Results of Eagle Flight 5401 Accident Investigation

T-prop

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Results of EGF 5401 Accident Investigation [font=verdana, arial, helvetica]NATIONAL TRANSPORTATION SAFETY BOARD

Public Meeting of September 7, 2005

(Information subject to editing)



Report of Aviation Accident

Crash During Landing, Executive Airlines Flight 5401,

Avions de Transport Regional 72-212, N438AT

San Juan, Puerto Rico

May 9, 2004

NTSB/AAR-05/02





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 May 9, 2004, about 1450 Atlantic standard time, Executive Airlines (doing business as American Eagle) flight 5401, an Avions de Transport Regional 72-212, N438AT, skipped once, bounced hard twice, and then crashed at Luis Muñoz Marin International Airport, San Juan, Puerto Rico. The airplane came to a complete stop on a grassy area about 217 feet left of the runway 8 centerline and about 4,317 feet beyond the runway threshold. The captain was seriously injured; the first officer, 2 flight attendants, and 16 of the 22 passengers received minor injuries; and the remaining 6 passengers received no injuries. The airplane was substantially damaged. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger flight. Visual meteorological conditions prevailed for the 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 captain’s failure to execute proper techniques to recover from the bounced landings and his subsequent failure to execute a go-around.



CONCLUSIONS



The captain was properly certificated and qualified under Federal regulations. No evidence indicated any preexisting medical or physical conditions that might have adversely affected his performance during the accident flight. The first officer held a current Federal Aviation Administration airman medical certificate at the time of the accident; however, he failed to provide information about his medical condition (anxiety) or his use of the prescription drug alprazolam when he applied for the certificate.


2. The airplane was properly certificated, equipped, and maintained in accordance with Federal regulations and approved company procedures. The airplane was loaded in accordance with approved company weight and balance procedures. The weight and balance of the airplane were within limits during all phases of the flight.



Winds were within the airplane’s performance capabilities and did not adversely affect the flight crew’s ability to maneuver the airplane during the approach and landing as significant aircraft control authority remained.


The emergency response was timely and appropriate. The passengers and crewmembers were safely evacuated from the airplane.


At some point during the accident sequence, the captain cockpit seat failed when it was subjected to vertical loads that exceeded those required for certification.


The flight crew did not account for winds when calculating the minimum approach airspeed, and, as a result, they were not in compliance with Executive Airlines’ approach airspeed procedures.


Given the relative positions of the accident airplane and the preceding Boeing 727, the runway configuration, and the existing winds, wake turbulence was not a factor in this accident.


The captain did not properly follow Executive Airlines’ before landing procedures.


The flight crew could have completed a successful landing after the initial touchdown.


After each bounce of the airplane on the runway, the captain did not make appropriate pitch and power corrections or execute a go‑around, both of which were causal to the accident.


The captain demonstrated poor cockpit oversight and piloting techniques before and during the accident sequence.


Written company guidance on bounced landing recovery techniques would have increased the possibility that the captain could have recovered from the bounced landings or handled the airplane more appropriately by executing a go‑around.


The performance of air carrier pilots’ would be improved if additional guidance and training in bounced landing recovery techniques were available.




The aileron flight control surface position sensors installed on airplanes in accordance with Supplemental Type Certificate No. ST01310NY are unreliable, and flight data recorder functional checks every 6 months could ensure the timely identification and correction of potentiometer malfunctions and ensure that accurate flight control data are available for accident and incident investigations.


Because the first officer started getting treatment for anxiety in July 2001, he should have reported this information on his last three Federal Aviation Administration airman medical certificate applications.


Although it is possible that the first officer was impaired by his medical condition or prescription drug use, not enough evidence was available to determine whether or to what extent either factor contributed to the accident.


The pitch control uncoupling mechanism uncoupled when the airplane touched down for the third time; as a result, the pitch uncoupling would not have prevented the flight crew from controlling or safely landing the airplane.


When the airplane touched down for the last time, the vertical forces on the left main landing gear exceeded those that the gear was designed to withstand, and these excessive forces resulted in overload failure.


PROBABLE CAUSE


The National Transportation Safety Board determines that the probable cause of this accident was the captain’s failure to execute proper techniques to recover from the bounced landings and his subsequent failure to execute a go-around.



SAFETY RECOMMENDATIONS


As a result of the investigation of the Executive Airlines Flight 5401 accident, the National Transportation Safety Board makes the following recommendations.



To the Federal Aviation Administration:



Require all 14 Code of Federal Regulations Part 121 and 135 air carriers to incorporate bounced landing recovery techniques in their flight manuals and to teach these techniques during initial and recurrent training.


Require the replacement of aileron surface position sensors installed in accordance with Supplemental Type Certificate (STC) No. ST01310NY with more reliable aileron surface position sensors within 1 year or at the next heavy maintenance check, whichever comes first, after the issuance of an approved STC. Until reliable aileron surface position sensors have been installed, require flight data recorder functional checks every 6 months and replacement of faulty sensors, as necessary.


