IAD97FA052

NTSB accident investigation · McDonnell Douglas DC-9-82 · Cleveland, OH · March 6, 1997

Accident · Minor injuriesField investigationFinal report
Date
March 5, 1997, 21:07 local (Mar 6, 1997, 01:07 UTC)
Place
Cleveland, OH
Injuries
3 minor, 106 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N275AAMcDonnell Douglas DC-9-82
Weather
Instrument (IMC) · Night/dark
Status
Completed · report February 28, 2000
Report
Approved by Office Director
FAA report
19970305013089A
Case key
28129

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 pilot in command did not maintain control while utilizing the full auto-land system. Factors to this accident were a contaminated runway, a crosswind, and inadequate guidance provided in the aircraft manual.

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.

Loss of control - on ground/waterLanding - roll
Terrain condition - slush coveredFactor
Terrain condition - snow coveredFactor
Weather condition - crosswindFactor
Autopilot - continuedPilot in commandCause
Directional control - not maintainedPilot in commandCause
Aircraft manuals - inadequateFactor

Analysis

The DC-9 was number 2 for the ILS approach behind a commuter airplane, and was placed in holding while chemicals were applied to the runway due to snow and slush. The DC-9 captain requested a braking action report, which the tower controller relayed to the commuter airplane that had not yet landed. A braking action report was not received prior to the DC-9 landing. The captain elected to continue the approach with full auto-land selected to a contaminated runway, without a braking action report and a crosswind component of 13 knots. On the runway, the auto-pilot responded and attempted to return the airplane to the centerline of the runway. After 18 seconds and with the airplane's nose drifting left, the captain disengaged the auto-pilot, and applied full right rudder and brake to stop the left drift. The DC-9 departed the left side of the paved runway approximately 5,500 feet down the 8,998 foot runway, and facing 80 degrees left of the runway heading. A review of the manual revealed that the operator's flight manual contain no guidance or limitations for pilots regarding the use of full auto land and roll-out on contaminated runways

Factual narrative

History of flight

On March 5, 1997, about 2107 eastern standard time, a McDonnell Douglas DC-9-82, N275AA, operated as American Airlines flight 320, was substantially damaged as it slid off the left side of runway 5R during landing rollout at Cleveland Hopkins International Airport (CLE), Cleveland, Ohio. The certificated airline transport pilot, first officer, and four flight attendants were uninjured. Three of the 103 passengers reported minor injuries. The scheduled domestic passenger flight, was conducted under 14 CFR Part 121. Night instrument meteorological conditions existed and a instrument flight rules flight plan was filed for the flight which originated from the Dallas/Fort Worth International Airport, Dallas/Fort Worth, Texas, at 1824.

A review of the Federal Aviation Administration radar data and the Cockpit Voice Recorder (CVR) revealed that flight 320 was vectored to and cleared for the ILS 5R approach, at 2100. Less than 2 minutes later, flight 320 was instructed to switch to the tower frequency and told that "there's commuter traffic four miles ahead. He's going to give a braking action report." The local controller cleared flight 320 to land and stated "wind three five zero at one six", at 2102:33. The pilot responded with a request for a braking action report, and the controller was heard answering, "I don't know sir. It (the runway) just opened up. We had chemicals applied to the runway. You'll be number two to the runway. As soon as I get something, I'll let you know."

On the CVR, the controller was heard requesting a braking action report from the commuter, at 2103:53. After the commuter landed, the tower controller again requested a braking action report, but was unsuccessful. At 2105:29, the commuter switched to the ground frequency and attempted to give a braking action report, but was unable due to frequency congestion.

The Flight Data Recorder (FDR) from flight 320 captured the touch down, at 2106:46. The airplane traveled 5,500 feet down the 8,998 foot runway, exiting the left side after taxiway "Romeo". The airplane stopped facing about 80 degrees left of the runway heading.

The accident occurred during the hours of darkness at about 041 degrees 24.5 minutes North latitude, and 81 degrees 51 minutes West longitude.

Flight crew information

Captain

The Captain held an Airline Transport Pilot Certificate for airplane single and multiengine land, and was type rated in the DC-9 in November, 1995, with additional type ratings for the Embraer 120 and the Boeing 727. He had accumulated nearly 900 hours of Pilot-in-Command time in the DC-9, with over 2,525 hours Second-in-Command time. He possessed both Flight Instructor and Flight Engineer (Turbojet) Certificates. His most recent Federal Aviation Administration (FAA) First Class Medical Certificate was issued on January 22, 1997, with no limitations or waivers.

The Captain was hired in October 1984, and flew as a Flight Engineer on the Boeing 727. This was the second day of the Captain's trip, and the second leg for the day. His reported total flying experience was 14,500 hours.

First officer

The First Officer held an Airline Transport Pilot Certificate for airplane single and multiengine land, and was type rated in the L300. He had accumulated 2,700 hours Second-in-Command time in the DC-9. He possessed a Flight Engineer (Turbojet) Certificate for Boeing 727. His most recent FAA First Class Medical Certificate was issued on October 21, 1996, with no limitations or waivers.

