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B737, New York La Guardia USA, 2016
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|On 27 October 2016, a Boeing 737-700 crew made a late touchdown on the runway at La Guardia and did not then stop before reaching the end of the runway and entered - and exited the side of - the EMAS before stopping. The Investigation concluded that the overrun was the consequence of a failure to go around when this was clearly necessary after a mishandled touchdown and that the Captain's lack of command authority and a lack of appropriate crew training provided by the Operator to support flight crew decision making had contributed to the failure to go around.|
|Actual or Potential
|Human Factors, Runway Excursion|
|Flight Conditions||On Ground - Normal Visibility|
|Type of Flight|
|Origin||Fort Dodge Regional Airport|
|Intended Destination||LaGuardia Airport|
|Take off Commenced||Yes|
|Location - Airport|
|Tag(s)||Inadequate Aircraft Operator Procedures,|
Ineffective Regulatory Oversight,
Copilot less than 500 hours on Type,
Deficient Pilot Knowledge
|Tag(s)||Inappropriate crew response - skills deficiency,|
Plan Continuation Bias,
Procedural non compliance,
Ineffective Monitoring - SIC as PF
|Tag(s)||Overrun on Landing,|
Significant Tailwind Component,
Ineffective Use of Retardation Methods
|Damage or injury||Yes|
|Causal Factor Group(s)|
On 27 October 2016, a Boeing 737-700 (N278EA) being operated by Eastern Airlines on a domestic passenger charter flight from Fort Dodge IA to New York La Guardia as EA3452 touched down over half way along the wet destination landing runway 22 in normal night visibility. The aircraft failed to stop before running off the end through the EMAS before emerging to the side of it and coming quickly to a stop. None of the 48 occupants were injured and the aircraft sustained only relatively minor damage.
An Investigation was carried out by the NTSB. Data from the DFDR and two hour CVR was successfully downloaded and used to inform the Investigation. Once no evidence was found of relevant airworthiness defects which might have been contributory to the excursion and its prelude, the main focus of the Investigation was on the operation of the aircraft during the approach and landing.
The 58 year-old Captain had 20,638 hours total flying experience including 3,000 hours on type but only 202 hours on type in command, all of the latter obtained since being promoted to Captain by Eastern Airlines in February 2016 after employment as a First Officer with the airline for the previous 8 months. In the 90 days prior to the accident, records showed that he had flown 75 hours in total. Prior to joining Eastern Airlines, he had worked for Centurion Cargo on the DC10 and MD11, achieving command there after 5 years as a First Officer. The 49 year-old First Officer, who was PF for the accident sector, had 6,200 hours flying experience including 225 hours on type. He had begun work as a flight instructor in 2007 and prior to joining Eastern Airlines 11 months prior to the accident had been employed by Republic Airlines on the ERJ-170. Both pilots were based in Miami and had been operating together on an extended 'trip' involving a wide range of domestic sectors since 14 October. The trip involved a succession of night stops, most recently at Indianapolis, Minneapolis and Omaha.
It was established from CVR data that the First Officer had “partially briefed” the runway 13 ILS approach at destination just under an hour before the landing occurred specifying Autobrake 3 and Flaps 30° based on the ATIS then current/ which gave the surface wind as from 130º at 9 knots, the visibility 3 miles in rain, the lowest cloud at ceiling 1,500 feet with braking action advisories in effect. A few minutes later the First Officer revised his briefing to cover an ILS approach to runway 22 after the Captain noted that the ATIS was giving runway 13 for departures and it was completed based on unchanged autobrake and flap settings as the aircraft descended through 18,000 feet QNH. The applicable Vref was noted as 137 KIAS and manual deployment of the speedbrakes by the Captain was also discussed since their automatic activation was inoperative and listed as an ADD in the Aircraft Technical Log.
The flight was radar vectored to the ILS LOC and shortly before the ILS GS was captured, the landing gear was selected down and, as the aircraft approached 5 miles from touchdown, flap 30 was selected and the landing checklist was completed. The Captain pointed out the approach lights soon afterwards and the First Officer subsequently disconnected the AP at about 300 feet agl “as required by Eastern Airlines SOP” and the A/T. FDR data indicated that shortly after this, the aircraft began to deviate above the ILS GS and crossed the runway threshold at a height consistent with the threshold crossing height of the PAPI which it was noted was not coincident with the ILS GS beam. Auto height callouts began at 50 feet and pitch attitude started to increase in the flare at about 40 feet which, after the 20 feet callout prompted the Captain to state “down” and after the 10 feet callout to state “down down down down you're three thousand feet remaining”. There was no callout of spoilers or thrust reversers during the subsequent rollout and “FDR data and performance calculations during the Investigation indicated that the aircraft had crossed the runway threshold at 66 feet agl with about a 750 fpm rate of descent". After the aircraft had travelled a little over a third of the way along the 2,134 metre-long runway without touching down, its descent rate had decreased to almost zero and it continued to float until it did eventually touchdown on the grooved wet surface almost 1,300 metres beyond the threshold.
