pilots were interviewed, including two first officers, a captain/check airman who had recently flown normal line trips with the captain, a captain who had completed a recent checkride administered by the accident captain, and the acting chief pilot, who had administered previous checkrides. (^10) Pinnacle records indicate that the first officer completed about 44 hours of CRJ simulator time and about 22 hours (of the minimum required 25 hours) of OE, consistent with the company’s standard new-hire first officer training.

Factual Information

Accident Report

9 shop, then met with the accident captain to review the flight paperwork for the April 11 trip sequence. The first officer stated that after reviewing the paperwork, he and the captain ate dinner together and socialized until about 2145 CDT. The first officer indicated that he had a beer with dinner and went to sleep that night at the hotel about 2200 CDT. He awakened on April 11 about 0630 CDT, and he and the captain caught the shuttle to the airport and checked in for the day. The first officer stated that he and the captain had fast food at MSP for lunch when they returned from CLE, then flew the round trip to DSM. The first officer indicated that the pilots were scheduled to have a 30-minute turnaround upon their return to MSP before departing for TVC. However, he stated that the MSP-TVC flight release was delayed, and the flight’s departure was further delayed because of deicing. The first officer stated that he was a little tired during the accident flight but felt okay. The first officer was described favorably by two company simulator instructors as a pleasant person and dedicated student with flying skills commensurate with his flight time. The accident captain described the first officer as progressing normally toward OE approval, with above average airplane handling skills but below average skills on airplane systems and company procedures. 1.6 Airplane Information 1.6.1 General The accident airplane, serial number (S/N) 7905, was manufactured by Bombardier and received its FAA airworthiness certificate in December 2003. According to the manufacturer, the CRJ was designed for use in regional airline operations and has swept-back wings with winglets and a T-tail.^11 The airplane was equipped with two tail-mounted General Electric (GE) CF34-3B1 turbofan engines, which were installed new in December 2003. At the time of the accident, the airplane had accumulated about 8,219 total flight hours and 6,462 cycles.^12 According to flight dispatch information, the airplane’s actual takeoff weight for the accident flight was 49,473 pounds; the estimated TVC landing weight was 46,473 pounds. Airplane documentation indicates that the maximum structural takeoff and landing weights are 53,000 and 47,000 pounds, respectively. The calculated landing center of gravity (cg) was 13.7 percent mean aerodynamic chord (MAC), and the airplane’s cg range extended from 9 to 35 percent MAC. (^11) A T-tail is a design in which the airplane’s horizontal tail surfaces are mounted to the top of the vertical tail surfaces above the fuselage. (^12) An airplane cycle is one complete takeoff and landing sequence.