Runway Overrun During Landing Pinnacle Airlines Flight 4712

212 Pages·2008·2.61 MB·English

Runway Overrun During Landing
Pinnacle Airlines Flight 4712
Bombardier/Canadair Regional Jet CL600-2B19, N8905F
Traverse City, Michigan
April 12, 2007
aviation
ACCIDENT REPORT
NTSB/AAR-08/02
PB2008-910402

NTSB/AAR-08/02
PB2008-910402
Notation 8015A
Adopted June 10, 2008
Aircraft Accident Report
Runway Overrun During Landing
Pinnacle Airlines Flight 4712
Bombardier/Canadair Regional Jet CL600-2B19, N8905F
Traverse City, Michigan
April 12, 2007
National
Transportation
Safety Board
490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
National Transportation Safety Board. 2008. Runway Overrun During Landing, Pinnacle Airlines, Inc.,
Flight 4712, Bombardier/Canadair Regional Jet CL600-2B19, N8905F, Traverse City, Michigan, April 12,
2007. Aircraft Accident Report NTSB/AAR-08/02. Washington, DC.
Abstract: This report explains the accident involving a Bombardier/Canadair Regional Jet
CL-600-2B19, N8905F, operated by Pinnacle Airlines, Inc., which ran off the departure end of
runway 28 after landing at Cherry Capital Airport, Traverse City, Michigan. 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. Safety recommendations concerning these issues
are addressed to the Federal Aviation Administration.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad,
highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through
the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents,
issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies
involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies,
special investigation reports, safety recommendations, and statistical reviews.
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A I R C R A F T
Accident Report
C
ontents
Abbreviations and Acronyms .......................................................................................v
Executive Summary .......................................................................................................ix
1. Factual Information.....................................................................................................1
1.1 History of Flight ..............................................................................................................................1
1.2 Injuries to Persons ...........................................................................................................................5
1.3 Damage to Airplane .......................................................................................................................5
1.4 Other Damage .................................................................................................................................5
1.5 Personnel Information ...................................................................................................................6
1.5.1 The Captain .............................................................................................................................6
1.5.2 The First Officer ......................................................................................................................8
1.6 Airplane Information .....................................................................................................................9
1.6.1 General .....................................................................................................................................9
1.6.2 Airplane Deceleration Device Information ......................................................................10
1.7 Meteorological Information .......................................................................................................10
1.7.1 Cherry Capital Airport Weather Forecast/Predispatch Information ..........................10
1.7.2 Dispatch Weather Information ...........................................................................................12
1.7.3 Updated Cherry Capital Airport Weather/Airport Information ..................................12
1.8 Aids to Navigation .......................................................................................................................13
1.9 Communications ...........................................................................................................................14
1.10 Airport Information ....................................................................................................................14
1.10.1 Cherry Capital Airport Closed Tower Operations ........................................................14
1.10.2 Radio Phraseology Guidance and Training Requirements ..........................................15
1.10.3 Cherry Capital Airport Winter Operations ....................................................................16
1.10.4 Cherry Capital Airport Winter Operations the Night of the Accident ......................17
1.11 Flight Recorders ..........................................................................................................................18
1.11.1 Cockpit Voice Recorder .....................................................................................................18
1.11.2 Flight Data Recorder ..........................................................................................................18
1.12 Wreckage and Impact Information ..........................................................................................18
1.13 Medical and Pathological Information ....................................................................................19
1.14 Fire ................................................................................................................................................19
1.15 Survival Aspects .........................................................................................................................19
1.15.1 Aircraft Rescue and Firefighting Response ....................................................................19
1.15.2 Airplane Egress ...................................................................................................................20
1.16 Tests and Research ......................................................................................................................21
1.16.1 Airplane Simulation and Study of Airplane Performance During
the Accident Sequence ..........................................................................................................................21
1.16.2 Airplane Simulations for Various V Speed Additives and Thrust Reverser
ref
Landing Scenarios .................................................................................................................................23
1.16.3 Use of Braking Systems During Landing Roll ..............................................................24
1.17 Organizational and Management Information ......................................................................24
1.17.1 Pinnacle Airlines’ Landing Distance Assessment Guidance (Operations
Specification C382) ................................................................................................................................25
1.17.2 Pinnacle Airlines Guidance for Landing and Thrust Reverser Usage .......................27
