DCA07FA037

NTSB accident investigation · Bombardier CL-600-2B19 · Traverse City, MI · April 12, 2007

Accident · No injuriesClass 1 · FieldFinal report
Date
April 12, 2007, 00:43 local (04:43 UTC)
Place
Traverse City, MI
Injuries
52 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N8905FBombardier CL-600-2B19
Weather
Instrument (IMC) · Night
Status
Completed · report November 12, 2008
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
AAI-100
Safety recommendations
Yes
FAA report
20070412006299A
Case key
65564

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

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Probable cause

The pilots' decision to land at Cherry Capital Airport (TVC), Traverse City, Michigan, without performing a landing distance assessment, which was required by company policy because of runway contamination initially reported by TVC ground operations personnel and continuing reports of deteriorating weather and runway conditions during the approach. This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions. Contributing to the accident were 1) the Federal Aviation Administration pilot flight and duty time regulations that permitted the pilots' long, demanding duty day and 2) the TVC operations supervisor's use of ambiguous and unspecific radio phraseology in providing runway braking information.

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-08-02.

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.

OverrunLanding
FatigueFlightcrewFactor
Weather condition - snowFactor
In-flight planning/decision - improperPilot in commandCause

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-08-02.

On April 12, 2007, about 0043 eastern daylight time, a Bombardier/Canadair Regional Jet (CRJ) CL600-2B19, N8905F, operated as Pinnacle Airlines flight 4712, ran off the departure end of runway 28 after landing at Cherry Capital Airport (TVC), Traverse City, Michigan. There were no injuries among the 49 passengers (including 3 lap-held infants) and 3 crewmembers, and the aircraft was substantially damaged. Weather was reported as snowing. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and had departed from Minneapolis-St. Paul International (Wold-Chamberlain) Airport (MSP), Minneapolis, Minnesota, about 2153 central daylight time (CDT). Instrument meteorological conditions prevailed at the time of the accident flight, which operated on an instrument flight rules (IFR) flight plan.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-08-02.

On April 12, 2007, about 0043 eastern daylight time, a Bombardier/Canadair Regional Jet (CRJ) CL600-2B19, N8905F, operated as Pinnacle Airlines flight 4712, ran off the departure end of runway 28 after landing at Cherry Capital Airport (TVC), Traverse City, Michigan. There were no injuries among the 49 passengers (including 3 lap-held infants) and 3 crewmembers, and the aircraft was substantially damaged. Weather was reported as snowing. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and had departed from Minneapolis-St. Paul International (Wold-Chamberlain) Airport (MSP), Minneapolis, Minnesota, about 2153 central daylight time (CDT). Instrument meteorological conditions prevailed at the time of the accident flight, which operated on an instrument flight rules (IFR) flight plan.

The accident occurred on the fifth and final scheduled flight segment on the first day of a scheduled 4-day trip for the flight crew. The flight was scheduled to depart MSP about 2030 CDT for a scheduled arrival time at TVC of 2251. However, when the pilots arrived at the gate for the accident flight, the gate agent advised them that the flight release paperwork was not available and that the flight might be cancelled. About 2022 CDT (about 8 minutes before the accident flight was originally scheduled to depart), the Pinnacle dispatcher provided the captain with details, indicating that the flight could not be dispatched to TVC because the forecast winds at TVC resulted in a tailwind component that exceeded the CRJ's 10-knot landing tailwind component limitation. However, about 22 minutes later, the dispatcher advised the captain that the flight could be dispatched because a new forecast predicted a smaller tailwind component for the landing at TVC. Postaccident interviews indicate that Pinnacle's system operations control (SOC) duty manager had reviewed the observed conditions and forecast for TVC (from Northwest Airline's [NWA] meteorology department) and approved the release.

The flight's dispatch documentation, which listed Detroit Metropolitan Wayne County Airport (DTW) as a destination alternate airport, was subsequently issued about 2043 CDT. However, because the flight was delayed, an update of the airplane's flight management system database software was required before the airplane could depart. After installation of this software, the airplane was pushed back from the gate at MSP about 2144 CDT. The pilots taxied the airplane to the runway 30R deice pad, where it was deiced and the departure clearance was issued. About 2153 CDT, an MSP air traffic control tower (ATCT) controller issued a takeoff clearance, and the accident flight departed for TVC.

