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B738, Kingston Jamaica, 2009

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Summary
On 22 December 2009, the flight crew of an American Airlines’ Boeing 737-800 made a long landing at Kingston at night in heavy rain and with a significant tailwind component and their aircraft overran the end of the runway at speed and was destroyed beyond repair. There was no post-crash fire and no fatalities, but serious injuries were sustained by 14 of the 154 occupants. The accident was attributed almost entirely to various actions and inactions of the crew. Damage to the aircraft after the overrun was exacerbated by the absence of a RESA.
Event Details
When December 2009
Actual or Potential
Event Type
Human Factors, Runway Excursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 737-800
Operator American Airlines
Domicile United States
Type of Flight Public Transport (Passenger)
Origin Miami
Intended Destination Kingston/Norman Manley International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Landing
LDG
Location - Airport
Airport Kingston/Norman Manley International Airport
General
Tag(s) Approach not stabilised,
Inadequate Aircraft Operator Procedures,
Inadequate ATC Procedures,
Ineffective Regulatory Oversight,
Inadequate Airport Procedures,
HUD used by PIC"HUD used by PIC" is not in the list (ATC Training, Flight Crew Training, Military use of civil airport, Civil use of military airport, Approach not stabilised, Aircraft-aircraft collision, Aircraft-aircraft near miss, Extra flight crew (no training), Safety pilot present, Non Precision Approach, ...) of allowed values for the "GeneralSub" property.,
Deficient Crew Knowledge-automation
HF
Tag(s) Ineffective Monitoring,
Manual Handling,
Plan Continuation Bias,
Procedural non compliance,
Ineffective Monitoring - PIC as PF
RE
Tag(s) Overrun on Landing,
Excessive Airspeed,
Late Touchdown,
Significant Tailwind Component
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Injuries Few occupants
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness,
Air Traffic Management,
Airport Management
Investigation Type
Type Independent

Description

On 22 December 2009, a Boeing 737-800 (N877AN) being operated by American Airlines on a scheduled passenger flight (AA331) from Miami to Kingston Jamaica ran off the eastern end of runway 12 during a night landing off an ILS approach at destination following a late touchdown in the presence of a significant tailwind component and heavy rain but with visibility still in excess of 2000 metres. The aircraft was destroyed but there was no post crash fire and no occupant or other fatalities.

The aircraft in its final resting position (reproduced from the Official Report)

Investigation

An Investigation was carried out by the Jamaican Civil Aviation Authority (JCAA) in accordance with the principles of ICAO Annex 13. The Flight Data Recorder (FDR) and 30 minute Cockpit Voice Recorder (CVR) were recovered and successfully downloaded to provide relevant data. It was noted that although the FDR recorded 1176 parameters, these did not include spoiler deployment or wheel speed. Use was also made of data from the Non Volatile Memory of some flight deck equipment. Overall, the evidence available led the Investigation to conclude that there had been “no mechanical aspect of the aircraft that contributed to the accident”.

An initial ‘News Release’ summarising some of the early factual findings was issued on 6 January 2010. Thereafter there were no further reports from the JCAA until the Investigation was complete. However, on 7 December 2011, the National Transportation Safety Board (USA) (NTSB), based on access to the findings of the Investigation up to that point, issued four new Safety Recommendations to the Federal Aviation Administration (FAA) and re-iterated one previously made to the FAA in 2007 but still open. These are reproduced at the end of this article from where the NTSB letter which explains the reasons for them may be accessed.

The JCAA Investigation (which provides the basis for what is presented in this article) noted that although there had been no post crash fire, “conditions were ideal for combustion, that is electrical sparks, spilt fuel, fuel fumes, hot mechanical parts etc.” and concluded that the prevailing heavy rain had probably reduced the risk of such a fire. The first ARFF unit had arrived within 3 minutes but had not actively assisted in the evacuation. However, all six crew members had been uninjured and had been able to provide the necessary assistance to passengers to evacuate the aircraft.

