CHI03IA070

NTSB incident investigation · Canadair CRJ-600 · Bloomington, IL · February 15, 2003

Incident · No injuriesIncident investigationFinal report
Date
February 14, 2003, 20:53 local (Feb 15, 2003, 02:53 UTC)
Place
Bloomington, IL
Injuries
29 uninjured
Damage
Minor damage
Phase of flight
Landing
Aircraft
N653BRCanadair CRJ-600
Weather
Instrument (IMC) · Night/dark
Status
Completed · report March 30, 2005
Report
Approved by Office Director
Parties
Atlantic Coast Airlines, FAA-Springfield FSDO, Messier-Dowty, ALPA, DeHavilland
FAA report
20030214006269I
Case key
56512

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The pilot's improper in-flight decision to land on a runway with a tailwind component that exceeded the airplane's tailwind limitation and his failure to perform a go-around which resulted in the proper touchdown point not being attained and the airplane landing long. Also causal was the inadequate snow removal procedures used by the airport personnel and the airport personnel failed to issue NOTAMS in accordance with existing regulations, resulting in the landing gear to fail in overload as a result of hitting a ridge of snow and/or ice on the runway during landing roll. Additional factors included the contaminated runway; the tailwind; the snow; and the dark night.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

On ground/water collision with objectLanding - roll
Object - otherFactor
In-flight planning/decision - improperPilot in commandCause
Procedures/directives - not complied withPilot in commandCause
Compensation for wind conditions - not performedPilot in commandCause
Airport snow removal - inadequateAirport personnelCause
Airport operations - inadequateAirport personnelCause
Information insufficientAirport personnelFactor
Airport facilities,runway/landing area condition - otherFactor
Weather condition - tailwindFactor
Weather condition - snowFactor
Light condition - dark nightFactor
Nose gear collapsedLanding - roll
Landing gear,nose gear - failureCause
Landing gear,nose gear - overloadCause

Analysis

The regional jet, operating as a 14 CFR Part 121 domestic passenger flight, sustained minor damage when the nose landing gear collapsed during landing rollout on runway 20. While en route to their destination, the flight crew obtained the airport Automated Terminal Information Service (ATIS) information. The ATIS information indicated the current winds were 060 degrees at 14 knots. Neither the captain nor the first officer checked the reported winds against the Wind Component Conversion Chart to determine whether the headwind/tailwind and crosswind components were within limits. The Wind Component Conversion Chart indicated that the tailwind component was 10.5 knots and the crosswind component was 9 knots. The airplane's tailwind limitation is 10 knots. The Flight Data Recorder (FDR) data indicated that the airplane landed with a 13 knot tailwind. Prior to the ILS instrument approach, the captain conducted an Approach Brief, but did not brief the missed approach procedures. The tower air traffic controller informed the pilot that snowplows had removed snow from the centerline of the runway and that the braking action was "fair to poor." The captain did not brief the first officer concerning procedures for landing on a contaminated runway. The FDR data indicated that the airplane touched down near the runway intersection, approximately 2,900 +/- 250 feet (2,650 feet to 3,150 feet) from the approach end of Runway 20. Runway 20 is 7,000 feet long. The desired touchdown point is 1,000 feet from the approach end of the runway, or the first 1/3 of the runway. Runway 20's touchdown zone limit is 2,333 feet from the approach end of the runway. The FDR data indicated that the aircraft touched down on a heading of 190 degrees at 124 knots computed airspeed with 0.4 degrees of nose up pitch. The data indicated the nose was pitching nose down at the time of touchdown. All three landing gear Weight-on-Wheels (WOW) switches changed from Air to Ground within 0.25 seconds of each other. Approximately 1.75 seconds later the nose landing gear WOW switched to Air again, indicating that the nose landing gear had collapsed. The vertical acceleration parameter did not show a significant load at touchdown. The airplane skidded to a stop on the runway. The captain reported that he inspected the runway and observed ridges of snow and ice near the runway intersection. The on-site inspection of the airplane revealed that the nose landing gear drag brace had broken and the nose landing gear collapsed rearward. The nose wheel and tire remained intact and were jammed under the airplane as it skidded to a stop. Metallurgical examination revealed that the drag brace failed due to the application of an overload and that there were no material defects. The Messier-Dowty analysis of the nose landing gear fracture indicated that the load required to fracture the drag brace was generated by hitting an obstacle. An investigation of airport operations revealed that the personnel inside the snow removal vehicles were making runway condition assessments by looking out their side view mirrors. The airport did not conduct or provide friction measurement reports and NOTAMS between the hours of 1900 and 2200 when airport conditions were rapidly changing with significant snowfall accumulations and snow removal equipment was actively operating on runway 20.