The First Officer was hired in January, 1990, and flew as a Flight Engineer on the Boeing 727. This too, was his second day of his trip, and the second leg for the day. His reported total flying experience was 5,200 hours.

Approach

The CVR/DFDR and the captain's statement indicated that he flew a coupled approach with auto-land and rollout programmed. The Manufacturer's Flight crew Operating Manual (FCOM) and the Aircrew Operations Manual (AOM) both state that the use of auto-land had a crosswind component limitation of 15 knots, that may be reduced by the prevailing visibility.

Aircraft information

The airplane was equipped with two Pratt & Whitney JT8D engines. Each engine had 20,000 pounds of thrust, with reverse available. The left engine had accumulated 1,044 hours since last inspection, and the right had accumulated 7,839 hours.

A review of the airplane's maintenance records did not reveal any repetitive discrepancies related to the engines, brakes or flight controls.

Meteorological information

Weather at Cleveland, Detroit (Alternate #1), and Indianapolis (Alternate #2)was:

KCLE (Cleveland Hopkins International Airport) at 060154Z: Winds 350013KT; Visibility 1/2 SM; Snow Fog; Ceiling 100 FEET OVERCAST; TEMPERATURE 33 DEGREES FAHRENHEIT; DEWPOINT 32 DEGREES FAHRENHEIT; ALTIMETER 29.77 Inches HG.

SPECI KDTW (Detroit Metro Airport) at 060134Z: Winds 31006KT; Visibility 1 3/4 SM; LIGHT SNOW; MIST; Ceiling 600 OVERCAST; TEMPERATURE 32 DEGREES FAHRENHEIT; DEWPOINT 30 DEGREES FAHRENHEIT; ALTIMETER 29.85 Inches HG.

SPECI KIND (Indianapolis International Airport) at 060112Z: Winds 31015KT; Visibility 6SM; MIST; Ceiling 1,600 OVERCAST; TEMPERATURE 32 DEGREES FAHRENHEIT; DEWPOINT 30 DEGREES FAHRENHEIT; ALTIMETER 30.04 Inches HG.

American Airlines Dispatch sent a message to flight 320 at 2058. It stated, "Cleveland implemented an internal ground stop for aircraft landing Cleveland until 2115. The airport management has closed runway 5L for treatment. Runway 5R will close after that, also for treatment. Users can expect up to 30 minutes of airborne holding."

Aerodrome information

The CLE elevation was 792 feet msl, and was located about 9 miles southwest of Cleveland. It was owned and operated by the City of Cleveland, and was certificated in accordance with the applicable provisions of Title 14 CFR Part 139. It had a Federal Aviation Administration (FAA) approved snow and ice control plan in accordance with 14 CFR Part 139.313. CLE was the winner of the Balchen/Post award for snow and ice control in the large commercial airport category for the winter of 1995-1996.

Runway Conditions

CLE runway 5R was concrete, 8,999 feet long, 150 feet wide, and transverse grooved full length. Runway 5R was configured and approved for category II instrument landings, and was equipped with high intensity runway edge lights, and centerline lights. It was equipped with pavement surface condition sensors, which detected and reported pavement surface conditions, and were used to plan and initiate snow removal operations. Prior to and following the accident, all sensors recorded surface conditions as wet, with surface temperatures varying between 32 and 34 degrees Fahrenheit.

The CLE operations department logbooks and written statements taken from airport operations and maintenance personnel, reported that the runway was covered with less than 1/8 inch of slush, at 2033, and snow plows were not considered because the amount of snow was insufficient to plow. Radar data showed that Flight 320 was put in holding at the outer marker at 2041. The CLE operations department logbooks showed entries for CLE maintenance personnel applying sodium formate to runway 5R/23L, at 2046, and finished, at 2055. CLE operations personnel issued a Notice to Airmen (NOTAM), at 2059, which stated: "Runway 5R/23L has a thin cover of wet snow. Chemical applied 30 feet either side of centerline. (Tapley braking action for runway) 5R: 35-30-24."

Sodium Formate was applied to combat the snow and ice which began to accumulate on the runway. The application procedure utilized for applying the chemical was two trucks, one on each side of the runway centerline and about 10 feet from the center. Each truck traveled about 20 to 30 mph, applying potassium acetate through a pre-wetting system to the sodium formate. It was dispensed at a

Aircraft

Registration
N275AA
Reported as
McDonnell Douglas DC-9-82
Category
Airplane
Serial number
49272
Airframe hours
37,922
Engine
P&W JT8D, 20,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
American Airlines, Inc.
Registered owner
Marmid Aircraft Leasing Corp
Airworthiness certificate
Standard, Transport
Departed
DFW · Dal/Fort Worth, TX
Destination
CLE
Flight plan
IFR
Airport
CLE · Cleveland Hopkins Intl, runway 5R, 8,998 × 150 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Certificates
Flight engineer, Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
14,500 total · 4,500 in this make and model · 13,000 as pilot in command

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
350° at 13 knots
Visibility
0.5 statute miles
Lowest ceiling
100 ft overcast
Temperature
34 °F
Altimeter
29.00 inHg
Observed at
CLE

Docket · 13

The files NTSB released with the investigation on March 2, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.9 MB in all.

FAA reports on this event · 1

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