It was established that the aircraft commander had been designated as PF for the sector and that both crew had considerable aircraft type and destination experience. The PF had briefed for the offset ILS Cat 1 approach to land on runway 12 knowing that there was likely to be a significant tailwind component and that the aircraft would be close to MLW. The Investigation noted that the offset ILS LOC intercepted the extended runway centreline at 0.75 nm from the threshold of the runway at an ILS GS height of 280 feet a.r.t.e. Flap 30 and Autobrake 2 were specified (the latter was subsequently changed to Autobrake 3 during final approach). It was noted that the recommended American Airlines SOPs for braking in the prevailing conditions was either “MAX autobrake or manual braking” and the recommended flap setting for tailwind landings was 40.

The aircraft was fitted with a HUD on the left side pilot position only which was used for the approach. The crew had agreed that this would be preferable to breaking off to follow the available circle-to-land procedure to runway 30 because of concerns about the chances of remaining visual -the minima for this were 1140 feet agl and 3.7 km. Although both pilots were qualified for GPS approaches, neither had been aware that there was an RNAV (GPS) approach to runway 30 with an MDH of 373 feet. A special weather observation made three minutes after the accident gave 320°/11 knots, 2200 metres in heavy rain showers, FEW Cb at 1600 feet aal, SCT at 3000 feet aal and BKN at 10,000 feet aal.

A coupled ILS approach was flown and configuration for landing was complete by the time the aircraft was 3 miles from touchdown. ATC gave landing clearance and advised of heavy rain and that the runway was “wet”. The AP was disconnected with just under 2 miles to run but the A/T was left engaged. It was noted that although concurrent A/T disconnection was not required in the FAA-approved American Airlines Operations Manual, the Boeing 737 NG Flight Crew Training Manual recommends that, other than during takeoff and climb, the A/T “should be used only when the autopilot is engaged in CMD”.

As the aircraft crossed the runway threshold in heavy rain at approximately 70 feet agl, aircraft pitch was increasing. The A/T was disconnected almost immediately after this and the aircraft then floated with a zero rate of descent until thrust was selected to flight idle when the aircraft was some 1130 metres along the 2716 metre-long runway. Initial runway contact at 5 knots above the applicable Flap 30 Reference Speed (Vref) of 148 KIAS with a corresponding ground speed of 162 knots then occurred from which the aircraft bounced once before finally settling on the runway 1310 metres from the landing threshold with just over half the runway remaining.

Autobrake 3 pressure (500 psi) was recorded from shortly after the final touchdown until manual braking began. Full reverse thrust was achieved with just over 1000 metres to go before the end of the runway and maximum manual brake pressure (3000 psi) was reached with just over 600 metres to go. The aircraft departed the paved surface at a ground speed of 62 knots and then passed through the chain link airport perimeter fence, crossed a public road some 12 feet below runway level and finally stopped on the shoreline. No warning of impending impact was given and there was no crew ‘brace, brace’ PA. However, the cabin crew ordered evacuation almost immediately after the aircraft had come to a stop. It was found that the evacuation slide at the L1 door malfunctioned - this was subsequently attributed to an installation error - and that some parts of the aircraft emergency lighting system had malfunctioned. However, neither of these had had a material effect on the evacuation.

The final impact led to the aircraft fuselage breaking into three pieces, the detachment/collapse of the main landing gear, the detachment of the right engine and the rupturing of the right wing fuel tanks which resulted in fuel leaking onto the beach sand. It was noted that neither end of the runway had a Runway End Safety Area.

The Investigation noted that the “typical landing flare time” described in the Boeing 737NG FCTM was four to eight seconds and that the FDR readout indicated an actual flare duration of about 10 seconds. Examination of the rate of deceleration once the aircraft was on the runway found that it had been less than would have been expected on a wet-smooth surface but better than would have been expected on a surface contaminated by standing water. No evidence of hydroplaning having occurred was found. It was concluded that “the factual evidence indicates that the airplane/ runway stopping performance interaction” for the accident landing was essentially consistent with what American Airlines documentation described as “Fair/Medium braking action”, whereas the crew assumed that Wet/Good braking action was appropriate.

