Several failures in close succession by a jetliner’s flight crew were the probable cause of Oct. 27, 2016, runway excursion at La Guardia Airport, according to the National Transportation Safety Board’s final report issued September 21, 2017. Some recurrent training issues were identified as contributing factors.
Photo (C) ABC news
History of Flight
Landing-flare/touchdown: Landing area overshoot
Landing-landing roll: Runway excursion (Defining event)
On October 27, 2016, about 1942 eastern daylight time, Eastern Air Lines flight 3452, a Boeing 737-700, N923CL, overran runway 22 during the landing roll at LaGuardia Airport (KLGA), Flushing, Queens, New York. The airplane travelled through the right forward corner of the engineered materials arresting system (EMAS) at the departure end of the runway and came to rest off the right side of the EMAS. The 2 certificated airline transport pilots, 7 cabin crewmembers, and 39 passengers were not injured and evacuated the airplane via airstairs.
The airplane sustained minor damage. The charter flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night instrument flight rules conditions prevailed at the airport at the time of the incident, and an instrument flight rules flight plan was filed for the flight, which originated at Fort Dodge Regional Airport (KFOD), Fort Dodge, Iowa, about 1623 central daylight time.
The first leg of the trip began on October 14, 2016, and the captain and first officer were paired from then to the incident. In post-incident statements, the flight crew indicated that the captain was the pilot monitoring (PM) for the incident flight, and the first officer was the pilot flying (PF). The first officer reported that the autopilot and autothrottles were engaged beginning about 2,500 ft after their takeoff from KFOD. Both pilots stated that the en route portion of the flight and the descent into the terminal area were uneventful but they encountered moderate to heavy rain during the final 15 minutes of the flight.
According to information from the airplane’s cockpit voice recorder (CVR), the first officer partially briefed the instrument landing system (ILS) approach for runway 13 beginning about 1848, indicating an autobrake setting of 3 and a 30º flap setting. ATIS information “Bravo” was current at that time and indicated visibility 3 miles in rain, ceiling 1,500 ft broken, overcast at 2,200 ft, wind from 130º at 9 knots, and that braking action advisories were in effect. About 1852, the first officer began briefing the ILS approach for runway 22 after the captain clarified, based on the ATIS recording, that runway 13 was being used for departures.
About 1902, as the airplane descended through 18,000 ft msl, the flight crew completed the approach briefing for runway 22, with the same autobrake and flap setting as indicated earlier, as well as the decision altitude and visibility required for the approach, the touchdown zone elevation, and a reference speed (Vref) of 137 knots. ATIS information “Charlie” was current at that time and indicated visibility 3 miles in rain, ceiling 900 ft broken, overcast at 1,500 ft, and wind from 120º at 9 knots.
The flight crew also discussed the captain manually deploying the speed brakes (the airplane’s automatic speed brake module had been deactivated 2 days before the incident and deferred in accordance with the company’s minimum equipment list (MEL), with corrective action scheduled for November 4, 2016). In reference to the manual deployment of the speed brakes, the captain stated at 1902:44.5 “you’re gonna do these. I’m gonna do this” to which the first officer replied “[that] is correct.”
About 1927, the flight was provided vectors to the final approach course for the ILS approach to runway 22. About 1936, the flight was cleared for the approach. The first officer then called for the landing gear to be extended and the flaps set at 15º. About 1937, the captain stated that the localizer and glideslope were captured. About 1938, as the airplane neared the final approach fix, the flight crew completed the landing checklist and configured the airplane for landing, with flaps set to 30º.
The CVR indicates that the captain pointed out the approach lights about 1939. The first officer reported, and flight data recorder (FDR) data indicate, that about 1940:12, he disconnected the autopilot when the airplane’s altitude was about 300 ft radio altitude, as required by Eastern Air Lines standard operating procedure. FDR data indicate that the first officer disconnected the autothrottles about 1940:19.
