DCA04MA045

NTSB accident investigation · ATR 72 · San Juan, PR · May 9, 2004

Accident · Serious injuriesClass 1 · MajorFinal report
Date
May 9, 2004, 00:01 local (04:01 UTC)
Place
San Juan, PR
Injuries
1 serious, 19 minor, 6 uninjured
Damage
Destroyed
Phase of flight
Landing
Aircraft
N438ATATR 72
Weather
Visual (VMC) · Day
Status
Completed · report December 8, 2005
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
Case key
59179

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

On this page

Probable cause

the captain's failure to execute proper techniques to recover from the bounced landings and his subsequent failure to execute a go-around.

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.

Hard landingLanding
Flare - improper
Recovery from bounced landing - attemptedPilot in commandCause
Go-around - not performedPilot in commandCause
Main gear collapsedLanding
Landing gear,main gear - overload
Landing gear,main gear - failure

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-05/02.

On May 9, 2004, about 1450 Atlantic standard time, Executive Airlines (doing business as American Eagle) flight 5401, an Avions de Transport Regional 72-212, N438AT, skipped once, bounced hard twice, and then crashed at Luis Muñoz Marin International Airport, San Juan, Puerto Rico. The airplane came to a complete stop on a grassy area about 217 feet left of the runway 8 centerline and about 4,317 feet beyond the runway threshold. The captain was seriously injured; the first officer, 2 flight attendants, and 16 of the 22 passengers received minor injuries; and the remaining 6 passengers received no injuries. The airplane was substantially damaged. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger flight. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-05/02.

On May 9, 2004, about 1450 Atlantic standard time, Executive Airlines (doing business as American Eagle) flight 5401, an Avions de Transport Regional 72-212, N438AT, skipped once, bounced hard twice, and then crashed at Luis Muñoz Marin International Airport (SJU), San Juan, Puerto Rico. The airplane came to a complete stop on a grassy area about 217 feet left of the runway 8 centerline and about 4,317 feet beyond the runway threshold. The captain was seriously injured; the first officer, 2 flight attendants, and 16 of the 22 passengers received minor injuries; and the remaining 6 passengers received no injuries. The airplane was substantially damaged. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger flight. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

Flight 5401 departed Eugenio Mariá de Hostos Airport, Mayagüez, Puerto Rico, for SJU about 1415. The captain was the nonflying pilot for the flight, and the first officer was the flying pilot. The flight crew stated that the takeoff, climb, and en route portions of the flight were uneventful.

At 1437:05, as the flight approached the SJU traffic area, the cockpit voice recorder (CVR) recorded the first officer confirming with the captain that automatic terminal information service Juliet, which reported that winds were 060° magnetic at 17 knots and gusting at 23 knots, was current. Shortly thereafter, the captain briefed a Vref (the minimum approach airspeed in the landing configuration before the airplane reaches the runway threshold) of 95 knots and told the first officer to "stand by for winds." The first officer asked the captain if he should set his airspeed bug to 95 knots, and the captain replied, "yeah."

At 1443:03, a controller from the SJU Terminal Radar Approach Control cautioned the pilots of possible wake turbulence from a preceding Boeing 727. The captain then told the first officer to "get your speed back. You do not want to take wake turbulence from a seven five." At 1443:44, the approach controller told the flight crew to reduce the airspeed to 160 knots. After this instruction, the captain again told the first officer to slow down because of the preceding airplane. The first officer replied, "[approach control] said one sixty though I thought." The captain stated, "yeah, slow it down even more though…just go about one forty."

At 1446:17, the captain stated, "San Juan tower Eagle four zero one ILS [instrument landing system] runway one zero, with eight in sight." The SJU air traffic control tower local controller stated, "one departure prior to your arrival…seven twenty seven, mile final just reported loss of ten knots." At 1446:33, the local controller cleared the airplane to land on runway 8. The captain acknowledged the clearance. At this time, the first officer turned the airplane left toward runway 8 and transitioned to the visual approach slope indicator, which is located near the approach end of the runway for glideslope guidance.

At 1449:07, during the approach to landing, the captain stated, "you better keep that nose down or get some power up because you're gonna balloon." The captain then told the first officer to "bring the power back." About 2 seconds later, the ground proximity warning system (GPWS) alerted "minimums," and the captain instructed the first officer to get the airplane's nose up. Four seconds later, the GPWS alerted "glideslope," and the captain stated, "below the glideslope." The first officer responded, "correcting."

At 1449:28, the captain told the first officer to "power in a little bit." Flight data recorder (FDR) data indicated that the airplane was about 45 feet above ground level and traveling at 110 knots indicated airspeed when it crossed the runway 8 threshold 2 seconds later. After the airplane crossed the runway threshold, the captain stated, "power in a little bit, don't pull the nose up, don't pull the nose up." At 1449:39, the captain stated, "you're ballooning," and the first officer replied, "all right."

CVR and FDR information indicated that the airplane touched down for the first time about 1449:41 and about 1,600 feet beyond the runway 8 threshold. At this time, the FDR recorded vertical and lateral loads of about 1.3 Gs and -0.10 G, respectively. At 1449:41, the captain stated, "get the power," and, 1 second later, "my aircraft." The first officer responded, "your airplane." FDR data indicated that, by 1449:43, the airplane had skipped to an altitude of about 4 feet.

CVR and FDR information indicated that the airplane touched down a second time about 1449:45 and about 2,200 feet beyond the runway 8 threshold. FDR data indicated that the airplane then pitched up to an angle of 9° while climbing to an altitude of 37 feet and that the engine torque increased from 10 to 43 percent. About 1449:49, the pitch angle decreased to -3°, and the engine torque started to decrease to 20 percent. The pitch angle continued to decrease to -10°.

CVR and FDR information indicated that the airplane touched down a third time about 1449:51 at a bank angle of 7° left wing down and about 3,300 feet beyond the runway 8 threshold. Concurrently, the FDR recorded vertical and lateral loads of about 5 Gs and 0.85 G, respectively. By 1449:54, the pitch angle was 11°, and the airplane had bounced to an altitude of about 24 feet.

CVR and FDR information indicated that the airplane touched down a fourth time about 1449:56 (about 15 seconds after the initial touchdown) and about 4,000 feet beyond the runway 8 threshold. FDR data indicated that the airplane pitched down to -7° and that it was banked 29° left wing down. The airplane came to a complete stop about 4,317 feet from the runway threshold.

Aircraft

Registration
N438AT
Reported as
ATR 72
Category
Airplane
Serial number
438
Airframe hours
19,273.59
Engines
Pratt & Whitney Canada PW-127TM, 2,750 horsepower, turbo propPratt & Whitney Canada PW-127TM, 2,750 horsepower, turbo prop
Damage
Destroyed
Flight
Part 121
Operator
Executive Airlines, doing business as American Eagle
Registered owner
AMR Leasing
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · May 8, 2004 · 19,273.59 hours before
Departed
MAZ · Mayaguez, PR
Destination
San Juan, PR
Flight plan
IFR
Airport
SUJ · Luis Munoz Minor, runway 8, 10,002 × 210 ft, asphalt

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

As NTSB recorded them. NTSB leaves out names.

Role
Co-pilot
Age
26
Injuries
Minor
Certificate
Commercial
Airplane ratings
Multi-engine land
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
2,000 total · 20 in this make and model · 20 in the last 90 days · 20 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 15 knots, gusting 22
Visibility
10 statute miles
Lowest ceiling
3,400 ft broken
Temperature
82 °F, dew point 75 °F
Altimeter
30.00 inHg

Other investigations on N438AT · 1

Matched to the same aircraft by N-number and date.