A close up view of the aircraft in its final position (reproduced from the Official Report)

The Investigation examined the runway markings and lighting and concluded that all those on runway 12 “met the standards for runway lighting and markings of ICAO Annex 14”. It was established from the AIPs that although “information on standing water ….is transmitted by ATS to landing and departing aircraft…no facilities exist for (its) measurement”. It was found that “ATC runway surface condition reporting did not fully conform to the ICAO Recommendations” and that there was no formal agreement in place between the airport operator and ATS which required the former to keep the latter informed of current runway conditions, which was contrary to ICAO Annex 11 and ICAO Annex 14. It was also noted that neither ATC, the airport operator or American Airlines used the recommended ICAO terminology for describing water on the runway.

The prevailing weather conditions were reviewed. It was concluded that the rain falling at the time of the accident landing had been ‘heavy’ and noted that although the crew had been aware of this, at no time were they advised of this by ATC. The wind velocity in the half hour before the accident had been consistently from 320° at 10-15 knots and the wind reading had been passed to the aircraft by APP and then by TWR on five occasions in the final 20 minutes.

It was considered that the temporary absence of the approach lights for runway 12, which had been communicated in a Notice To Airmen provided to the crew prior to the flight, “may have reduced depth perception cues for the Captain during the final stages of the approach” although it was observed that these were lead-in lights to assist pilots in acquiring and lining up with the runway during the final stages of an approach when transitioning to visual flight.

It was noted that TDZ lighting (not provided on the accident runway) is not an ICAO standard for a Cat 1 Precision Approach runway and that reflective painted markings, which were also not provided for the accident runway, are an ICAO Recommended Practice rather than a Standard.

It was noted that on initial contact with APP, the crew had been advised to “expect an ILS runway 12” and advised that the wind was 310°/10 knots and that they “might have to conduct a circling procedure for runway 30”. The crew immediately replied that “they could take a straight in ILS approach to runway 12. The option to conduct an RNAV (GPS) Runway 30 instrument approach to runway 30 was not suggested” by ATC and it was noted that based on the cloud being reported at the time as BKN at 1000 feet, the circling approach would not have been possible since the minimum for circling was 1150 feet agl. It was evident that the straight in RNAV (GPS) approach to runway 30 “would have offered a better option than the circle-to-land procedure” since it afforded an MDA of 373 feet agl and “the advantage of an into-wind landing”. It was noted that “all of the necessary elements for this flight to conduct the RNAV (GPS) Rwy 30 approach were available, except that the flight crew was not aware of it and the controller did not offer it as an option, which resulted in a continuing lack of awareness of it by the flight crew”. It was concluded that if the flight crew had used the RNAV (GPS) Runway 30 approach and landed on that runway, “the accident would probably have been avoided”.

It was noted that the American Airlines B737 Operations Manual did not include a SOPs which allowed the First Officer acting as PM to call for a go-around, with the pilot flying (that is, the captain) being obliged to follow through. Instead, the Manual clearly indicated that “a Captain could disregard any First Officer’s call to go-around call.” The Investigation was not able to determine exactly what “the philosophy of American Airlines” was in respect of this subject, but it was concluded that First Officer acting as PM “might be reluctant to call for a go-around”.

The Investigation noted that although the option to make a go around had been available until such time as reverse thrust was selected and that the Captain had reported during interview that he had briefly considered this “when the aircraft was on the runway and not decelerating as expected”, he had decided against it. In the light of this it was considered possible that, had the First Officer called for go-around between when the aircraft crossed the runway threshold and before the Captain selected reverse thrust, then “the accident might have been avoided”. However, this tentative conclusion was qualified by further remarks that the prevailing circumstances once the aircraft was on the ground , the engines were at flight idle and there was relatively little runway remaining might have collectively mitigated against a successful go around.