Postaccident crew interviews and review of the cockpit voice recorder (CVR) transcript indicated that the departure, climb, and en route portion of the flight from MSP to TVC was routine. The captain/check airman was the flying pilot and was overseeing the first officer's initial operating experience (OE); the first officer performed the duties of the monitoring pilot. The CVR recorded several instances during the accident flight in which the pilots indicated that they were tired. For example, the CVR recorded the following statements on the captain's channel: 1) about 2332:12, "yeah, just tired. Too late for this...;" 2) about 2341:53, "aw I'm tired dude, just (expletive) worn out;" and 3) about 0018:43 "...a wet dog ready to go to sleep tonight dude." Additionally, about 0020:41, the CVR recorded the first officer stating, "jeez, I'm tired." Further, several yawns were recorded on the captain's channel (about 2340:00, 0001:06, 0004:00, and 0009:47).

Because the TVC ATCT had closed at 2200 the night of the accident (consistent with its normal operations), the captain briefed the first officer regarding landing at TVC at night, after the tower closed, in snowy windy weather conditions. Records indicate that the Pinnacle dispatch personnel who were providing flight-following services for the accident flight occasionally provided the pilots with updated TVC weather information during earlier portions of the flight. Specifically, the aircraft communications addressing and reporting system (ACARS) log showed that about 2354, dispatch personnel sent weather updates to the accident airplane indicating IFR conditions with restricted visibility in light snow. After reviewing the weather information (about 2357), the captain made a public address statement advising the passengers that the winds at TVC were "dying down significantly...so it looks like we're gonna have no problems gettin' in this evening."

About 0010, the pilots listened to the TVC automated surface observation system (ASOS) for updated airport weather information, which indicated, in part, that winds were out of 040º at 7 knots and visibility of 1 1/2 miles in light snow. About 0021, the MSP Air Route Traffic Control Center (ARTCC) controller confirmed that the accident pilots had received the current TVC weather and began to issue radar vectors for the instrument landing system (ILS) approach to runway 28 at TVC. About 0025, the captain sent a message to dispatch indicating that the TVC weather looked good for the approach, citing winds out of 040 degrees at 8 knots. Company dispatch personnel responded, stating, "[w]e show that too, looks like we should be good."

The weather data subsequently recorded by the TVC's ASOS showed that the conditions at TVC began to deteriorate rapidly after 0025, with visibility of 1/2 mile in moderate snow, sky obscured, and vertical visibility of 400 feet. The pilots did not listen to the ASOS again as they continued to follow ATC-provided radar vectors for the ILS approach to TVC; however, they did obtain information regarding runway conditions from TVC airport operations personnel. For example, beginning about 0025, the CVR recorded a radio conversation between the captain and the TVC airport operations supervisor regarding the runway condition and ongoing snow removal operations. The airport operations supervisor indicated that he had "multiple pieces of [snow removal] equipment" on runway 28 and that he was "running numbers for you as we speak." The captain indicated that they would be landing in about 13 minutes.

According to the CVR, about 0026:56, the airport operations supervisor radioed the pilots, advising that the braking action on runway 28 was "40 plus," with "thin wet snow [over] patchy thin ice...give us about [5 to 8] minutes to clear the runway...when you're ready to land." About 0029:10, the CVR recorded the captain stating, "there's snow removal on the field yet they're showing forty or better sounds like a contaminated...runway to me." During the next 4+ minutes, the CVR recorded additional conversation between the pilots, TVC operations, and MSP ARTCC personnel regarding the status of the snow removal equipment on the runway and the timing of the approach. About 0032:16 (about 6 minutes before the captain's estimated arrival time), the airport operations supervisor contacted the pilots to indicate that the last snow plow was off the runway. The captain responded, advising that the accident flight would be turning inbound and requesting additional airport traffic advisories if applicable.

