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SF34, New York JFK USA, 1999
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|An SF34 overan New York JFK 04R after an unstabilised ILS approach in IMC was continued to a deep landing at excessive speed and the aircraft overan into the installed EMAS.|
|Actual or Potential
|Human Factors, Runway Excursion|
|Operator||American Eagle Airlines|
|Type of Flight||Public Transport (Passenger)|
|Origin||Baltimore Washington International/Thurgood Marshall Airport|
|Intended Destination||New York/John F Kennedy International Airport|
|Take off Commenced||Yes|
|Location - Airport|
|Airport||New York/John F Kennedy International Airport|
|Tag(s)||Approach not stabilised|
Inappropriate crew response - skills deficiency,
Procedural non compliance,
|Tag(s)||Overrun on Landing,|
|Safety Net Mitigations|
|Malfunction of Relevant Safety Net||No|
|GPWS||Available but ineffective|
|Damage or injury||Yes|
|Causal Factor Group(s)|
On 8 May 1999 a Saab 340B being operated by American Eagle Airlines on a scheduled passenger flight from Baltimore/Washington International to New York JFK made an continuously unstabilised ILS approach to runway 04R in day Instrument Meteorological Conditions (IMC) and continued to a late touchdown at excessive speed before overrunning the end of the runway into the installed Engineered Materials Arresting System and coming to a stop within it. The aircraft sustained substantial damage and one of the 29 occupants was seriously injured whilst exiting the aircraft.
An investigation was carried out by the National Transportation Safety Board (USA) (NTSB). The FDR and CVR were available as were ATC radar and RTF recordings.
It was established that initially, the RVR was below the required minimum and ATC offered a hold on the ILS LLZ at 4000ft. The RVR then improved and ATC offered, at pilot discretion, a straight in ILS approach from current position. This was accepted and descent was immediately commenced clean from 4000ft at a distance of 5.7nm from the runway by the First Officer who was PF. The Captain then extended the landing gear and took control of the aircraft. The rate of descent was excessive and reached a maximum of nearly 3000 ft/min. A GPWS ‘Sink Rate’ and several ‘Too Low Terrain’ Warnings occurred and were ignored. The flaps were not deployed at any setting and the aircraft crossed the runway threshold at 180KIAS before touching down 2130 metres from the start of the 2560 metre runway at 157KIAS. The aircraft departed the end of the runway at about 75KIAS before entering the 122 metre long EMAS and stopping approximately 75 metres into it. The landing gear was found to have sunk approximately 0.75 metre into the EMAS bed by the time it stopped, with damage to the nose landing gear, fuselage and propellers.
The investigation noted that the entire approach had been conducted with total disregard for Company SOPs including those relating to stabilised approaches and the response to GPWS/TAWS Warnings. of descent. During interviews both pilots stated that they had been fatigued.
The Probable Cause of the accident was adopted by the NTSB on 4 December 2000 as:
- The pilot-in-command's failure to perform a missed approach as required by his company procedures.
It was also noted by the Board at this determination that “factors were the pilot-in-command's improper in-flight decisions, the pilot-in-command's failure to comply with FAA regulations and company procedures, inadequate crew coordination, and fatigue.”
No Safety Recommendations were made as a result of the Investigation.
- Runway Excursion
- Engineered Materials Arresting System
- DGAC (France) Publications on Non-Stabilised Approaches
- Low Visibility Procedures (LVP)
- Stabilised Approach
- Fatigue Manifestations (OGHFA BN)
- Runway Overrun After Unstabilised Approach (OGHFA SE)