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Shuttle America / 2007 CLE over run

tyuwerty

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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.

http://www.ntsb.gov/Publictn/2008/AAR0801.htm
 

The_Russian

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So what is the FAA going to do to Shuttle to ensure that this NEVER happens again?

Fatigue is a serious issue, and should never have a negative effect on one's job if they use that card. No one man can judge another's level of fatigue, ever.
 

AWACoff

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Maybe Shuttle will ask their crews not to shoot an ILS to minimums to a runway that doesn't have an operational GS. They may also ask crews not to land on the shortest runway at the airport during whiteout conditions. Additionally, after crashing, Shuttle may ask the crews to converse with the passengers instead of remaining locked in the cockpit.

Come on Russian...you and I both know that since nobody died, the FAA will do nothing.
 

erikgigem

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So what is the FAA going to do to Shuttle to ensure that this NEVER happens again?

Fatigue is a serious issue, and should never have a negative effect on one's job if they use that card. No one man can judge another's level of fatigue, ever.

And what is the FAA going to do to MESA to ensure that both pilots don't fall asleep as the wheel? Good thing the Flight Attendant went banging on the cockpit door to wake the pilots.

Fatigue, duty periods, and legal rest issues all need to be re-addressed as a safety issue. -Erik
 

rickair7777

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And what is the FAA going to do to MESA to ensure that both pilots don't fall asleep as the wheel? Good thing the Flight Attendant went banging on the cockpit door to wake the pilots.

Fatigue, duty periods, and legal rest issues all need to be re-addressed as a safety issue. -Erik

Absolutely true.

But shooting a localizer to ILS mins? Come on...that has nothing to do with fatigue. There's another adjective for that.
 

UnstableAviator

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But shooting a localizer to ILS mins? Come on...that has nothing to do with fatigue. There's another adjective for that.

I'm surprised it wasn't a "careless and reckless" for this action. I believe the GS was operable and transmitting a signal, but the Notam must still be complied with.
 

flyf15

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My guess is they never intentionally said "you know what, we'll just go to ILS mins anyway"... that didn't happen.

What happened was they were too dang tired and screwed up. Simple as that.
 

Rez O. Lewshun

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3000ft down the runway! Plan to put on the 1000ft marker everytime. Guys going for greasers contributed to this event!

Also... inability to call fatigue... and the choice to not use GS out minima.


In other words... Unprofessional!!!
 

Soverytired

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Far as I'm concerned, if fatigue was a factor (as it was ruled to be), ever other point is moot.

If the NTSB had ruled the pilots were intoxicated, everyone would immediately assume that all other errors comitted on this flight stemmed directly from their intoxicated state. THE SAME SHOULD BE ASSUMED FOR FATIGUE.

Nice to see the NTSB put in at least 5 points that either directly or indirectly addressed fatigue.

I have no doubt the NTSB desperately wants to change the duty time/rest rules, but lacks the authority to do so.
 
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The_Russian

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My guess is they never intentionally said "you know what, we'll just go to ILS mins anyway"... that didn't happen.

What happened was they were too dang tired and screwed up. Simple as that.
Good post!

Far as I'm concerned, if fatigue was a factor (as it was ruled to be), ever other point is moot.

If the NTSB had ruled the pilots were intoxicated, everyone would immediately assume that all other errors comitted on this flight stemmed directly from their intoxicated state. THE SAME SHOULD BE ASSUMED FOR FATIGUE.

Nice to see the NTSB put in at least 5 points that either directly or indirectly addressed fatigue.

I have no doubt the NTSB desperately wants to change the duty time/rest rules, but lacks the authority to do so.
Also a good post.
 

The_Russian

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3000ft down the runway! Plan to put on the 1000ft marker everytime. Guys going for greasers contributed to this event!

Also... inability to call fatigue... and the choice to not use GS out minima.


In other words... Unprofessional!!!
Did you consider the actions of their Chief Pilot before you typed that?
 

Caspian27

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Stop letting children play in airline cockpits

Yeah, since the "adults" have done much, much better (How about United 173 or Eastern 401. Both from the "Good-Old Days." Both simple light problems).

At least there weren't any fatalities in this accident.
 
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Soverytired

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Also... inability to call fatigue... and the choice to not use GS out minima.

In other words... Unprofessional!!!

The NSTB and NASA studies have conclusively proven that there are cases where pilots are fatigued and don't even know it.

Clearly, their "choice" to use GS out minima and poor crew coordination was heavily influenced by fatigue. Remember, some levels of fatigue are as bad or worse than being intoxicated.

I'm not picking a fight here. The fact is that failing to call "fatigue" is not necessarily a lack of character, guts or unprofessionalism.

There are valid reasons that the FAA has established bottle-to-throttle time rules and max blood alcohol limits. By following these rules, it's impossible for a pilot to arrive on the job intoxicated.