About 0033, the captain advised the MSP ARTCC controller that the TVC runway was clear of snow removal equipment; the controller advised him that it would "be about another...2 minutes 'til I get you out far enough to turn you back onto the ILS." The pilots then discussed the length of the landing runway, and, about 0033:46, the captain stated, "...and at night it'll feel short too...with contaminant...more than likely." About 0034, the airport operations supervisor contacted the accident pilo

Aircraft

Registration
N8905F
Reported as
Bombardier CL-600-2B19
Category
Airplane
Serial number
7905
Airframe hours
8,219
Engines
General Electric CF34B, 9,100 lbs thrust, turbo fanGeneral Electric CF34B, 9,100 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Pinnacle Air Inc, doing business as Northwest Airlink
Registered owner
Northwest Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 1, 2007
Departed
MSP · Minneapolis, MN
Destination
TVC · Traverse City, MI
Flight plan
IFR
Airport
KTVC · Cherry Capitol Airport, runway 28, 6,501 × 150 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Check pilot
Age
28
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 1, 2007
Seat
Left
Toxicology
Performed
Flight hours
5,600 total · 4,243 in this make and model
Role
Co-pilot
Age
27
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 1, 2007
Seat
Right
Toxicology
Performed
Flight hours
2,590 total · 22 in this make and model · 2,373 as pilot in command

Weather

Conditions
Instrument (IMC) · Night
Wind
40° at 8 knots
Visibility
0.5 statute miles
Lowest ceiling
400 ft indefinitevv
Temperature
32 °F, dew point 30 °F
Altimeter
29.52 inHg
Observed at
TVC

