NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


FAILURE TO EXECUTE A MISSED APPROACH CAUSED SHUTTLE AMERICA'S RUNWAY OVERRUN

April 15, 2008

Washington, D.C. - The National Transportation Safety Board today determined that the probable cause of the runway excursion of an Embraer ERJ-170, operated by Shuttle America, Inc., was the failure of the flight crew to execute a missed approach when visual cues for the runway were not distinct and identifiable.

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

On February 18, 2007, a Delta Connection flight 6448, an Embraer ERJ-170, 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. There were 71 passengers and four crewmembers on board. Three passengers received minor injuries.

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 crewmembers 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 crewmembers 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.

As a result of the investigation of this accident, the Safety Board made recommendations to the Federal Aviation Administration in the following areas: 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 synopsis of the Board's report, including the probable cause and recommendations, is available on the NTSB's website, www.ntsb.gov, under "Board Meetings." The Board's full report will be available on the website in several weeks.

NTSB Media Contact:
Keith Holloway
(202) 314-6100
hollowk@ntsb.gov  

 

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The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.