FDR data indicate that, shortly after the first officer disconnected the autopilot and autothrottles (about 300 ft radio altitude), the airplane began to increasingly deviate above the glideslope beam and crossed the threshold at a height consistent with the threshold crossing height of the VGSI, which was not coincident with the glide slope beam. CVR data indicate that between 1940:35 and 1940:46, the enhanced ground proximity warning system alerted the decreasing altitude in increments of 10, beginning at 50 ft. The pitch attitude started to increase in the flare from 2.8° at a radio altitude of about 38 ft. After the 20-ft alert, the captain stated “down” at 1940:43.3. After the 10-ft alert, the captain stated, “down down down down you’re three thousand feet remaining” at 1940:46.6. There was no callout of spoilers or thrust reversers during the rollout on the CVR.
FDR data and performance calculations indicate that the airplane crossed the runway threshold at a radio altitude of 66 ft, with an increasing glideslope deviation and a descent rate of about 750 ft per minute. When the airplane had travelled about 2,500 ft beyond the runway threshold, its descent rate decreased to near zero, and it floated before touching down. The captain later reported that the descent to the touchdown zone was normal until the flare. He stated that the airplane floated initially in the flare, which prompted the captain to tell the first officer to “get it down.”
The first officer recalled hearing the captain’s instruction to “put [the airplane] down” during the flare but was not certain how far down the runway the airplane touched down. FDR data indicate that at 1940:51.8, the airplane’s main landing gear touched down; maximum manual wheel brakes were applied at main gear touchdown. The throttles were not fully reduced to idle until about 16 seconds after the flare was initiated, and after the airplane had touched down.
The touchdown point was about 4,242 ft beyond the threshold of the 7,001-ft-long runway. The nose gear initially touched down about 2 seconds after the main landing gear but rebounded into the air due to aft control column input. The nose gear touched down a second and final time at 1940:56.8.
The captain reported that, as briefed, he manually deployed the speed brakes, which FDR data indicate were manually extended to full at 1940:56.3, about 4.5 seconds after the main landing gear touched down and the airplane had travelled about 1,250 ft farther down the runway from the touchdown point. At 1940:59.8, when the airplane had travelled about 1,650 ft down the runway from the touchdown point (and 5,892 ft from the threshold), maximum reverse thrust was commanded. The captain reported that he saw the end of the runway approaching and began to apply maximum braking, as well as right rudder because he thought it would be better to veer to the right rather than continue straight to the road beyond the end of the runway.
The first officer reported that the captain did not, as required in the operator’s procedures, tell him that he was attempting to brake and steer the airplane during the landing rollout, and no such callout is recorded on the CVR. The first officer stated that the airplane was pulling to the right “really hard,” which prompted him to apply left rudder. He reported that the left rudder input was counter to his expectation due to a 9-knot crosswind from the left, which he expected to counteract with right rudder input. He attempted to maintain alignment with the runway centerline by applying left rudder and overriding the autobrakes with pressure on the brake pedal.
At 1941:08.3, the CVR recorded the sound of rumbling, consistent with the airplane exiting the runway. The airplane then entered the EMAS about 35 knots groundspeed and came to rest 172 ft beyond the end of the runway and to the right of the EMAS. Review of the CVR recording revealed that, after the airplane came to a stop, the first officer twice remarked that they should have conducted a go-around, and the captain agreed. The first officer later reported that he did not believe the approach or landing were abnormal at the time. The captain later stated that he should have called for a go-around when the airplane floated during the flare.
Photo (C) REUTERS Lucas Jackson
Flight Crew Information
Meteorological Information and Flight Plan
At 1851 EDT, (ASOS) at KLGA reported the wind from 090° true at 9 knots, visibility of 3 statute miles (sm), moderate rain, ceiling broken at 900 ft agl, overcast clouds at 1,500 ft agl, temperature of 13°C and a dew point temperature of 11°C, and altimeter setting of 30.14 inches of mercury. Remarks included: surface visibility of 4 sm, precipitation accumulation of 0.14 inch since 1751 EDT.
At 1951 EDT, KLGA ASOS reported the wind from 100° true at 10 knots with gusts to 15 knots, visibility of 3 sm, moderate rain, mist, ceiling overcast at 1,000 ft agl, temperature of 13°C and a dew point temperature of 12°C, and an altimeter setting of 30.10 inches of mercury. Remarks included: surface visibility of 4 sm, precipitation accumulation of 0.32 inch since 1851 EDT, precipitation accumulation of 0.61 inch during previous 3 hours.