Maximum manual braking commenced at main gear touchdown but thrust was not set completely to Idle until about 16 seconds after the flare had been initiated which was after touchdown. Initial nose gear touchdown was about 2 seconds after the mains but briefly rebounded because of an aft control column input. Manual full deployment of the speed brakes occurred within 5 seconds of main gear touchdown and maximum reverse was commanded with less than 340 metres remaining. The Captain reported that having seen the end of the runway approaching, he had also begun to apply maximum braking and also right rudder because, unaware of the EMAS ahead, “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 stated that the Captain had not, as per the Operator's procedures, told him that he was attempting to brake and steer the aircraft and he had been unaware of these inputs so that when he detected that the aircraft was pulling "really hard" to the right, he automatically responded with a left rudder input which was contrary to his expectations because of the 9 knot crosswind from the left. He reported having continued to attempt to maintain the centreline by overriding the autobrakes with pressure on the left brake pedal. Eleven seconds after main gear touchdown, the CVR recorded a rumbling sound consistent with the aircraft leaving the runway and it then entered the Engineered Materials Arresting System at about 35 knots before exiting it and coming to a stop to the right of it just over 50 metres from the end of the runway.
A comprehensive examination of the aircraft after recovery found that EMAS material had entered and damaged the fan blades in the No. 1 engine only and both engines’ inboard thrust reverser sleeves and blocker doors had been damaged. Subsequent inspection of the aircraft found that the lower and forward parts of the aircraft fuselage landing gear and antennas were “coated with a dried residue resulting from the mixture of the EMAS material and rainwater” with pieces of a matting material used in the EMAS found in various places on the aircraft. When this debris was subsequently removed, it was found that the underside of each gear strut had been damaged as had wiring support brackets on both main gear assemblies and the wire conduit sleeve on the left main gear assembly.
Conversation recorded on the CVR once the aircraft had stopped included the pilots agreeing that they should have conducted a go-around. The Captain later stated that he should have called for a go-around when the aircraft floated during the flare.
It was noted that the runway involved had TDZ markers on positioned 500, 1,200, 2,000 and 2,500 feet (152, 366, 610 and 762 metres) from the threshold as well as TDZ lights which consisted of two rows of steady white transverse light bars running symmetrically about the runway centreline between 100 feet (30 metres) and 3,000 feet (914 metres) from the threshold. There were also lighted signs indicating the runway distance remaining at 1,000 foot (305 metre) increments measured from the runway end. The runway centreline lights were out of service at the time of the excursion. The EMAS installation was set back about 30 feet (9 metres) from the end of the runway and had originally been installed in 2005 and then replaced in 2014. It was capable of decelerating and stopping an aircraft overrunning the runway on the extended centreline at up 80 mph (70 knots) and had been installed because it was not possible to provide the full 1,000 feet (305 metre) RESA.
Detailed analysis of the FDR data found that there had been an increasing tailwind component as the aircraft approached the runway and at touchdown it had reached about 10 knots, the FCOM maximum for a landing. A Boeing simulation of the aircraft’s stopping performance requested for the Investigation showed that had the speed brakes been manually deployed within 1 second of touchdown - the criteria for automatic deployment - and followed by thrust reverser deployment 7 seconds later, only the nose of the aircraft would have left the paved surface and had the thrust reversers been deployed within about 2 seconds after manual speed brake deployment, the entire aircraft would have remained on the runway. An NTSB review of FDR data for previous landings of the accident aircraft found that on average, manual deployment of the speed brakes had been achieved within half a second of touchdown.
It was noted that the FAA had approved the Eastern Airlines SMS implementation plan 8 months prior to the accident. It was noted that at the time of the accident, “EMAS training was not part of Eastern Air Lines' pilot training program” and the Captain stated during interview that “he had forgotten that an EMAS was installed at the end of runway 22” although he “had read about the system”. It was found that the FAA Principal Operations Inspector assigned to Eastern Airlines considered that “the training in the manual for a go-around was similar to the syllabus used by other airlines” and he had "assumed" that they did some go-around training in the flare and some training in low visibility. In fact, the Investigation found that “training did not include any scenarios that addressed performing go-arounds in which pilots must decide to perform the manoeuvre rather than being instructed or prompted to do so”.
The Conclusions of the Investigation included the following:
- the absence of adequate go around decision training had contributed to both the Captain's and the First Officer's failure to call for a go-around.
- the recorded increase in pitch attitude in the flare occurred at almost twice the height recommended in the FCTM and contributed to the aircraft floating above the runway.
- the delay in reducing the thrust to idle in the flare also contributed to the aircraft floating above the runway.
- given the known wet runway conditions and aircraft 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 and contributed to the overrun.
- an unannounced input to the controls by the Captain as the end of the runway approached represented a breakdown of crew resource management.
- the Captain's failure to call for a go-around demonstrated his lack of command authority.
The Probable Cause of the investigated event was determined as "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”.
Four Contributory Factors were also identified:
- 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.
- 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.
Safety Action taken by Eastern Airlines whilst the Investigation was in progress was noted to have included the enhancement of pilot go-around training by the addition of scenarios requiring them to decide to conduct a go around rather than just doing so when instructed to by ATC. Scenarios in which go-arounds are initiated from idle thrust and rejected landings commenced after touchdown with the automatic speed brake inoperative were also stated to have been added. A training module emphasising that if a touchdown is predicted to be outside of the TDZ, a go around should be flown had been added with the declared intent to make this mandatory.
The Final Report of the Investigation was adopted by the NTSB on 18 September 2017 and published on 21 September. No Safety Recommendations were made.