NTSB Identification: DCA08FA018
Scheduled 14 CFR Part 121: Air Carrier operation of Air Wisconsin Airlines
Accident occurred Sunday, December 16, 2007 in Providence, RI
Probable Cause Approval Date: 12/30/2008
Aircraft: BOMBARDIER CL600-2B19, registration: N470ZW
Injuries: 34 Uninjured.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
The flight crew was conducting a straight-in ILS approach during instrument meteorological conditions with reported cloud ceilings about 100 feet above the decision height. During the descent into the terminal area and initial approach, tailwinds of up to 100 knots were affecting the flight and the crew reported feeling rushed because of the high ground speed. The crew did establish the airplane on the approach course at the proper speed and altitude, however they did not perform a complete approach briefing. The first officer (FO) was the pilot flying, and had very little instrument approach experience in the CRJ-200. Prior to making visual contact with the runway, the FO disengaged the autopilot and flight director, but only mentioned the autopilot in his verbal callout. At the time of the accident, there was no prohibition against making a raw data approach to minimums in the Air Wisconsin (AWAC) flight manual. Subsequently, the airplane drifted left of course and above the glidepath. As the airplane deviated from the approach course the flight was outside stabilized approach criteria, and as the airplane descended beneath the ceiling, both pilots noticed the deviation and misalignment with the runway.
At this point, the captain offered to take over control of the airplane and salvage the landing instead of abandoning the approach and executing a missed approach. At the time of the accident, Air Wisconsin procedures provided the crews latitude in determining when a go-around was necessary.
As the captain took control of the airplane, the FO misunderstood a statement by the captain and reduced power to idle without the captain’s knowledge. The airplane developed a high sink rate and during the flare likely stalled, impacting the runway at a high vertical rate. The forces developed during the flare and touchdown exceeded the certified limit loads of the landing gear and the gear support trunnion fractured as intended. There was no evidence of any pre-existing damage to the gear components, and the fracture and gear separation occurred as designed.
During his postaccident interview, the FAA aircrew program manager discussed the circumstances of some AWAC new-hire pilots who did not successfully complete initial training. Specifically, the FAA official stated that AWAC had changed the simulator time requirements for these pilots because they had completed a type rating course (provided by another training program) before starting AWAC’s training program. AWAC determined that these pilots needed fewer hours of simulator time than other new-hire pilots. However, according to the FAA official, these pilots had high initial operating experience times and “weren’t getting it, so [AWAC] let them go.” It is possible that these pilots might have performed better if they had been more thoroughly trained by the company.
A captain who was also a CL-65 flight instructor stated that, because of constraints with simulator time, all pilots needed to complete their training during the time that had been scheduled. The director of flight training stated that the simulator, at full utilization, provided 600 hours of training per month, but that the company needed 1,000 hours of simulator training per month. The amount of IOE time provided to new-hire FOs had significantly increased because AWAC had not revised its simulator training to accommodate the needs of pilots with little or no jet experience. As a result, IOE had to be routinely extended beyond the FAA’s requirement. Since many simulator training scenarios cannot be accomplished in an airplane, particularly during passenger carrying flights, IOE is not an adequate substitute for simulator training exercises.
Further, new-hire FOs who completed AWAC’s initial training program were subject to a 1-year probation period. However, unlike other 14 Code of Federal Regulations Part 121 operators, AWAC did not effectively conduct a program to assess the performance of probationary pilots. The accident FO’s training and checkrides did not reveal his weaknesses with automation, pacing, and crew coordination, which rendered him unprepared to properly execute the approach into Providence during the accident flight. In addition, captains did not produce trip reports after flying with first officers, and, according to the Norfolk base manager, meetings to discuss probationary FO’s progress during their first year were no longer held because the base managers were “too busy.” Thus, two potential methods to identify FOs’ weaknesses were not used by AWAC.
Because the first officers hired by AWAC in the 2 years preceding this accident had decreased levels of experience, these first officers would have benefited from additional training and oversight. However, AWAC’s training program was ineffective because it did not accommodate these needs.
The FAA’s Principal Operations Inspector (POI) was based in Des Planes, Illinois, but AWAC’s primary training center was in Charlotte, NC. The POI stated that providing oversight of AWAC was difficult because of the required travel. Because of the limited on-site oversight of AWAC’s training program of new first officers, the FAA did not identify the shortcomings of AWAC’s program in preparing these less experienced first officers for flying in high-performance jet airplanes.
The National Transportation Safety Board determines the probable cause(s) of this accident to be: the captain’s attempt to salvage the landing from an instrument approach which exceeded stabilized approach criteria, resulting in a high sink rate, likely stall, and hard landing which exceeded the structural limitations of the airplane.
Contributing to the accident was the first officer’s poor execution of the instrument approach, and the lack of effective intra-cockpit communication between the crew. Additional contributing factors to the accident are the lack of effective oversight by AWAC and the FAA to ensure adequate training and an adequate experience level of first officers for line operations. Full narrative available
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