Wreckage and Impact Information
Crew: 11 Injuries: None
Passenger: 37 Injuries: None
Ground Injuries: N/A
Total 48 Injuries: None
Aircraft Damage: Minor
Aircraft Fire: None
Aircraft Explosion: None
Latitude, Longitude: 40.769167, -73.885000
As a result of the airplane’s travel through the EMAS, pulverized EMAS material (a gray, powdery residue) was noted on portions of the airplane’s exterior during postincident examination. The lower and forward portions of the airplane—fuselage, landing gear, and antennas—were coated with a dried residue resulting from the mixture of the EMAS material and rainwater. In addition, pieces of a matting material used in the EMAS were found in various locations on the airplane.
No damage or anomalies were noted during the visual examination of the nosewheel landing gear and associated assemblies. A preliminary visual examination of the main landing gear strut, doors, assemblies, associated hydraulic lines, and antiskid components did not reveal evidence of physical damage. However, after the airplane was cleaned of EMAS debris and the main landing gears were retracted, damage was noted on the underside of each gear strut. The operator indicated that the lower wire bundle support brackets for the left and right main landing gear were both damaged, as well as the wire conduit sleeve on the left main landing gear.
Each of the four main wheel tires showed cut damage in addition to normal wear. None of the observed cuts were deep enough to reach the tire treads. No flat spots or other evidence of hydroplaning was noted on any of the tires. Examination of the four brake assemblies found no evidence of damage or hydraulic leaks. No evidence of a hydraulic power malfunction or damage to any of the visible hydraulic lines was noted.
Both engines showed evidence of EMAS material and matting on the engine inlet and internal components. The No. 1 engine sustained fan blade damage, including four blades bent in the direction opposite of rotation, at the tip corner. No visible blade damage was noted on the No. 2 engine. Visual examination of the thrust reversers found no preincident anomalies. The operator later reported that, after cleaning and deploying the thrust reversers, damage was found on the inboard thrust reverser sleeves and blocker doors for both engines.
Photo (C) NTSB
Examination of the speed brake control components on the incident airplane noted the speed brake handle positioned full forward. All spoiler panels, including the ground spoilers, were found in the down or retracted position. No damage was noted to any of the ground spoilers.
No problems with communications equipment were reported.
The airplane was equipped with a cockpit voice recorder (CVR) and a flight data recorder (FDR). Both recorders were removed from the airplane and retained by the NTSB for further examination and readout at the NTSB’s Recorder Laboratory in Washington, DC. The recorders showed no signs of damage.
Cockpit Voice Recorder
The CVR, a Honeywell 6022, serial number 3452, was a solid-state CVR that recorded 120 minutes of digital audio. It was played back normally without difficulty and contained excellent quality audio information. The recording was transcribed in two parts focusing on the en route approach briefing and the approach, landing, and events thereafter until the end of the recording. Part one began at 18:48:06 EDT, when flight 3452 was en route at FL390, and continued until 1902:52 EDT. Part two began at 1918:01 EDT and ended at 1948:32 EDT (the end of the recording
Flight Data Recorder
The FDR, a Honeywell 4700, serial number SSFDR-16936, recorded airplane flight information in digital format using solid-state flash memory as the recording medium. The FDR could record a minimum of 25 hours of flight data and was configured to record 256 12-bit words of digital information every second. The FDR was designed to meet the crash survivability requirements of Technical Standard Order C-124.
Data from the FDR were extracted normally. The event flight was the last flight of the recording, and its duration was about 2 hours and 19 minutes.
Medical And Pathological Information
Eastern Air Lines conducted drug and alcohol testing for both pilots about 6 hours after the incident. Test results were negative for alcohol and major drugs of abuse.
Organizational And Management Information
Company Overview and Management Organization
Eastern Air Lines, Inc., received certification to operate as a Part 121 supplemental carrier on May 15, 2015. Subsequently, Eastern Air Lines began scheduled charter services to Havana and four other cities in Cuba. Before the incident, the airline also launched charter service to other Latin American and Caribbean destinations. The airline’s sole base of operations was at Miami International Airport, Miami, Florida, at the time of the incident. It employed 64 pilots and had a fleet of five Boeing 737 airplanes, including the incident airplane; the other four airplanes were Boeing 737-800 series.