Factual narrative

History of flight

On February 14, 2003, at 2053 central standard time, a Canadair CL-65, N653BR, operated by Atlantic Coast Airline (ACA), flight 7675, sustained minor damage when the nose gear collapsed during landing rollout. The Title 14 CFR Part 121 domestic passenger flight departed the Chicago O'Hare Airport (ORD) at 2026 and landed on runway 20 (7,000 feet by 100 feet, concrete) at the Central Illinois Regional Airport (BMI), Bloomington, Illinois. The captain, first officer (FO), flight attendant, and 26 passengers were not injured. An emergency evacuation was not required. Instrument meteorological conditions prevailed and the flight was on an IFR flight plan.

The flight to BMI was the second, and final, flight of the day for the flight crew. On the first flight of the day they had departed from Lexington, Kentucky, at 1808, and arrived at ORD at 1911. During the flight to BMI, the captain was the pilot flying the airplane and the FO was the pilot not flying.

The cockpit voice recorder (CVR) transcript indicated that ACA flight 7675 (Blue Ridge 675) departed from ORD Runway 9L at approximately 2026, and was cleared to climb to flight level 200 (20,000 feet).

At 2033, the FO listened to Automated Terminal Information Services (ATIS) information Delta (D). ATIS information D contained the following:

"Bloomington tower information Delta, time zero one four five Zulu. Wind zero six zero at one four; visibility one, one half miles; light snow; ceiling two hundred overcast; temperature zero; dewpoint zero; altimeter two niner niner zero. Airfield advisories all runways and taxiways and ramp areas, loose wet snow less than one quarter of an inch with MU ratings above four zero. Advise on initial contact, you have information Delta."

At 2036, the captain stated, "Ehh, there you go ... ninety-two, left and center."

At 2036:26, Chicago Center cleared Blue Ridge 675 direct to BMI and to descend at pilot's discretion to 10,000 feet.

Between 2038:00-2038:39, the FO provided the captain the ATIS brief and set approach speeds. He stated, "ILS is two zero. Here's your ATIS. It's um, zero six zero at fourteen, one and a half, light snow, two hundred over, zero and zero." ... "We got the visibility for it ... ninety on the meters. ILS twenty is in use." ... "There's loose wet snow on taxiways ... but its MU is greater than four." ... "Approach is forty, REF is thirty-five, go-around N1 is off the box, V2's one forty one, VT's sixty-eight. They are set ... my flow's complete."

Between 2038:41-2039:16, the captain gave the Approach Brief. He stated, "All right. ILS two zero. It's in the box. One ninety-eight inbound, top's at twenty four forty eight, bottom's at we're gonna call it ten eighty here." ... "Bottom at uh, ten eighty, airport at eight seventy one, MSA twenty eight hundred. Looks like there's some big MALSR lights on the runway." ... "We will put in on runway twenty, take it probably down to Golf and come back. Let's make sure we don't turn on that little stub down there." ... "And Golf will take us right across the other runway to the ramp."

At 2039, the flight was cleared to descend to 6,000 feet.

At 2041, the FO contacted the company's operations personnel at BMI to inform them that the airplane was 13 minutes from BMI and was inbound for landing. The operation's personnel responded, "All right, good luck in landing. We'll hopefully see you in 15." ... "Uhh. Northwest just did a missed approach because of the snow, so good luck."

At 2042, the FO reported the information received from BMI operations to the captain by stating, "Yeah, he goes, 'I hope you make it in. Northwest just went missed.'"

At 2042:44, the captain asked, "What are they calling the weather?"

The FO responded, "Two hundred over ... but you got plenty of vis."

The captain asked, "Oh, they're calling it two hundred over?"

The FO responded, "Yeah, it's two hundred over, but a mile and a half, so we should be fine."

At 2048, Peoria Approach Control cleared Blue Ridge 675 for the BMI ILS Runway 20 approach.

At 2049, flight 7675 contacted the BMI tower.

At 2050, BMI tower reported, "Blue Ridge 675, reference runway 20, I have had my snow removal been able to plow down the centerline of the, of the field, and I did have a Saab aircraft report braking action uh ... fair to poor." The tower subsequently cleared Blue Ridge 675 to land on runway 20.