1.17.3 Pinnacle Airlines Expeditious Deplaning Guidance ....................................................28
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National Transportation Safety Board
A I R C R A F T
Contents Accident Report
1.17.4 Recent Pinnacle Airlines Safety-Related Actions ...........................................................28
1.17.4.1 Postaccident Procedural/Operational Changes ......................................................29
1.17.4.2 Postaccident Staffing/Scheduling/Training Changes ...........................................30
1.18 Additional Information ..............................................................................................................30
1.18.1 Fatigue-Related Information .............................................................................................30
1.18.2 Previously Issued Safety Recommendations .................................................................33
1.18.2.1 Landing Distance Assessment ....................................................................................33
1.18.2.2 Standardized Phraseology ...........................................................................................35
1.18.2.3 Crash Detection and Location Technology ...............................................................35
2. Analysis .......................................................................................................................37
2.1 General ...........................................................................................................................................37
2.1.1 Aircraft Rescue and Firefighting Crash Detection ...........................................................38
2.1.2 Postaccident Alcohol Testing ..............................................................................................39
2.2 Pilot Performance, Actions, and Decision-Making During the Flight ..................................39
2.2.1 Pilot Actions and Decision-Making During the Approach ............................................40
2.2.1.1 Landing Distance Assessments ....................................................................................40
2.2.1.1.1 Landing Distance Assessment Training ..................................................................42
2.2.1.2 “Nil” Braking Reports ....................................................................................................43
2.2.2 Pilot Actions During the Landing and Landing Roll ......................................................44
2.3 Pilot Fatigue Issues .......................................................................................................................45
2.3.1 Accident Pilot Fatigue ..........................................................................................................46
2.3.2 Line Check Airman Fatigue Issues ....................................................................................48
2.4 Dissemination of Weather and Field Condition Reports ........................................................49
2.4.1 Weather Information Available to the Flight Crew.........................................................49
2.4.2 Airport and Runway Condition Reports and Ground Personnel Phraseology .........50
2.4.3 Runway Closure Procedures in Snow and Ice Conditions ............................................52
3. Conclusions ................................................................................................................53
3.1 Findings ..........................................................................................................................................53
3.2 Probable Cause ..............................................................................................................................55
4. Recommendations .....................................................................................................56
4.1 New Recommendations ...............................................................................................................56
4.2 Previously Issued Recommendations Reiterated in This Report ..........................................56
5. Appendixes .................................................................................................................59
A: Investigation and Public Hearing ................................................................................................59
B: Cockpit Voice Recorder Transcript ..............................................................................................60
C: Pinnacle’s Operations Specification C382 (Landing Distance Assessment) .........................200
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National Transportation Safety Board
A I R C R A F T
Accident Report
A A
bbreviAtions And Cronyms
AC advisory circular
ACARS aircraft communications addressing and reporting system
AFD airport facility directory
agl above ground level
AIM Aeronautical Information Manual
ALPA Airline Pilots Association
ARC aviation rulemaking committee
ARFF aircraft rescue and firefighting
ARTCC air route traffic control center
ASAP aviation safety action program
ASOS automated surface observing system
ATC air traffic control
ATCT air traffic control tower
ATIS automatic terminal information service
°C degrees Celsius
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National Transportation Safety Board
A I R C R A F T
Abbreviations and Acronyms Accident Report
CAMI Civil Aerospace Medical Institute
CDT central daylight time
CFM company flight manual
CFR Code of Federal Regulations
cg center of gravity
CLE Cleveland-Hopkins International Airport
CRJ Bombardier/Canadair Regional Jet
CTAF common traffic advisory frequency
CVR cockpit voice recorder
DOT Department of Transportation
DSM Des Moines International Airport
DTW Detroit Metropolitan Wayne County Airport
°F degrees Fahrenheit
FAA Federal Aviation Administration
FCTM flight crew training manual
FDR flight data recorder
FLIR forward-looking infrared device
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National Transportation Safety Board
A I R C R A F T
Abbreviations and Acronyms Accident Report
FOM flight operations manual
FOQA flight operational quality assurance
GE General Electric
Hg mercury
IFR instrument flight rules
ILS instrument landing system
KIAS knots indicated airspeed
MAC mean aerodynamic chord
MDW Chicago Midway International Airport
MEM Memphis International Airport
METAR meteorological aerodrome report
MLG main landing gear
MSP Minneapolis-St. Paul International Airport
MU coefficient of friction
N1 engine fan speed
NASA National Aeronautics and Space Administration
NOTAM notice to airmen
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A I R C R A F T
Abbreviations and Acronyms Accident Report
NWA Northwest Airlines
NWS National Weather Service
OE operating experience
OpSpec operations specification
POI principal operations inspector
RVR runway visual range
S/N serial number
SAFO safety alert for operators
SOC system operations control
SPECI special weather observation
TAF terminal aerodrome forecast
TR thrust reverser
TVC Cherry Capital Airport
Vapp approach landing speed (Vref + 5 knots)
Vref reference landing speed
WSFO National Weather Service forecast office

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