The airline’s vice president of flight operations was responsible for the flying operations of the airline, flight crew training, the operations control center (OCC), and ground operations. The chief pilot, manager of flight operations training, director of inflight, OCC director, manager of flight standards, and manager of charter operations all reported to the vice president of flight operations.
At the time of the incident, Eastern Air Lines’ director of safety and security reported directly to the chief executive officer and was the only staffed position in the safety department. The director of safety and security had been hired about 2 weeks before the incident and was in the process of being trained by his predecessor, who had held the position from 2013 until September 2016. While he was being trained, the vice president of regulatory compliance served as the acting director of safety and security.
According to the vice president of flight operations and the manager of flight operations training, the Boeing 737 Flight Crew Training Manual and the Boeing 737 Flight Crew Operations Manual were used as the airline’s systems training material and procedures manual, respectively.
The FAA approved Eastern Air Lines’ safety management system (SMS) implementation plan in February 2016. The first segment of implementation included administering the SMS implementation plan and developing a tool (Aviation Resource Management Solutions) that was designed to help the company with safety risk assessment, assurance, and risk management. The former director of safety and security stated that, at the time of the incident, the first segment of the implementation was not fully realized and they were working toward an October 30, 2016, full implementation date.
Crew Resource Management (CRM) and EMAS Training
The manager of flight operations training at the time of the incident was also a check airman. He had been manager of training for about 1.5 years and had been with the company for 2 years.
The airline provided three courses on CRM: new hire, captain’s upgrade, and recurrent. The new hire CRM course consisted of a 2-hour segment covering CRM background, communications processes and decision behavior, team building and leadership, workload management and situational awareness, individual factors and stress reduction, and error management. The upgrade training included 1 day of ground school in which 1 hour was dedicated to CRM. Upgrade training also incorporated a captain’s leadership course that included content on the captain’s authority, briefings, workload management, and sterile cockpit procedures in accordance with 14 CFR 121.542, “Flight Crewmember Duties.” The recurrent training included a 3.5-day ground school for captains and first officers in which 1 hour was devoted to CRM training. All courses were taught using presentation slides, open discussion, and videos created by contracted training organizations.
The captain reported after the incident that he believed he and the first officer were working well as a crew during the trip. He stated that he did not call for a transfer of controls during the landing rollout and that, in hindsight, he should have. He further mentioned that he thought it was “OK” for both crewmembers to be applying brakes. The first officer reported a “lack of communication” during the landing rollout because the captain did not say that he was taking control of the airplane. Another Eastern Air Lines first officer who had flown with the captain before the incident described the captain’s CRM as “good.”
At the time of the incident, EMAS training was not part of Eastern Air Lines’ pilot training program. The captain stated during postincident interviews that he had forgotten that an EMAS was installed at the end of runway 22, that he had read about the systems, but had not had any training on them.
The former FAA principal operations inspector (POI) stated that he had been assigned to Eastern Air Lines before the company received its operating certificate. He stated that his duties included, most critically, surveillance and reviewing the airline’s manuals, including any changes to the manuals. He traveled to the airline’s headquarters about once or twice a week.
He also stated that he interacted most with the operations management, director of safety and security, and the CEO.
The former director of safety and security stated that during his time at Eastern Air Lines, he “seldom” interacted with the FAA POI or other FAA personnel. Other management personnel stated they interacted with the FAA daily or multiple times per week, via telephone, e-mail, or in person at the FAA’s office or at Eastern Air Lines’ office. The manager of flight operations training stated that he did not directly interact with the POI and usually went through the vice president of flight operations or the chief pilot. The vice president of flight operations stated that they had been assigned a new POI 5 months before the incident and that the interaction with the new POI was “really great.”