At 2051, while on the approach to runway 20 with the landing ckecklist complete, the captain said, "Forty-five knots of wind." The FO responded, "I see that. Quartering, uh."

Approximately 500 feet above ground level (agl), the FO reported seeing "lights."

At 2052:12, the airplane's Ground Proximity Warning System (GPWS) stated, "Minimums."

At 2052:13, BMI tower reported, "Windcheck. Zero eight zero at one five."

At 2052:25, the CVR transcript indicated, "Sound similar to touchdown."

At 2052:26, the CVR transcript indicated, "End of recording."

In a written statement, the captain reported, "We broke out of the overcast at approximately 300' AGL, lights and runway in sight. Touched down in the touchdown zone and approximately a few seconds later as we were rolling across the stub end of RWY 11-29 and E taxiway, I heard and felt a bang and the nosegear collapsed. We received a "nosegear disagree" aural warning as we continued the rollout. As the flying pilot I maintained directional control of the aircraft using rudder, differential braking and thrust reversers and brought the aircraft to a stop a few feet to the right of the centerline with about 1500' of runway remaining. Per company procedures we ran the QRC (Quick Reference Checklist) for a shutdown/evacuation."

The captain reported that because the weather was so extremely cold, snowy, and windy on the runway, he stopped the emergency evacuation and kept the passengers on board the airplane until buses arrived to take the passengers to the terminal. The captain reported, "After the passengers were deplaned I obtained a ride with airport personnel in a pickup truck to the touchdown zone and observed snowbanks and FOD (large ice and snow chunks) in the touchdown zone. I inquired of the driver about this and he said they were just presently plowing RWY 11-29. I returned to the aircraft, completed the QRC shutdown and the crew was transported to the terminal."

During an interview, the captain reported the ridges of snow and ice on the runway were located between Echo taxiway and the intersection of runway 02/20 and runway 11/29.

Personnel information

The captain was an airline transport rated pilot with single-engine land, multi-engine land, glider, and instrument airplane ratings. He was a certified flight instructor in single engine land airplanes, multi-engine land airplanes, gliders, and an instrument airplane instructor. He held a First Class medical certificate. He had a total of 4,550 flight hours with 2,140 hours in make and model. He flew 255 hours in the last 90 days. He had been employed by ACA for approximately five years.

The FO was an airline transport rated pilot with single-engine and multi-engine land ratings. He was a certified flight instructor in single-engine land airplanes, multi-engine land airplanes, and as an airplane instrument instructor. He held a First Class medical certificate. He had a total of 3,337 flight hours with 1,269 hours in make and model. He flew 174 hours in the last 90 days. He had been employed by ACA for approximately two years.

Aircraft information

The airplane was a twin-engine Canadair CL-65, serial number 7438, with a maximum takeoff weight of 53,000 pounds. The engines were General Electric CF-34-3B1 engines that delivered 8,729 pounds of thrust. The airplane was on a Continuous Airworthiness maintenance program. The last service check was conducted on February 11, 200

Aircraft

Registration
N653BR
Reported as
Canadair CRJ-600
Category
Airplane
Serial number
7438
Airframe hours
5,962
Engine
General Electric CF34-3B1, 8,729 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
Atlantic Coast Airlines
Registered owner
First Union Bank
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · February 11, 2003
Departed
ORD · Chicago, IL
Destination
BMI · Bloomington, IL
Flight plan
IFR
Airport
BMI · Central Illinois Regional, runway 20, 7,000 × 100 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
January 29, 2003
Seat
Left
Flight hours
4,550 total · 2,140 in this make and model · 255 in the last 90 days · 88 in the last 30 days · 9 in the last 24 hours
Role
Co-pilot
Injuries
None

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
60° at 14 knots
Visibility
1.5 statute miles
Lowest ceiling
200 ft overcast
Temperature
32 °F, dew point 32 °F
Altimeter
29.89 inHg
Observed at
BMI

Docket · 64

The files NTSB released with the investigation on May 12, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 31.5 MB in all.