In considering a possible explanation for the abnormal and inappropriate pitch up inputs made by the PF which were the primary cause of the long landing, it was considered that the lack of available depth perception cues could have made it difficult for the PF to reliably judge the position of the TDZ. The cumulative consequence of this would have amounted to a ‘black hole effect’ to which “the following night visual illusion factors and depth perception impediments may contributed:

  • The landing was conducted in the hours of darkness, with visibility as low as 2200 metres in heavy rain to a runway with the sea at both ends thereby creating large unlit areas.
  • The absence of TDZ and runway centre line lighting and the absence of reflective material in the runway marking paint would have led to most of the light from the aircraft landing lights being reflected away from the runway surface and away from the aircraft instead of back to the cockpit. There would also have been a halo effect caused by the diffusion of light by water when viewing runway edge lights through a wet windshield.
  • Forward visibility may have been impeded by the heavy rain on the windshield, and the rapid movement of the windshield wipers.
  • There was no clear far-visual horizon for lateral and vertical reference due to the absence of lights beyond the runway and the reduced visibility in the rain.
  • An impression that the aircraft was lower than it actually was because of its higher groundspeed, caused by the tailwind, would have resulted in the runway lights going by faster, and may have induced premature pitch up inputs to flare for landing.

The Investigation concluded that the situational awareness of both members of the flight crew had been “incomplete”. They “did not make themselves familiar with all the available information before departure” or “give any consideration to the expected landing conditions at Kingston before departing from Miami, nor is there any evidence that they had any concerns about the runway conditions or braking action at Kingston until just before landing”.

It was also considered that the decision-making process of the flight crew during the flight was narrowly focussed. There was a “lack of discussion about the worsening conditions and the lack of any further discussion about a possible go-around” with the only significant concern being that the tail wind component remained within the landing limit of 15 knots or less. In fact “the controllers appeared more concerned with the tailwind conditions than was the flight crew”. It was noted that the 30 minute CVR recording included “no discussion or extra briefing about the hazards of the tailwind landing”. It was concluded that greater awareness of the potential hazards inherent in a landing on runway 12 in the prevailing conditions might have led them not to attempt the landing and “the accident might have been avoided”.

Overall, it appeared to the Investigation that:

as the flight crew continued the approach, their situational awareness was diminishing as the situation changed and they were embarking on a difficult and hazardous landing without any concerns. The plan upon which they were acting was inadequate, and did not include consideration of the American Airlines recommended techniques for a tailwind landing on a wet runway

In considering the American Airlines system for delivering “management and operational control”, the Investigation considered that a number of factors which had been shown to have been possible contributors to the accident indicated “weakness” in some parts of it. These were identified as:

  • The use by AA dispatch in Miami of a Field Report for Kingston which included an unmeasured “measurement” of water depth was contrary to company procedures.
  • The failure of the AA331 flight crew to follow some prescribed and recommended operating procedures.
  • The lack of a clear AA definition of the term “Wet” in runway condition reporting.
  • The lack of understanding by AA flight training staff of the hazards of tail wind landing.
  • The lack of AA flight crew training on the hazards of tail wind landing.

It was considered that “factors such as these should have been corrected during training, Line Checks, internal audits or FAA Inspections”.

Safety Action taken as a result of the accident findings was noted to have included the following:

  • American Airlines made a series of changes to the content of Volume 1 of the 737 Operations Manual. These included changes to the sections on standard callouts, deviation callouts, stabilised approach requirements and go arounds. The latter involved changes to go around requirements which included but were not limited to go around after touchdown / rejected landing. The maximum tailwind component for landing was also reduced to 10 knots pending a general ‘safety risk assessment’ of the use of the 15 knot limit which was in place at the time of the accident.
  • The Airports Authority Jamaica has included provision of a RESA in their runway extension project.
  • Boeing have indicated their intention to revise the 737 Aircraft Maintenance Manual to reduce the chances of the installation error which caused the malfunction to the L1 evacuation slide from recurring.

The Investigation determined that the Probable Cause of the accident was that “the aircraft touched down 4,100 feet beyond the threshold and could not be stopped on the remaining runway”.