The comparable FAA duty time/rest requirement rules do NOT guarantee the lack of fatigue for pilots . . . far from it. NASA, the NTSB, ALPA, and most pilots know this, but the FAA fails to re-write rules that could virtually eliminate this elusive yet very real safety hazard.

=====================

If fatigued and you know it, certainly call in "fatigued." But what do you do when you've taken off "ok" but are "fatigued" en-route . . . due to your 8-hr reduced rest overnight the night before and are into your 5th leg of a 12 hour day?

Your stance seems to suggest you have never been in this situation. You are quite fortunate. Maybe you could cut a little slack to those who have, eh?
 
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Rez O. Lewshun

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The NSTB and NASA studies have conclusively proven that there are cases where pilots are fatigued and don't even know it.

And what is the FAA and NTSB doing about helping pilots recognize fatigue.

A cozy mx relationship with carrier?

Clearly, their "choice" to use GS out minima and poor crew coordination was heavily influenced by fatigue. Remember, some levels of fatigue are as bad or worse than being intoxicated.

I disagree. That was choice. If a pilot consistently operates the same way then when fatigue is a factor s/he will default to common past practice. Not flying below minimums

That is the arguement with aiming for the 1000ft marker everytime. If you make each landing conditional... for example.. "I got 10000ft of runway its sunny and dry...does it matter if I touchdown in the touchdown zone?"

Why make it hard on yourself ....when there is ice or low vis or both and you have to rethink your technique.

I'm not picking a fight here. The fact is that failing to call "fatigue" is not necessarily a lack of character, guts or unprofessionalism.

It certianly is a lack of judgement. In addition if a pilot flies for a carrier that can get away with intimidation, doesn't have a solid safety structure and ability to enforce "wrongful termination" and pilot pushing then pilots will fly fatigue. In the end its a choice and the responsibility we accept as PIC.

There are valid reasons that the FAA has established bottle-to-throttle time rules and max blood alcohol limits. By following these rules, it's impossible for a pilot to arrive on the job intoxicated.

Wrong. Say that to the NWA crew in 1990.

The comparable FAA duty time/rest requirement rules do NOT guarantee the lack of fatigue for pilots . . . far from it. NASA, the NTSB, ALPA, and most pilots know this, but the FAA fails to re-write rules that could virtually eliminate this elusive yet very real safety hazard.

Do you know why?

If fatigued and you know it, certainly call in "fatigued." But what do you do when you've taken off "ok" but are "fatigued" en-route due to your 8-hr reduced rest overnight the night before and are into your 5th leg of a 12 hour day?

Through professionalism, experience, judgement and a support system pilots don't.

Easier said than done.

That is similiar to saying...What if you fly into a dark cloud and realize your in a T-strom.
 

NEDude

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And the ATA wants the FAA to reduce rest requirements for regular line holders and eliminate rest requirements for reserves.
 

Soverytired

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Do you know why?

Through professionalism, experience, judgment and a support system pilots don't.

Easier said than done.

Well, thanks for keeping it professional in your reply. Rather than go at it point by point (which would probably be "pointless"), we'll have to agree to disagree on most points.

With one exception. By your own admission (re: "experience"), the only way you'd ever realize that you pushed the limit too far and have put yourself in a "fatigued" flying condition is to have done it. You may learn from it, but for the duration of that flight you're screwed.

In actuality, you've probably already flown fatigued, muddled through and never even realized it. On a normal day with a good co-pilot, how would you even tell?

The NTSB has no regulatory authority or these changes would have been made a decade ago. The FAA, as you say, is throughly in bed with big business.

However, the "I can tell when I'm fatigued, 100% of the time, and I can overcome it by sheer force of will if I have to .. . plus I've done this a million times before" attitude of some pilots isn't helping them make changes any faster.
 
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Rez O. Lewshun

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Well, thanks for keeping it professional in your reply. Rather than go at it point by point (which would probably be "pointless"), we'll have to agree to disagree on most points.

With one exception. By your own admission (re: "experience"), the only way you'd ever realize that you pushed the limit too far and have put yourself in a "fatigued" flying condition is to have done it. You may learn from it, but for the duration of that flight you're screwed.

In actuality, you've probably already flown fatigued, muddled through and never even realized it. On a normal day with a good co-pilot, how would you even tell?

The NTSB has no regulatory authority or these changes would have been made a decade ago. The FAA, as you say, is throughly in bed with big business.

However, the "I can tell when I'm fatigued, 100% of the time, and I can overcome it by sheer force of will if I have to .. . plus I've done this a million times before" attitude of some pilots isn't helping them make changes any faster.

You seem to want to put the cause of this event all on fatigue.

Even if I were fatigued... I use GS out minima, land in the TDZE and use TR and brakes.
 
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