NYC01IA068

NTSB incident investigation · Airbus Industrie A320-232 · Jamaica, NY · January 21, 2001

Incident · No injuriesIncident investigationFinal report
Date
January 21, 2001, 08:08 local (13:08 UTC)
Place
Jamaica, NY
Injuries
145 uninjured
Damage
No damage
Phase of flight
Landing
Aircraft
N509JBAirbus Industrie A320-232
Weather
Instrument (IMC) · Day
Status
Completed · report October 23, 2002
Report
Approved by Office Director
Parties
FAA FSDO, Airbus, Bureau Enquetes - Accidents, Jet Blue
Case key
51369

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

On this page

Probable cause

The pilot's decision to perform an auto rollout on a snow contaminated runway, which had not been demonstrated, and which resulted in a loss of directional control, when the capability of the autoland system to maintain directional control was exceeded. Factors were the failure of the control tower to ensure that the results of the latest MU reading were available to the pilots, the crosswind, and the snow covered runway.

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
Updating of recorded weather information - not performedAtc personnel(lcl/gnd/clnc)Factor
Aircraft performance,landing capability - exceededCause
Planned approach - performedPilot in commandCause
Weather condition - crosswindFactor
Terrain condition - snow coveredFactor

Analysis

The flight crew planned and briefed for an autoland to runway 4R, with winds from 340 degrees at 17 knots, and gusts to 23 knots. The runway had been plowed, and was covered with thin wet snow. On final approach to runway 4R, the control tower gave the pilots winds from 340 degrees at 15 knots, and braking action poor. About 1 second after nose wheel touchdown, the airplane deviated left and the auto-pilot system corrected back. About 11 seconds after touchdown, the airplane deviated left again, did not correct back, and the pilot disconnected the autopilot to regain directional control. He was unable to restore runway heading, and kept the airplane straight as it departed the runway on the left side. The MU readings given to the flight crew, and on the ATIS, of .28, .28, and .26 were 5 hours old. A more recent MU reading of .21, .23, and .24, was 3 hours old, and had not been placed on the ATIS. The control tower did not have a tracking procedure in place for adding revised MU readings to the ATIS, nor was it required. However, airport operations personnel reported they had transmitted the revised readings to the control tower. The airplane FCOM stated, "...automatic roll out performance has been approved on dry and wet runway, but performance has not been demonstrated on snow covered or icy runway." Heavy snow had been falling earlier. Light snow was reported at the 0506 and all subsequent weather observations. The runway was last plowed and treated 3 hours earlier. An FAA inspector reported the runway condition was loose snow over patches of hard packed snow and ice.

Factual narrative

History Of Flight

On January 21, 2001, at 0808 eastern standard time, an Airbus A320-232, N509JB, operated by JetBlue Airways, Inc., as flight 88, departed the left side of Runway 4R during landing roll, at John F. Kennedy Airport (JFK), Jamaica, New York. There was no damage to the airplane, and there were no injuries to the 2 certificated pilots, 4 flight attendants, or 139 passengers. Instrument meteorological conditions prevailed for the scheduled passenger flight, which originated from Ontario, California. The flight was operated on an instrument flight rules flight plan conducted under 14 CFR Part 121.

There were no problems reported with the en route or approach phases of the flight. At the time of the incident, runways 13L/31R, and 13R/31L were being plowed to remove snow and were not available for use.

At 0625, the winds at JFK were reported to be from 340 degrees at 17 knots with gusts to 23 knots. The winds did not change until the 0751 observation.

A transcript of the cockpit voice recorder was prepared by the Vehicle Recorder Division of the Safety Board in Washington, DC.

According to a summary of events prior to the transcript:

At 0647:29,the flight crew discussed using autoland.

At 0658:24 the flight crew conducted an approach briefing for runway 31R, missed approach with autopilot, minimum sector altitudes, fuel state, divert/holding options, autobrake setting medium, autoland winds and wind limitations for autopilot.

At 0724:17 the flight crew re-briefed for an approach for runway 4R.

At 0733:50, the flight crew received JFK airport Automatic Terminal Information Service (ATIS) information Yankee.

According to ATIS Yankee, issued at 0651:

"...wind three four zero at one seven, gust two three, visibility two, light snow, blowing snow, mist, ceiling one thousand five hundred broken...approach in use ILS runway four right, departing runway four left, notice to airmen runway four left, two two right, three inches loose snow, runway four right, two two left, plowed one hundred twenty feet wide, thin wet snow, the remainder six inches loose snow, runway four right mu, two eight, two eight, two six, at zero seven four five zulu [0245 est]...."

At 0739:06, the company dispatcher reported:

"okay eighty eight ah they're still landing on four right here at JFK ah and they're gonna stay on that ah at least until about fifteen Z is what their latest estimate so that's gonna be your runway and ah braking action's have been varying with the different types of aircraft I would say generally fair to poor on the braking action and ah the first two thirds of the runway in fairly decent shape as far as ah snow cover and ah the taxiways are going to be the bigger concern ah there's ice under the snow and ah looking at them or find them is a not the easiest thing today so extreme caution in taxiing."