It was additionally determined that Contributory Factors were the flight crew’s

  • decision to land on a wet runway in a 14 knot tailwind
  • reduced situational awareness
  • failure to conduct a go-around after the aircraft floated longer than usual

A large number of implied or explicit Safety Recommendations were made by the Investigation under the general heading of “Safety Action Required”. Most but not all of these were assigned to specific recipients either explicitly or implicitly. In the order published, they were as follows:

[Note that the abbreviation ‘NMIA’ refers to the Kingston Airport Operator, ‘Norman Manley International Airport Limited’ and that the JCAA provides ATS in Jamaican airspace]

  • that Operators of Transport Category Aircraft should be required to conduct landing performance assessments before every landing, based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and incorporating a minimum safety margin of 15 per cent.
  • that the FAA should make the guidance provided in FAA AC 91-79 ‘Runway Overrun Prevention’ that “if there is rain actively falling on the runway, standing water should be assumed” mandatory for the operation of Transport Category Aircraft, such that when active moderate to heavy rain is falling on the runway, the runway surface condition shall be considered to be in a Wet/Poor or Contaminated state for the purposes of landing performance assessments, that is, water depth more than 1/8 inch.
  • that the FAA should ensure that the guidance related to runway surface descriptors in AC 91-79 and SAFO 06012 is unambiguous and compatible, so that operators and flight crews have ready access to consistent FAA guidance regarding runway surface condition definitions and their proper use in FAA acceptable landing distance assessments.
  • that although there was no ICAO requirement at the time of the accident for tailwind landing training, the FAA should make such training and the hazards involved a mandatory part of Transport Category Aircraft flight and ground training programs.
  • that Operators of Transport Category Aircraft should include in their Standard Operating Procedures a requirement that either pilot, whether acting as pilot flying or pilot monitoring, should be required to call for go-around if he/she sees that the aircraft will not land in the touchdown zone, and that the other pilot will follow through with the go around procedure without question or hesitation.
  • that the landing of Transport Category Aircraft in tailwind conditions on contaminated runways and on runways where heavy rain is actively falling should be firmly discouraged.
  • that Operators of Transport Category Aircraft should:
    • caution their flight crews against conducting tailwind landings on wet (not contaminated) runways, when an alternative and suitable into-wind runway is available.
    • inform their flight crews of the hazards related to tailwind landings on wet (not contaminated) runways when the aircraft is at or near its maximum landing weight.
  • that Air Operators should ensure their flight crews follow the company’s recommended procedures for landing on wet or contaminated runways.
  • that Flight Crews of Transport Category Aircraft should assume the runway is contaminated when heavy rain is actively falling on the runway of intended landing and complete a landing performance assessment based on contaminated runway surface performance data.
  • that the NMIA should install a Runway End Safety Area which meets the standards of ICAO Annex 14 for a Code 4D precision approach runway and/or an Engineered Materials Arrestor Systems Engineered Materials Arresting System of an appropriate length for the airport's design aircraft.
  • that ICAO should amend its guidance for runway condition inspection and reporting procedures to include a description of the recommended training for airport operations personnel carrying out these procedures. The training syllabus should cover the criteria for conducting routine and non-routine inspections and provide guidance on reporting the results of those inspections. The guidance above should include criteria for determining the frequency for performing special runway surface condition inspections when there is, or has been, heavy rainfall on the active runway.
  • that the NMIA should, pending the publication by ICAO of the recommended guidance material, conduct regular inspections of the runway surface during or following inclement weather, prior to aircraft landings, and should report runway standing water coverage as a percentage of runway covered to the aerodrome control tower for inclusion in ATC voice advisories and/or the ATIS.
  • that the NMIA and JCAA ATS should conclude an agreement which details the responsibilities and procedures each organisation will follow for runway surface condition inspection and reporting.
  • that the NMIA should replace the present runway surface guidance markings as soon as practicable using retro-reflective glass bead paint markings.
  • although it is not an ICAO standard, safety would be enhanced if the NMIA installed reflective distance-to-go markers for the last 4,000 feet of each runway at Kingston.
  • that the NMIA should install touch down zone lighting and centreline lighting on runways 12 and 30.
  • that the emergency equipment stowage compartments in the passenger cabin should be relocated to a position which allows easier access in emergency conditions and/or the doors to those compartments should be made of a softer cover.
  • that American Airlines should ensure that the proposed revision to the Boeing 737 Maintenance Manual regarding installation of the slide pack is followed in the company’s maintenance procedures.
  • that American Airlines should ensure that its FAA-approved manuals for the Boeing 737 reflect the instruction on the matching of AP and A/T use contained in the Boeing 737 NG Flight Crew Training Manual, page 1.34, which states: Autothrottle use is recommended during takeoff and climb in either automatic or manual flight. During all other phases of flight, auto throttle use is recommended only when the autopilot is engaged in CMD.
  • that Boeing should design an emergency cabin lighting system for the B738 aircraft which will continue to operate when there are breaks in the fuselage after an accident.
  • that American Airlines should develop a means of verifying the field reports of runway surface conditions reports sent by its outstations.
