NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of April 15, 2008
(Information subject to editing)
Aviation Accident Report
Runway Overrun During Landing, Shuttle America, Inc.,
Doing Business as Delta Connection Flight 6448,
Embraer ERJ-170, N862RW,
Cleveland, Ohio, February 18, 2007
NTSB/AAR-08/01
This is a synopsis from the Safety Board’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.
EXECUTIVE SUMMARY
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 (ILS) 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 flight was operating under the provisions of 14 Code of Federal Regulations Part 121 from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Instrument meteorological conditions prevailed at the time of the accident.
The safety issues discussed in this report focus on (1) flight training for rejected landings in deteriorating weather conditions and maximum performance landings on contaminated runways, (2) standard operating procedures for the go-around callout, and (3) pilot fatigue policies. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration.
CONCLUSIONS
1. The captain and the first officer were properly certificated and qualified under Federal regulations.
2. The accident airplane was properly certificated, equipped, and maintained in accordance with Federal regulations. The recovered components showed no evidence of any preimpact structural, engine, or system failures.
3. Although marginal visual flight rules weather conditions existed at Cleveland-Hopkins International Airport during most of the accident flight, the weather conditions had rapidly deteriorated while the airplane was on approach, with moderate to heavy snow reported during the approach and at the time of the landing.
4. The approach and tower controllers that handled the accident flight performed their duties properly and ensured that the flight crew had timely weather and runway condition information. Airport personnel at Cleveland-Hopkins International Airport appropriately monitored runway conditions and provided snow removal services in accordance with the airport’s Federal Aviation Administration-approved snow removal plan. The emergency response to the accident scene was timely.
5. Because the flight crewmembers were advised that the glideslope was unusable, they should not have executed the approach to instrument landing system minimums; instead, they should have set up, briefed, and accomplished the approach to localizer (glideslope out) minimums.
6. When the captain called for a go-around because he could not see the runway environment, the first officer should have immediately executed a missed approach regardless of whether he had the runway in sight.
7. When the first officer did not immediately execute a missed approach, as instructed, the captain should have reasserted his go-around call or, if necessary, taken control of the airplane.
8. Because the first officer lost sight of the runway just before landing, he should have abandoned the landing attempt and immediately executed a missed approach.
9. The rejected landing training currently required by the Federal Aviation Administration is not optimal because it does not account for the possibility that pilots may need to reject a landing as a result of rapidly deteriorating weather conditions.
10. Pilots need to perform landing distance assessments because they account for conditions at the time of arrival and add a safety margin of at least 15 percent to calculated landing distances, and this accident reinforces the need for pilots to execute a landing in accordance with the assumptions used in the assessments.
11. On the basis of company procedures and flight training criteria, the airplane’s touchdown at 2,900 feet down the 6,017-foot runway was an unacceptably long landing.
12. The flight crewmembers did not use reverse thrust and braking to their maximum effectiveness; if they had done so, the airplane would likely have stopped before the end of the runway.
13. Specific training for pilots in applying maximum braking and maximum reverse thrust on contaminated runways until a safe stop is ensured would reinforce the skills needed to successfully accomplish such landings.
14. The runway safety area for runway 28 still does not meet Federal Aviation Administration standards.
15. The Shuttle America chief pilot’s instruction not to use the slide was inappropriate because he did not have the same knowledge as the flight crew and on-scene airport rescue and firefighting personnel and his instruction restricted the options for deplaning the passengers.
16. The captain’s use of imprecise terminology for the go-around callout, his failure to clearly assert the callout, and the lack of a clear company procedure that would allow the monitoring pilot to make the callout contributed to the first officer’s failure to discontinue the approach.
17. Both flying and monitoring pilots should be able to call for a go-around because one pilot might detect a potentially unsafe condition that the other pilot does not detect.
18. The captain was fatigued, which degraded his performance during the accident flight.
19. Even though the first officer had been flying a heavy schedule through the time of the accident, there was insufficient evidence to determine whether fatigue was a factor in his performance during the flight.
20. Shortcomings in Shuttle America’s attendance policy limited its effectiveness because the specific details of the policy were not documented in writing and were not clearly communicated to pilots, especially the administrative implications or consequences of calling in as fatigued.
21. Shuttle America’s failure to administer its attendance policy as written might have discouraged some of the company’s pilots, including the accident captain, from calling in when they were sick or fatigued because of concerns about the possibility of termination.
22. By not advising the company of his fatigue or removing himself from duty, the captain placed himself, his crew, and his passengers in a dangerous situation that could have been avoided.
23. A fatigue policy that allows flight crewmembers to call in as fatigued without fear of reprisals would be an effective method for countering fatigue during flight operations.
PROBABLE CAUSE
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 National Transportation Safety Board makes the following recommendations:
To the Federal Aviation Administration:
1. Require 14 Code of Federal Regulations Part 121, 135 and 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 maneuver. (A-08-XX)
2. Require 14 Code of Federal Regulations Part 121, 135, and 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-XX)
3. Require 14 Code of Federal Regulations Part 121, 135, and 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-XX)
4. 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 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-XX)
5. Once the fatigue policy described in Safety Recommendation [4] has been developed, require 14 Code of Federal Regulations Part 121, 135, and 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-XX)
Previously Issued Recommendations Classified in This Report
1. Safety Recommendations A-03-11 and -12 are classified “Open—Acceptable Response” in section 2.2.3 of this report.
2. Safety Recommendation A-07-57 (urgent) is classified “Open—Unacceptable Response” and Safety Recommendation A-07-61 is classified “Open—Acceptable Response” in section 2.2.1.4 of this report.
!