Meteorology 5 - Report of Weather SpecialistItem 1 · .PDF · 8.5 MBFlight Data Recorder 10 - Specialist's Factual ReportItem 2 · .PDF · 83 KBFlight Data Recorder 10 - Flight Data StudyItem 3 · .PDF · 1.0 MBFlight Data Recorder 10 - Attachment 1 Plotted DataItem 4 · .PDF · 183 KBFlight Data Recorder 10 - Attachment 2 Tabular DataItem 5 · .CSV · 883 KBFlight Data Recorder 10 - Study Attachment 1 Tabular DataItem 6 · .CSV · 55 KBFlight Data Recorder 10 - Study Attachment 2 Tabular DataItem 7 · .CSV · 5 KBFlight Data Recorder 10 - Study Attachment 3 Tabular DataItem 8 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 4 Tabular DataItem 9 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 5 Tabular DataItem 10 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 6 Tabular DataItem 11 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 7 Tabular DataItem 12 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 8 Tabular dataItem 13 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 9 Tabular dataItem 14 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 10 Tabular DataItem 15 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 11 Tabular DataItem 16 · .CSV · 21 KBFlight Data Recorder 10 - Study Attachment 12 Tabular DataItem 17 · .CSV · 21 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 18 · .PDF · 288 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 19 · .PDF · 303 KBPilot StatementsItem 20 · .PDF · 125 KBInterview - CaptainItem 21 · .PDF · 1.6 MBErrata SheetItem 22 · .PDF · 37 KBSketch Made By Captain Concerning the Location of the Snow Drifts on Runway 20Item 23 · .PDF · 20 KBInterview - First OfficerItem 24 · .PDF · 1.1 MBRecord of InterviewItem 25 · .PDF · 53 KBCorrespondence From FAA ReportItem 26 · .PDF · 258 KB8/04 to 5/03 BMI InterviewsItem 27 · .PDF · 567 KB6/17-18/03 BMI InterviewsItem 28 · .PDF · 420 KB4/16/03 BMI InterviewsItem 29 · .PDF · 236 KBPilot Statements Mesaba/Blue RidgeItem 30 · .PDF · 184 KBATC Statements - ATC TranscriptsItem 31 · .PDF · 224 KBBMI ATC Transcript Between Tower and Mesaba 3294Item 32 · .PDF · 76 KBACM Violations 201(b) 139.5Item 33 · .PDF · 5.8 MBFAA Incident ReportsItem 34 · .PDF · 140 KBCIRA 5/13/03 LetterItem 35 · .PDF · 104 KB3/4 Telephone Conversation - LaPierItem 36 · .PDF · 23 KBNOAA Weather ReportsItem 37 · .PDF · 127 KBFss NOTAMS bmi - 2/14/03Item 38 · .PDF · 61 KBBMI Fire Department ReportsItem 39 · .PDF · 335 KBDigital Pictures Taken By CIRA 2/14/03Item 40 · .PDF · 982 KBATIS Information for BMIItem 41 · .PDF · 62 KBBMI Airport InformationItem 42 · .PDF · 140 KBACA's Airport Analysis and Landing Field Length RequirementsItem 43 · .PDF · 430 KBExcerpts From ACA's Flight Standards Manual and Flight Operations ManualItem 44 · .PDF · 512 KBLanding Limitation: Destination AirportsItem 45 · .PDF · 72 KBACA Information for ACA Flight 7675 on 2-14-03Item 46 · .PDF · 321 KBACA Dispatch Release and Weather BriefingItem 47 · .PDF · 453 KBCanadair Regional Jet "Wind Component Conversion Chart" and Pilot's Solutions for Tailwind ComponentItem 48 · .PDF · 406 KBJeppeson Approach Charts for BMIItem 49 · .PDF · 242 KBCanadair Regional Jet Procedures for Operations on Contaminated RunwaysItem 50 · .PDF · 561 KBBombardier Materials Laboratory Report 2003 Lab 03947Item 51 · .PDF · 1.0 MBCIRA Information Supplied to FAAItem 52 · .PDF · 1.3 MBCorrespondence Concerning Inspection of Nose Landing Gear and the Main Landing Gear, and the "Release" of the NLG to OwnerItem 53 · .PDF · 243 KBMessier-Dowty's Correspondence: Destruction of Main Landing GearItem 54 · .PDF · 254 KBALPA SubmissionItem 55 · .PDF · 633 KBStatement of Party Representatives to NTSB InvestigationItem 56 · .PDF · 318 KBPhoto 1.Item 57 · .PDF · 36 KBPhoto 2.Item 58 · .PDF · 36 KBPhoto 3.Item 59 · .PDF · 67 KBPhoto 4.Item 60 · .PDF · 44 KB
All 64 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.