The FAA POI at the time of the incident reported that he mostly communicated with Eastern Air Lines’ director of flight operations and chief pilot but had also communicated with the director of flight training. He categorized the communication as “very good.” He added that Eastern Air Lines was the only certificate he managed and that FAA resources were limited such that they only had one person in the office who was able to conduct checkrides in the Boeing 737. He estimated that he was at Eastern Air Lines’ operations a “couple of times a week;” however, he had not taken part in Eastern Air Lines’ pilot training. He also stated that the training in the manual for a go-around was similar to the syllabus used by other airlines, and he “assumed” that they did some go-around training in the flare and some training in low visibility. The POI stated that, following the incident, he and Eastern Air Lines management had discussed training go-arounds once the airplane was on the ground and that further discussion was needed.
Sterile Cockpit Regulations
The CVR also contained conversation between the flight crew during the descent and approach below 10,000 ft that was not pertinent to the flight. Title 14 CFR 121.542, “Flight Crewmember Duties” states, in part, the following:
No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as…engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews…are not required for the safe operation of the aircraft.
…critical phases of flight include all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight.
Runway Condition Reports from Other KLGA Arrivals
Flight crews from four flights that landed on runway 22 within 10 minutes of the incident flight reported braking as “good” or “fair.” One crew reported noticing their airplane’s antiskid brake system pulsating during the landing rollout. Others reported that there was no hydroplaning or decrease in braking performance.
Automatic terminal information service (ATIS) “Bravo” was current when the first officer, who was the pilot flying, began to brief the instrument landing system approach for runway 22. The ATIS indicated visibility 3 miles in rain, ceiling 1,500 ft broken, overcast at 2,200 ft, wind from 130º at 9 knots, and that braking action advisories were in effect. The approach briefing included the decision altitude and visibility for the approach and manual deployment of the speed brakes by the captain, with the captain stating “you’re gonna do these. I’m gonna do this” to which the first officer replied “[that] is correct.” (The airplane’s automatic speed brake module had been deactivated 2 days before the incident and deferred in accordance with the operator’s minimum equipment list, which was appropriate).
The flight crew completed the approach briefing after descending through 18,000 ft mean sea level and completed the landing checklist when the airplane was near the final approach fix.
The airplane was configured for landing with the autobrake set to 3 and the flaps set to 30º.
ATIS information “Charlie” was current at that time and indicated visibility 3 miles in rain, ceiling 900 ft broken, overcast at 1,500 ft, and wind from 120º at 9 knots.
Flight data recorder (FDR) data and postincident flight crew statements indicate that the airplane was stabilized on the approach in accordance with the operator’s procedures until the flare. The airplane crossed the runway threshold at 66 ft radio altitude at a descent rate of 750 ft per minute. When the airplane had traveled about 2,500 ft beyond the runway threshold, its descent rate decreased to near zero, and it floated during the flare. Its pitch attitude started to increase in the flare from 2.8° at a radio altitude of about 38 ft, which is high compared to the 20 ft recommended by the Boeing 737 Flight Crew Training Manual. Further, the first officer didn’t fully reduce the throttles to idle until about 16 seconds after the flare was initiated and after the airplane had touched down. The initiation of the flare at a relatively high altitude above the runway and the significant delay in the reduction of thrust resulted in the airplane floating down the runway, prompting the captain to tell the first officer to get the airplane on the ground, stating “down down down down you’re three thousand feet remaining.”
The airplane eventually touched down 4,242 ft beyond the runway threshold. According to the operator’s procedures, the touchdown zone for runway 22 was the first third of the 7,001-ftlong runway beginning at the threshold, or 2,334 ft. Touchdown zone markers and lights (the latter of which extended to 3,000 ft beyond the threshold) should have provided the flight crew a visual indication of the airplane’s distance beyond the threshold and prompted either pilot to call for a go-around but neither did. The point at which the airplane touched down left only about 2,759 ft remaining runway to stop. The airplane’s groundspeed at touchdown was 130 knots.
The captain manually deployed the speed brakes about 4.5 seconds after touchdown and after the airplane had traveled about 1,250 ft down the runway. Maximum reverse thrust was commanded about 3.5 seconds after the speed brakes were deployed, and, with fully extended speed brakes and maximum wheel brakes (which were applied at main gear touchdown) the airplane achieved increasingly effective deceleration. Its groundspeed was about 35 knots when it entered the EMAS. With the effective deceleration provided by the fully extended speed brakes, maximum wheel brakes, and reverse thrust, the flight crew would have been able to safely stop the airplane if it had touched down within the touchdown zone.