Docket · 61

The files NTSB released with the investigation on September 13, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 28.3 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 3.5 MBAirworthiness Factual Report of Group ChairmanItem 2 · .PDF · 290 KBAirworthiness Factual Report of Group Chairman - Addendum 1, Braking and Antiskid SystemsItem 3 · .PDF · 126 KBOperations 2 - Factual Report of Group ChairmanItem 4 · .PDF · 2.1 MBOperations 2 - Attachment 1 Interview SummariesItem 5 · .PDF · 231 KBOperations 2 - Attachment 2 Flight PapersItem 6 · .PDF · 966 KBOperations 2 - Attachment 3 Operations Specifications C382Item 7 · .PDF · 135 KBOperations 2 - Attachment 4 CRJ Company Flight Manual: LimitationsItem 8 · .PDF · 197 KBOperations 2 - Attachment 5 CRJ Company Flight Manual: Adverse WeatherItem 9 · .PDF · 130 KBOperations 2 - Attachment 6 CRJ Company Flight Manual: PerformanceItem 10 · .PDF · 1.3 MBOperations 2 - Attachment 7 CRJ Company Flight Manual: Maneuvers and ProfilesItem 11 · .PDF · 360 KBOperations 2 - Attachment 8 Flight Operations Manual: General AdministrationItem 12 · .PDF · 174 KBOperations 2 - Attachment 9 Flight Operations Manual: System Operations ControlItem 13 · .PDF · 362 KBOperations 2 - Attachment 10 Flight Operations Manual: Flight OperationsItem 14 · .PDF · 225 KBOperations 2 - Attachment 11 Safety Alert for Operatios (SAFO)Item 15 · .PDF · 962 KBOperations 2 - Addendum 1Item 16 · .PDF · 22 KBOperations 2 - Addendum 2Item 17 · .PDF · 47 KBATC 3 - Factual Report of Group ChairmanItem 18 · .PDF · 166 KBATC 3 - Attachment 1 - ZMP ARTCC Corrected Partial Transcript R5-R16-R4-4DItem 19 · .PDF · 1.2 MBATC 3 - Attachment 2 - TVC Notice to AirmenItem 20 · .PDF · 385 KBATC 3 - Attachment 3 - TVC ASOS weather printoutItem 21 · .PDF · 65 KBATC 3 - Attachment 4 - TVC ATCT 7220.30H Appendix 5 - Openning/Closing/Watch ChecklistItem 22 · .PDF · 117 KBATC 3 - Attachment 5 - ZMP ARTCC 7220.11 Standard Operating Procedures Appendix 1 - Sector 4Item 23 · .PDF · 324 KBATC 3 - Attachment 6 - ZMP ARTCC Facility Accident/Incident Notification RecordItem 24 · .PDF · 64 KBATC 3 - Attachment 7 ZMP ARTCC Controller statementsItem 25 · .PDF · 188 KBATC 3 - Attachment 8 ZMP ARTCC Daily Record of Facility OperationsItem 26 · .PDF · 49 KBATC 3 - Attachment 9 - Memoradum of Agreement between FAA and Northwestern Regional Airport Commission - Reimbursable Agreement AGL-350 for the extended air traffic control servicesItem 27 · .PDF · 200 KBATC 3 - Attachment 10 - TVC Airport Director's letter to TVC air traffic manager to request extended hoursItem 28 · .PDF · 101 KBATC 3 - Attachment 11 - TVC Air Traffic Manager's letter to TVC Airport DirectorItem 29 · .PDF · 64 KBMeteorology 5 Factual - Revision 1Item 30 · .PDF · 1.4 MBMeteorology 5 - Attachment 1 Dispatch release and weather documentItem 31 · .PDF · 127 KBMeteorology 5 - Attachment 2 interviewsItem 32 · .PDF · 71 KBSurvival Factors Factual Report of Group ChairmanItem 33 · .PDF · 293 KBSurvival Factors Factual Report - Attachment 1 - Summary of Company Flight Attendant InterviewItem 34 · .PDF · 424 KBSurvival Factors Factual Report - Attachment 2 - TVC Snow PlanItem 35 · .PDF · 574 KBSurvival Factors Factual Report - Attachment 3 - Letter from FAA Great Lakes Region Airports OfficeItem 36 · .PDF · 221 KBSurvival Factors Factual Report - Attachment 4 - TVC Field Condition Reports/NOTAMSItem 37 · .PDF · 1.5 MBSurvival Factors Factual Report - Attachment 5 - Information Regarding Problems with NOTAM DisseminationItem 38 · .PDF · 405 KBSurvival Factors Factual Report - Attachment 6 - Traverse City Fire Department incident logsItem 39 · .PDF · 1.1 MBFlight Data Recorder 10 - Specialist's Factual ReportItem 40 · .PDF · 356 KBFlight Data Recorder 10 - Errata 1 (Time correlation changed from original report)Item 41 · .PDF · 350 KBFlight Data Recorder 10 - Attachment 1 (tabular data for FDR plots provided in the FDR Factual Report)Item 42 · .CSV · 1.2 MBFlight Data Recorder 10 - Attachment 1 Errata 1(tabular FDR data for FDR plots provided in FDR Errata 1 report; Time correlation changed from original data)Item 43 · .CSV · 1.2 MBFlight Data Recorder 10 - Addendum 1 (Explanation of Anti-Skid Status-OB and Anti-Skid Status-IB FDR parameters)Item 44 · .PDF · 16 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 45 · .PDF · 277 KBCockpit Voice Recorder 12 - Errata 1Item 46 · .PDF · 20 KBAircraft Performance 13 - Study of Group ChairmanItem 47 · .PDF · 1.2 MBAircraft Performance 13 - Addendum 1, Landing Distance CalculationsItem 48 · .PDF · 373 KBAircraft Performance 13 - Attachment 1, Memo from Bombardier on Rudder BlankingItem 49 · .PDF · 554 KBHuman Performance 14 - Factual Report of Group ChairmanItem 50 · .PDF · 30 KBMiscellaneous - Technical Review ErrataItem 51 · .PDF · 72 KBVideo File - Airport Security Camera 2 FilesItem 52 · .PDF · 53 KBReports from Parties to the Investigation - ALPAItem 53 · .PDF · 562 KBReports from Parties to the Investigation - Cherry Capital AirportItem 54 · .PDF · 138 KBReports from Parties to the Investigation - GEItem 55 · .PDF · 98 KBReports from Parties to the Investigation - NWAItem 56 · .PDF · 504 KBReports from Parties to the Investigation - Pinnacle correctedItem 57 · .PDF · 118 KBEmail From Accident CaptainItem 58 · .PDF · 182 KBState of Manufacture Comments to DraftItem 59 · .PDF · 525 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 60 · .PDF · 56 KB
All 61 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.