  • that American Airlines should immediately instruct their flight crews that if they use an “advance analysis” technique to assess landing performance, they should take all factors into account, including runway surface condition, recommended aircraft configuration, and use of recommended deceleration techniques. If the flight crews do not use an “advance analysis”, they should be instructed to perform, when required, the Landing Performance Assessment prescribed in Company Bulletin 737-07 prior to landing.
  • that American Airlines should immediately ensure that their flight crews understand that a runway described as “wet” by ATC in overseas locations does not necessarily signify that the runway surface is in a condition equivalent to (that assumed by) the American Airlines Landing Data Card “Wet/Good”.
  • that American Airlines should instruct all their flight crews that in the absence of a runway condition report when rain is actively falling on a runway, standing water should be assumed, as per FAA AC 91-79.
  • that the JCAA should ensure that the ATS Operations Manual clearly defines the circumstances under which Air Traffic controllers should inform Aerodrome Authorities of conditions associated with inclement weather, so that the Aerodrome Authorities conduct runway surface inspections and provide the results of these inspections to ATS units.
  • that the JCAA should ensure that Air Traffic Controller ab initio, advanced and recurrent training includes sensitization to the hazards of Aerodrome and ATS operations which are amplified by the presence of inclement weather.
  • that the JCAA should have a consistent system of QA Audits.
  • that the JCAA ATS should ensure that its Air Traffic Controllers undergo awareness training of performance based navigation procedures, including RNAV.
  • that the JCAA ATS should ensure that its Air Traffic controllers should have recurrent training and proficiency checks.
  • that Boeing should further investigate means of securing the overhead bins and PSUs in Boeing 737 aircraft with a view to modification which would avoid injuries to passengers in similar accidents.
  • that Boeing should further investigate the requirements for the Captain’s seat belt crotch bracket and introduce modifications to prevent failure of this in similar accidents.
  • that American Airlines should take action to prevent the use of uncertified replacement seat bottom cushions by flight crew.
  • that the NMIA implement transverse grooving of runway 12/30
  • that the NMIA should continue progress towards the goal of meeting the JCAA and Annex 14 requirement of full aerodrome certification.
  • that the JCAA and the NMIA should organise a coordinated training program for their staff on certification standards, conduct and development of a certification program and consider self-inspection/condition-reporting.
  • that the JCAA and the NMIA should develop and publish specific maintenance standards particularly on the subject of pavement and runway strip maintenance and provide detailed maintenance training to those responsible for self- inspections and for aerodrome maintenance.
  • that the NMIA should coordinate additional detail in the Airport Emergency Plan, particularly in the water rescue section of the plan.
  • that the NMIA should coordinate in respect of the runway 12/30 paved surface:
    • a full runway assessment to determine current longitudinal slope, current transverse slope (along the full runway length) and the existing grade in first third of runway 30 (from approximately taxiway D to the 30 threshold).
    • a hydrologic engineering assessment to determine water flow on the first third of runway 30 from approximately taxiway D to the 30 threshold.
    • completion of a full friction assessment of the runway to determine compliance with established friction maintenance standards and deviation from the findings of the last friction assessment (2004).
  • that the NMIA should add additional runway designation signs at every runway holding point.
  • that the NMIA should consider revising current PAPI configuration to the ICAO standard (PAPI 4L) by removing the additional 4 boxes on the right side of 12 and 30.
  • that the NMIA should, in respect of the Airport Rescue and Fire Fighting Services:
    • develop detailed training lesson plans for required training subjects of initial and recurrent training.
    • consider acquisition of a simple SCBA bottle refill system for aerodrome use.
    • acquire powered rescue saw(s) for aerodrome use.
    • enhance existing training procedures used for aircraft familiarisation…to include acquisition of current training aids for each commercial service aircraft currently using the airport.
  • that the NMIA should consider undertaking a review of all declared runway distance figures published in the Jamaica AIP to accommodate the fact that there is no existing runway strip or runway end safety area at either runway end.
  • that the NMIA should, in respect of the runway strip and RESA (as provided):
    • remove existing debris and vegetation from the existing drains in the runway strip between taxiway D to E and verify that these drains are operational and that they are tied into the drain system and box-culvert under the aerodrome
    • conduct periodic surveys of the runway strip and the RESA (as provided) to determine safety issues and correct found deficiencies on a more frequent basis
    • remove all current deviations (objects not required) from the runway strip
    • feather the existing localiser base to grade (sic)
  • that the NMIA should institute a specific maintenance/calibration periodicity and a periodic maintenance schedule to service the PAPIs.
  • that all aircraft manufactured after 2002 should be equipped with CVRs capable of recording 120 minutes to enhance the usefulness of the CVR for accident/incident investigation.
  • that the FAA should amend one or both of the conflicting statements in AC91-79, Appendix 4, 10 b. (2), “If a runway is contaminated or not dry, that runway is considered wet and in SAFO 06012, item 4. Definitions, “i. A wet runway is one that is neither dry nor contaminated” which although both FAA guidance material are inconsistent.
  • that a cancelled NOTAM should not just ‘disappear’ but a notification of cancellation should be issued .
  • that ATIS transmissions should be recorded as the record might be necessary for occurrence investigation.
  • that the JCAA ATS should be required to fully align the content of the JCAA ATS Operations Manual with the provisions of ICAO Doc 4444.
  • that the JCAA ATS Operations Manual and the NMIA Operations Manual should be amended to include the ICAO definitions for reporting water on the runway.