Conduct a review of all flight data recorder systems that have been modified by a supplemental type certificate to determine the reliability of all sensors used as flight control surface position sensors. If the review determines that a sensor does not provide reliable flight control surface position data, require that the sensor be replaced with a more reliable sensor.
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MJG

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Not good.....

So who was the PF, the FO or CAPT?

How "seriously" was the capain injured? Mentioned his seat failed, was that the cause of his injuries??
 

LearLove

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from what I understand it was the FO's leg and it was first day of IOE and his second leg of the day, the Capt flew the first leg.


Question: what does the flight control position indicator have to do with this? Unless they are referring that they could get better data on the accident if they had better data flight control position.
 

chperplt

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I wonder how long before the FAA charges him with falsifying his medical application.
 

tk855

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LearLove said:
from what I understand it was the FO's leg and it was first day of IOE and his second leg of the day, the Capt flew the first leg.

It was his first flight OFF of IOE, and yes the captain flew the first leg. Chperplt hit the nail on the head, it didn't come out until the NTSB debrief with the fo that he was taking a prescription medication and not listing it on his medical application. The fo more or less volunteered the fact that he was taking a prescription medication.
 

AlabamaMan!!

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chperplt said:
I wonder how long before the FAA charges him with falsifying his medical application.

That's been dealt with, chper.

As for the accident itself, it doesnt state much of what occured. Obviously, the captain has to fry for having inadequate supervision/control of his ship.
 

chperplt

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That's been dealt with, chper.

In what manner has it been dealt with? I imagine he lost his medical immediately, but have charges been filed?
 

AlabamaMan!!

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chperplt said:
In what manner has it been dealt with? I imagine he lost his medical immediately, but have charges been filed?

As an aquaintance of persons involved, I do know that legal procedings, etc. have been in process for well over a year.


Also, where did you guys find this info? It isnt up yet on the NTSB site. Just curious.
 

NYCPilot

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The prescription drug they mention is the generic name of Xanax, a medication used to treat anxiety, panic attacks and social phobias. It is also a tranqualizer and much stronger than Valium, which is similar but not as potent.

That guy must be crazy to have flown under these meds., as many OTC cold remedies are forbidden by the FAA. Let alone, more benign maintenance medications that do not alter the mind are prohibited.

According to one site, it causes memory loss, decreased motor skills and has very serious withdrawal symptoms along with addictive qualities.
 

T-prop

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MJG said:
Not good.....

So who was the PF, the FO or CAPT?

How "seriously" was the capain injured? Mentioned his seat failed, was that the cause of his injuries??

FO was landing, from the simulation recreation he touched down rather smooth and somehow got it airborne again, It looked like he was a little fast. It's rather easy to get her airborne again if your not careful, especially as light as they were. CA took over, bounced once more attempted to do a go around and failed when she stalled about 20 ft in the air and the left wing dropped. Too little too late. The go around may have been successful if they had completed the before landing checklist. Which calls to put the power management selector to takeoff which, in the event of a go-around the condition-levers will automatically snap to max RPM. It was left in the cruise position. Now we are required to bring the condition levers to max rpm before landing no matter what.

From the tower controller I talked to, the last bounce went as high as the trees next to the rwy. Look on airliners.net you'll see how high that is.

The FO was just out of IOE and the CA, as rumor has it, was not an easy person to get along with and was riding the FO pretty hard on the 20 min flight.
 
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T-prop

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AlabamaMan!! said:
T-PROP,

Where did you find that NTSB synopsis? I can't locate it.

They will probably post it soon. They just concluded the investigation last week.
 

StaySeated

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From the video it looks like everything was fine until numnuts capytan said my airplane and the thing took off again.
 

Cardinal

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If somebody would've just closed the power levers the first OR second time around, there would've been lot less paperwork. FO's - you haven't felt joy until the captain takes the controls from you and then promptly fcuks both parties. That is a precious moment.
 

propjockey

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I agree with the last two posts. Although it's difficult to tell from the animation, it definitely does appear that if the captain had left well enough alone, everyone would have walked away from just another less-than-stellar landing.

Having flown in both seats myself, I'm going to go further out on a limb here and say that captains who ride FOs like this guy often are not very good pilots themselves (domineering, yet insecure and/or inept -- a very bad combination), and ought to think twice before taking the controls away from the FO at high speed and close to the ground.
 

check6

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I didn't think he sounded that dominating. He may have just had a bad day.
 

CA1900

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I couldn't help but notice the nonstandard callouts might have contributed to the accident.

"Your power in a little bit."
"Get the power"

What does that mean?

"Add power." "Reduce power." That's a clear instruction.

"Get the power" is about as ambiguous as you can get. A guy on his first trip off IOE might not have any idea what he wanted.
 
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