Amazon Air MIA Runway Excursion


Approximate Time to End of CVR Recording (mm:ss)Observation
06:02A pilot called for flaps to be set to 1 degree.
04:18The flight crew checked in with Miami tower and were cleared to
land on runway 30.
02:53A pilot called for flaps to be set to 5 degrees.
02:37The flight crew lowered the landing gear.
02:14A pilot called for flaps to be set to 15 degrees.
01:42A pilot called for flaps to be set to 20 degrees, and the other pilot cautioned they were too fast. The other pilot made additional comments regarding the aircraft’s excessive speed throughout the remainder of the recording. There was not a consistent verbal response to the comments about speed.
01:23Sounds consistent with autopilot disconnect.
01:12Electronic “one thousand” callout.
01:04Electronic “sink rate sink rate” callout.
00:58Electronic “five hundred” callout.
00:57Electronic “sink rate sink rate” callout.
00:54Electronic “one hundred” callout.
00:50Electronic “minimums” callout.
00:48Electronic “too low terrain” callout. Annunciated four times.
00:41A pilot called for flaps to be set to 30 degrees.
00:40Electronic “forty” callout.
00:39Electronic “too low terrain” callout.
00:36Electronic “ten” callout.
00:31Sounds similar to the aircraft touching down.
00:15A pilot called for a go-around.
00:10Sounds similar to the aircraft departing the paved surface.
00:00The CVR recording ended.
A summary of select events captured on the FDR during the final few minutes of the FDR recording is provided below. All times are referenced relative to the end of the FDR recording. Note that the CVR and FDR times have not been precisely synchronized. The times and descriptions are preliminary and subject to change.

Approximate Time to End of FDR Recording
(mm:ss)
Observation
00:30The nose and right main gear touched down at a groundspeed of 158 knots.
00:23The brakes were applied at a groundspeed of 146 knots.
00:19The left main gear touched down at a groundspeed of 134
knots.
00:15Brakes were released at a groundspeed of 120 knots and throttles were increased to a value consistent with go-around thrust.
00:11The throttles were reduced to idle power and the brakes were re-applied. The groundspeed was 117 knots. The throttles remained at idle, and brakes remained applied until the end of the recording.
00:07Recorded lateral, longitudinal, and vertical acceleration values
changed markedly; the FDR data indicated a groundspeed of 96 knots.
00:00The FDR recording ended. The final recorded groundspeed was 65 knots. There was no indication in the recorded data that speed brakes or thrust reversers were deployed.


Images are available on NTSB's Flickr
 
Yeah, but we don’t do safety that way.

We weigh cost vs risk vs convenience and consider unexpected consequences.

EMAS was designed to address runways that could not economically meet the FAA’s post-facto RSA standards. It’s wasn’t designed to be especially effective at slowing and stopping planes.

The big picture is longer runways contribute more to public safety than EMAS. A 9000’ runway with no EMAS is probably safer than a 7000’ runway with 2000’ EMAS. And yes, for a heavy like a 767 you would need a very long EMAS … that might not work with smaller aircraft. Yeah, it’s complicated.

Why don’t we reduce Interstate speed limits to
35mph and make occupants wear helmets? Why do we let homeowners purchase ladders and use them without hard hats and OSHA oversight?

Bottom line is that risk=severity*probability. Playing whack-a-mole with the last hole in the Swiss cheese is reactive and performative and not a good way to drive meaningful safety improvements.

But we also get the blue-glove specials from the TSA for coming up on 25 years so…I expect to see EMAS at the end of every runway at DEN soon.

ok class:
Everyone take out your SMS manual and Risk Matrix chart.
(everyone groans)
 

Approximate Time to End of CVR Recording (mm:ss)Observation
06:02A pilot called for flaps to be set to 1 degree.
04:18The flight crew checked in with Miami tower and were cleared to
land on runway 30.
02:53A pilot called for flaps to be set to 5 degrees.
02:37The flight crew lowered the landing gear.
02:14A pilot called for flaps to be set to 15 degrees.
01:42A pilot called for flaps to be set to 20 degrees, and the other pilot cautioned they were too fast. The other pilot made additional comments regarding the aircraft’s excessive speed throughout the remainder of the recording. There was not a consistent verbal response to the comments about speed.
01:23Sounds consistent with autopilot disconnect.
01:12Electronic “one thousand” callout.
01:04Electronic “sink rate sink rate” callout.
00:58Electronic “five hundred” callout.
00:57Electronic “sink rate sink rate” callout.
00:54Electronic “one hundred” callout.
00:50Electronic “minimums” callout.
00:48Electronic “too low terrain” callout. Annunciated four times.
00:41A pilot called for flaps to be set to 30 degrees.
00:40Electronic “forty” callout.
00:39Electronic “too low terrain” callout.
00:36Electronic “ten” callout.
00:31Sounds similar to the aircraft touching down.
00:15A pilot called for a go-around.
00:10Sounds similar to the aircraft departing the paved surface.
00:00The CVR recording ended.
A summary of select events captured on the FDR during the final few minutes of the FDR recording is provided below. All times are referenced relative to the end of the FDR recording. Note that the CVR and FDR times have not been precisely synchronized. The times and descriptions are preliminary and subject to change.

Approximate Time to End of FDR Recording
(mm:ss)
Observation
00:30The nose and right main gear touched down at a groundspeed of 158 knots.
00:23The brakes were applied at a groundspeed of 146 knots.
00:19The left main gear touched down at a groundspeed of 134
knots.
00:15Brakes were released at a groundspeed of 120 knots and throttles were increased to a value consistent with go-around thrust.
00:11The throttles were reduced to idle power and the brakes were re-applied. The groundspeed was 117 knots. The throttles remained at idle, and brakes remained applied until the end of the recording.
00:07Recorded lateral, longitudinal, and vertical acceleration values
changed markedly; the FDR data indicated a groundspeed of 96 knots.
00:00The FDR recording ended. The final recorded groundspeed was 65 knots. There was no indication in the recorded data that speed brakes or thrust reversers were deployed.


Images are available on NTSB's Flickr

So, stabilized, on speed, on glideslope. What happened?
 
ok class:
Everyone take out your SMS manual and Risk Matrix chart.
(everyone groans)
Fun fact, the aviation safety stuff I did in college was almost entirely due to senioritis and wanting the easiest possible capstone project and also was what got me a promotion and doing SMS work when I finally got a real job. Because, as our safety prof always said, “it’s DVD Friday!”
 
Apparently a 1 yr stint at Skywest, 7 yrs as a B737 FO+CA at Kalitta, and then DEC at 21 Air onto the 767. Plus all the mil heli experience before. Cursory glance seems like enough experience.
TRue, extract all the helo time and Its probably like 5000-6000 hours, which is enough to know better.
 
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