National Transportation Safety Board
Office of Public Affairs
Washington, DC - The National Transportation Safety Board said that a regional jet overran the end of a runway in Michigan last year because the pilots elected to land on a contaminated (snowy) runway without performing the required landing distance calculations.
The Board adopted its final report on the April 12, 2007 accident in which, a Bombardier/Canadair Regional Jet (CRJ) CL600-2B19, operated as Pinnacle Airline 4712, ran off the departure end of runway 28 after landing at Cherry Capital Airport, (TVC) Traverse City, Michigan. There were no injuries among the 49 passengers and 3 crewmembers and the aircraft was substantially damaged. The weather at the time of the accident was reported as snowing. Instrument meteorological conditions prevailed at the time of the accident, which was operated on an instrument flight rules flight plan.
"Our recommendations are designed to reduce injuries and deaths and prevent accidents like this from occurring," said NTSB Chairman Mark Rosenker."Piloting an aircraft should not be guess work. There are rules and guidelines that need to be followed at all times and it is imperative that the Federal Aviation Administration enforce these recommendations."
The probable cause cites the pilots' decision to land without performing a landing distance assessment, which was required by company policy because of runway contamination initially reported by TVC ground operations personnel and continuing reports of deteriorating weather and runway conditions throughout the approach. This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day, and, for the captain, the duties associated with check airman functions.
Also contributing to the accident were the Federal Aviation Administration pilot flight and duty time regulations that permitted the pilots' long, demanding duty day; and the TVC operations supervisor's use of ambiguous and unspecific radio phraseology in providing runway braking information.
During its investigation, the Safety Board evaluated the pilots' actions and decisions during the flight, including their decision to land at TVC, their awareness of/attention to the weather and runway conditions at TVC, and their actions during the landing roll. The Safety Board concluded that the pilots failed to perform the landing distance assessment that was required by Pinnacle's Operations Specifications. Had the pilots done so, using current weather information, the results would have shown that the runway length was inadequate for the contaminated runway conditions described.
The investigation also examined pilot fatigue. The accident occurred after midnight at the end of a demanding day during which the pilots had flown over 8 hours, made five landings, been on duty more than 14 hours, and been awake more than 16 hours. The Safety Board further notes that the pilots had also flown in challenging weather conditions throughout the day.
Therefore, the Safety Board concluded that the poor decision-making shown by the accident pilots, including their failure to account for the changing weather and runway conditions during the approach; their failure to perform a landing distance calculation; and their failure to reassess or discontinue the approach accordingly, likely reflected the effects of fatigue.
As a result of the investigation of this accident, the Safety Board made recommendations to the Federal Aviation Administration in the following areas: the pilots' actions and decision-making during the approach, landing, and landing roll; landing distance assessment training; weather and field condition information and ground operations personnel communications; criteria for runway closures in snow and ice conditions; and alcohol testing.
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.
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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.