The captain later stated that he had considered calling for a go-around before touchdown but the “moment had slipped past and it was too late.” He said that “there was little time to verbalize it” and that he instructed the first officer to get the airplane on the ground rather than call for a go-around. He reported that, in hindsight, he should have called for a go-around the moment that he recognized the airplane was floating in the flare. The first officer said that he did not consider a go-around because he did not think that the situation was abnormal at that time.
Training and practice improve human performance and response time when completing complex tasks. In this case, the operator’s go-around training did not include any scenarios that addressed performing go-arounds in which pilots must decide to perform the maneuver rather than being instructed or prompted to do so. Thus, the incident flight crew lacked the training and practice making go-around decisions, which contributed to the captain’s and first officer’s failure to call for a go-around.
Following the incident, the operator incorporated go-around training scenarios in which flight crews must decide to go around rather than being instructed to do so. The company’s director of operations also stated that the company has incorporated scenarios in which go-arounds are initiated from idle power and rejected landings are performed after touchdown with the automatic speed brake inoperative. It also added a training module emphasizing that “if touchdown is predicted to be outside of the [touchdown zone], go around” and intended to require a go-around if landing outside of the touchdown zone were predicted. The operator also intended to incorporate go-around planning into the approach briefing. Flight crews would determine the cues for the touchdown zone using the airport diagram and decide at which point they would initiate a go-around if the airplane had not touched down.
Given the known wet runway conditions and airplane manufacturer and operator guidance concerning “immediate” manual deployment of the speed brakes upon landing, the captain’s manual deployment of the speed brakes was not timely. NTSB analysis of FDR data for previous landings in the incident airplane determined an average of 0.5 second for manual deployment of the speed brakes. Using the same touchdown point as in the incident, post incident simulations suggest that, if the speed brakes had been deployed 1 second after touchdown followed by maximum reverse thrust commanded within 2 seconds, the airplane would have remained on the runway surface. Therefore, the captain’s delay in manually deploying the speed brake contributed to the airplane’s runway departure into the EMAS.
During the landing roll, the captain did not announce that he was assuming airplane control, contrary to the operator’s procedures, and commanded directional control inputs that countered those commanded by the first officer. The captain later reported that he had forgotten that an EMAS was installed at the end of runway 22 and attempted to avoid the road beyond the runway’s end by applying right rudder because he thought it would be better to veer to the right. However, the first officer applied left rudder to maintain alignment with the runway centerline and to counter the airplane pulling “really hard” to the right because of the captain’s inputs. The breakdown of crew resource management during the landing roll and the captain’s failure to call for a go-around demonstrated his lack of command authority, which contributed to the incident.
At the time of the incident, EMAS training was not part of the operator’s pilot training program, but such training was added after the incident. The circumstances of this event suggest that the safety benefit of EMASs could be undermined if flight crews are not aware of their presence or purpose.
PROBABLE CAUSE AND FINDINGS
The National Transportation Safety Board determines the probable cause(s) of this incident to be:
The first officer’s failure to attain the proper touchdown point and the flight crew’s failure to call for a go-around, which resulted in the airplane landing more than halfway down the runway. Contributing to the incident were, the first officer’s initiation of the landing flare at a relatively high altitude and his delay in reducing the throttles to idle, the captain’s delay in manually deploying the speed brakes after touchdown, the captain’s lack of command authority, and a lack of robust training provided by the operator to support the flight crew’s decision-making concerning when to call for a go-around.
Aircraft Landing flare – Not specified (Factor)
Personnel issues Use of policy/procedure – Copilot (Cause)
Use of policy/procedure – Flight crew (Cause)
Lack of action – Flight crew (Cause)
Delayed action – Copilot (Factor)
Delayed action – Pilot (Factor)
Decision making/judgment – Pilot (Factor)
Organizational issues Recurrent training – Operator (Factor)
Excerpted from National Transportation Safety Board Aviation Incident Final Report DCA17IA020
- Let’s go around
- The Organizational Influences behind the aviation accidents & incidents
- Speaking of going around
- Going around with all engines operating
By Laura Duque-Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@dralaurita. Human Factors information almost every day