The Final Report was published on 2 May 2014.

The four Safety Recommendations issued to the FAA by the NTSB on 7 December 2011 as a result of this accident and referred to earlier were as follows:

  • that the FAA should require principal operations inspectors to review flight crew training programs and manuals to ensure training in tailwind landings is (1) provided during initial and recurrent simulator training; (2) to the extent possible, conducted at the maximum tailwind component certified for the aircraft on which pilots are being trained; and (3) conducted with an emphasis on the importance of landing within the touchdown zone, being prepared to execute a go-around, with either pilot calling for it if at any point landing within the touchdown zone becomes unfeasible, and the related benefits of using maximum flap extension in tailwind conditions. [A-11-92]
  • that the FAA should revise Advisory Circular 91-79, “Runway Overrun Prevention”, to include a discussion of the risks associated with tailwind landings, including tailwind landings on wet or contaminated runways as related to runway overrun prevention. [A-11-93]
  • that the FAA should, once Advisory Circular 91-79, “Runway Overrun Prevention”, has been revised, require principal operations inspectors to review airline training programs and manuals to ensure they incorporate the revised guidelines concerning tailwind landings. [A-11-94]
  • that the FAA should require principal operations inspectors to ensure that the information contained in Safety Alert for Operators 06012 is disseminated to 14 Code of Federal Regulations Part 121, 135, and 91 subpart K instructors, check airmen, and aircrew program designees and they make pilots aware of this guidance during recurrent training. [A-11-95]

At the same time as issuing the above recommendation, the NTSB also reiterated the following recommendation made to the FAA in 2007 and reclassified it “Open - Unacceptable Response”:

  • that the FAA should require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent. [A-07-61]

The context for these NTSB actions can be found in the letter in which they are contained.

Further Reading