Wednesday, April 16, 2008

NTSB: Shuttle America ERJ-170 accident in 2007 caused by pilot error

Shuttle America logoYesterday, the U.S. National Transportation Safety Board (NTSB) announced its findings regarding a runway overrun accident in 2007 at Cleveland involving an Embraer ERJ-170 aircraft operated by Shuttle America. The NTSB has determined that the probable cause for the accident was "the failure of the flight crew to execute a missed approach when visual cues for the runway were not distinct and identifiable."

The accident happened at Cleveland Hopkins International Airport (CLE) on February 18, 2007. The accident aircraft, operating as Delta Connection Flight 6448, had arrived at CLE from Atlanta, landing on runway 28 during snow conditions. It overran the end of the runway, contacted an instrument landing system (ILS) antenna, and struck an airport perimeter fence, according to the NTSB report. The airplane's nose gear collapsed during the overrun. There were 71 passengers and four crew members on board. Three passengers received minor injuries.

Here is a summary of the findings regarding contributing factors, based on the NTSB report:
The Board found that contributing to the accident was the crew's decision to descend to the ILS decision height instead of the localizer (glideslope out) minimum descent altitude. Because the flight crew members were advised that the glideslope was unusable, they should not have executed the approach to ILS minimums; instead, they should have set up, briefed, and accomplished the approach to localizer (glideslope out) minimums.

Also contributing to the accident was 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. When the first officer lost sight of the runway just before landing, he should have abandoned the landing attempt and immediately executed a missed approach. Furthermore, the report states that had the flight crew used the reverse thrust and braking to their maximum effectiveness the airplane would likely have stopped before the end of the runway.

The Board concluded that 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.

In its final report on its investigation, the Safety Board noted that the captain's fatigue, which affected his ability to effectively plan for and monitor the approach and landing, contributed to the accident. By not advising Shuttle America of this fatigue or removing himself from duty, the captain placed himself, his crew, and his passengers in a dangerous situation that could have been avoided, the Board said.

Another contributing factor to the accident was Shuttle America's failure to administer an attendance policy that permitted flight crew members to call in as fatigued without fear of reprisals. The policy had limited 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.
The NTSB has made several recommendations to the Federal Aviation Administration (FAA) as a result of this investigation. Those recommendations have to do with flight training for rejected landings in deteriorating weather conditions and for maximum performance landings on contaminated runways; standard operating procedures for the go-around callout; and pilot fatigue policies.

A press release that announced the accident investigation report quoted NTSB Chairman Mark V. Rosenker who said, "Professional pilots have the daunting task of operating these passenger aircraft on a daily basis under a variety of weather conditions. Their decision making process and training must be comprehensive enough to take all conditions into account."

For more detailed information about the accident investigation and the resulting safety recommendations, see the synopsis of the accident investigation report on the NTSB website. The entire report will be made available within the next few weeks.