Description

On 18 February 2007, while landing at Cleveland Hopkins International Airport, USA, an Embraer ERJ170 overran the snow contaminated runway. The crew failed to execute a go-around at the minimum decision altitude (MDA) of the localizer approach when adequate visual reference was not available.

Synopsis

This is an extract from the official Report (NTSB/AAR-08/01) by the National Transportation Safety Board (USA) (NTSB):

"On February 18, 2007, about 1506 eastern standard time, Delta Connection flight 6448, an Embraer ERJ-170, N862RW, operated by Shuttle America, Inc., was landing on runway 28 at Cleveland Hopkins International Airport, Cleveland, Ohio, during snow conditions when it overran the end of the runway, contacted an instrument landing system antenna, and struck an airport perimeter fence. The airplane’s nose gear collapsed during the overrun. Of the 2 flight crewmembers, 2 flight attendants, and 71 passengers on board, 3 passengers received minor injuries. The airplane received substantial damage from the impact forces."

The Investigation

In Section 1.8 titled Aids to Navigation, the Report, states:

"The Federal Aviation Administration (FAA) issued a Notice To Airmen regarding the runway 28 glideslope, stating, “due to the effects of snow on the glide slope minimums temporarily raised to localizer only for all category aircraft. Glide slope remains in service. However angle may be different than published.” This NOTAM was included in the flight crew’s preflight paperwork, but both pilots indicated that they had not read the NOTAM."

The Report reconstructs the following events shortly prior the accident:

"About 1502:01, the first officer stated that the glideslope had been captured. During a post-accident interview, the first officer stated that he and the captain did the “mental math” for a 3° glideslope and that, on the basis of this calculation, they assumed that the glideslope was functioning normally. Also, the captain stated that the cockpit instrumentation showed the airplane on the glideslope with no warning flags. Because the flight crewmembers assumed that the glideslope was working properly, they used the ILS decision height (DH), which was 227 ft above ground level (agl), instead of the localizer (glideslope out) minimum descent altitude (MDA), which was 429 ft agl. […]

[…]About 1504:58, the captain announced that the runway lights were in sight but then stated that he could not see the runway; this statement was immediately followed by “let’s go [around].” The first officer then stated, “I got the end of the runway.” About 1505:07, the CVR recorded the 50-foot agl electronic callout followed immediately by the captain’s statements, “you’ve got the runway?” and “yeah, there’s the runway, got it.” During a post-accident interview, the first officer stated that, when the airplane was 10 ft agl, he momentarily lost sight of the runway because a snow squall came through and he “could not see anything.” Flight data recorder (FDR) and CVR data showed that the airplane was about 1050 ft past the runway threshold when it descended to a height of 10 feet agl.

The CVR recorded the sound of the airplane touching down about 1505:29. According to the aircraft performance study for this accident, the airplane touched down about 2900 ft down the 6017 ft runway." […]

Probable Cause and Contributory Factors

The NTSB determined the following probable cause and contributory factors to the accident:

• "The National Transportation Safety Board determines that the probable cause of this accident was the failure of the flight crew to execute a missed approach when visual cues for the runway were not distinct and identifiable."

Contributing to the accident were:

1. "the crew’s decision to descend to the instrument landing system decision height instead of the localizer (glideslope out) minimum descent altitude;
2. the first officer’s long landing on a short contaminated runway and the crew’s failure to use reverse thrust and braking to their maximum effectiveness;
3. the captain’s fatigue, which affected his ability to effectively plan for and monitor the approach and landing; and
4. Shuttle America’s failure to administer an attendance policy that permitted flight crewmembers to call in as fatigued without fear of reprisals."

Safety Recommendations

As a result of the investigation of this accident, the NTSB made the following recommendations:

To the FAA:

• "Require 14 Code of Federal Regulations Part 121, 135, and Part 91 subpart K operators to include, in their initial, upgrade, transition, and recurrent simulator training for turbojet airplanes,
  1. decision-making for rejected landings below 50 feet along with a rapid reduction in visual cues and
  2. practice in executing this manoeuvre. (A-08-16)
• Require 14 Code of Federal Regulations Part 121, 135, and Part 91 subpart K operators to include, in their initial, upgrade, transition, and recurrent simulator training for turbojet airplanes, practice for pilots in accomplishing maximum performance landings on contaminated runways. (A-08-17)
• Require 14 Code of Federal Regulations Part 121, 135, and Part 91 subpart K operators to have a written policy emphasizing that either pilot can make a go-around callout and that the response to the callout is an immediate missed approach. (A-08-18)
• In cooperation with pilot unions, the Regional Airline Association, and the Air Transport Association, develop a specific, standardized policy for 14 Code of Federal Regulations Part 121, 135, and Part 91 subpart K operators that would allow flight crewmembers to decline assignments or remove themselves from duty if they were impaired by a lack of sleep. (A-08-19)
• Once the fatigue policy described in Safety Recommendation A-08-19 has been developed, require 14 Code of Federal Regulations Part 121, 135, and Part 91 subpart K operators to adopt this policy and provide, in writing, details of the policy to their flight crewmembers, including the administrative implications of fatigue calls. (A-08-20)

Related Articles

Runway Excursion

• Runway Excursion
• Low Visibility Procedures (LVP)
• Runway Availability
• Landing on Contaminated Runways
• Runway End Safety Area

Human Factors

• Fatigue Manifestations (OGHFA BN)
• Runway Overrun On Landing (OGHFA SE)

Further Reading

The Aircraft Accident Report NTSB/AAR-08/01 PB2008-910401