Traverse City, Michigan
April 12, 2007
NTSB Number AAR-08/02
NTIS Number PB2008-910402
Adopted June 10, 2008
On April 12, 2007, about 0043 eastern daylight time, a Bombardier/Canadair Regional Jet (CRJ) CL600-2B19, N8905F, operated as Pinnacle Airlines flight 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 (including 3 lap-held infants) and 3 crewmembers, and the aircraft was substantially damaged. Weather was reported as snowing. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 121 and had departed from Minneapolis-St. Paul International (Wold-Chamberlain) Airport, Minneapolis, Minnesota, about 2153 central daylight time. Instrument meteorological conditions prevailed at the time of the accident 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 pilots' decision to land at TVC 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 during 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. Contributing to the accident were 1) the Federal Aviation Administration pilot flight and duty time regulations that permitted the pilots' long, demanding duty day and 2) the TVC operations supervisor's use of ambiguous and unspecific radio phraseology in providing runway braking information.
The safety issues discussed in this report include the pilots' actions and decision-making during the approach, landing, and landing roll; pilot fatigue and line check airman duty time regulations; weather and field condition information and ground operations personnel communications; and criteria for runway closures in snow and ice conditions.
As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:
Emphasize with principal operations inspectors the importance of conducting timely postaccident drug and alcohol testing. (A-08-40)
As part of the Takeoff/Landing Performance Assessment Aviation Rulemaking Committee, address the need for initial training on the rationale for and criticality of conducting landing distance assessments before landing on contaminated runways. (A-08-41)
Issue a CertAlert to all 14 Code of Federal Regulations Part 139 certificated airports that describes the circumstances of this accident, emphasizes the importance of specific and decisive radio communications, and urges airports to ensure that those criteria are being met in all airfield radio communications. (A-08-42)
Require all 14 Code of Federal Regulations Part 139 certificated airport operators to include in their airport's snow and ice control plan absolute criteria for type and depth of contamination and runway friction assessments that, when met, would trigger immediate closure of the affected runway to air carrier operations. Friction assessments should be based on pilot braking action reports, values obtained from ground friction measuring equipment, or estimates provided by airport ground personnel. (A-08-43)
The Safety Board reiterates the following recommendations to the Federal Aviation Administration:
Evaluate crash detection and location technologies, select the most promising candidate(s) for ensuring that emergency responders could expeditiously arrive at an accident scene, and implement a requirement to install and use the equipment. (A-01-66)
Immediately require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to conduct arrival landing distance assessments before every landing based on existing performance data, actual conditions, and incorporating a minimum safety margin of 15 percent. (A-07-57) (Urgent)
Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. (A-06-10)