The flight crew then entered into a discussion of runway conditions including the possibility of snow over ice, and braking action reports of fair to poor and medium to poor. However, there was no discussion about conducting an auto-rollout on a snow contaminated runway.

At 0752:22, New York approach reported to the flight crew of flight 88, that braking action for runway 4R, poor, runway 4L, fair to poor.

At 0753:27, the flight crew asked if runway 4L had been plowed. Approach control said they would check on it; however, the question was not answered by approach control, and the flight crew did not ask it again.

At 0801:45, flight 88 was cleared for the ILS runway 4R approach.

At 0803:18, approach control advised the flight crew that company traffic had landed on runway 4L and reported the braking action as poor.

At 0804:01, the flight crew contacted the control tower, and the local controller replied, "JetBlue eighty eight, Kennedy tower, good morning, you are number two following a Learjet on short final, the wind three four zero at one five, braking action reported as poor by all types, continue for runway four right."

At 0805:29, the local controller re-issued the winds as from 340 degrees at 15 knots, and then issued the landing clearance.

At 0805:37, the first officer called the landing checklist complete

At 0805:59, the local controller reported that the preceding Learjet reported the braking action as fair to poor.

At 0806:37, the first officer called the runway in sight, followed by the captain making the same call.

At 0807:19, according to the transcript from the CVR, the cockpit area microphone recorded increased background noise similar to touchdown of the main landing gear.

At 0807:51, the first officer transmitted, "and JetBlue eighty eight, we're off the runway."

The passengers were deplaned, and taken to the terminal by ground transportation.

According to a written statement from the captain:

"Stabilized approach to Runway ILS 4R. Aircraft touched down on runway centerline. Medium brakes used for landing. After touchdown, brakes automatically deployed with fair braking action. Autopilots engaged, dual auto land, normal approach and landing. After touchdown slight drift to left of centerline with normal return by autopilots back to centerline. After approximately 1/3 of runway used, aircraft started left drift again with no sign of recovery. Disconnected autopilot and tried to recover manually back to centerline without success. Tried to keep aircraft straight without side skid condition so as not to induce a great side load on landing gears. Came to rest 15 feet off left edge of runway, about 2/3 of the way down the runway."

Runway Friction Readings

According to the Aeronautical Information Manual, Section 4-3-9; Runway Friction Reports And Advisories:

"...MU (friction) values range from 0 to 100 where zero is the lowest friction value and 100 is the maximum friction value obtainable. For frozen contaminants on runway surfaces, a MU value of 40 or less is the level where the aircraft braking performance starts to deteriorate and directional control begins to be less responsive. The lower the MU value, the less effective braking performance becomes and the more difficult directional control becomes...."

"...When the MU value for any one-third zone of an active is 40 or less, a report should be given to ATC by airport management for dissemination to pilots. The report will identify the runway, the time of measurement, MU values for each zone, and the contaminant conditions, e.g., wet snow, dry snow, slush, deicing chemicals, etc. Measurements for each one-third zone will be given in the direction of takeoff and landing on the runway...."

According to Advisory Circular AC-150/5200-30A - AIRPORT WINTER SAFETY AND OPERATIONS, Section 13, Runway Friction Surveys; after the runway has been cleared:

"...Realistically, a small amount of dry snow, or wet snow/slush will often remain on the surface. It is generally accepted that friction surveys will be reliable as long as the depth of dry snow does not exceed 1 inch (2.5 cm), and/or the depth of wet snow/slush does not exceed 1/8 inch (3 mm)."

Further, the advisory circular reports that runway friction measurements are unreliable when there is more than 0.04 inch (1 mm) of water or more than 1 inch of wet snow and/or slush.

While the advisory circular did not specify a minimum time between runway friction checks, it did list several criteria for taking additional runway friction checks. One of these was whenever pilot reports of runway braking action have changed.

Airport Information

According to archived weather reports of JFK airport from the National Climatic Data Center, precipitation of varying types and intensity had preceded the snow that was first reported at 0020 on January 21. Snow of varying intensity, including periods of heavy snow was recorded. At 0447, the snow accumulation had reached 4.7 inches. The 0751 weather observation recorded

Aircraft

Registration
N509JB
Reported as
Airbus Industrie A320-232
Category
Airplane
Serial number
1270
Airframe hours
1,801.9
Engine
International Aero Engines V2527-A5, 27,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
JetBlue Airways, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 16, 2001 · 42 hours before
Departed
ONT · Ontario, CA
Destination
JFK · Jamaica, NY
Flight plan
IFR
Airport
JFK · John F. Kennedy, runway 4R, 11,351 × 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
Pilot
Age
51
Injuries
None
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
October 11, 2000
Seat
Left
Flight hours
11,500 total · 665 in this make and model · 7,500 as pilot in command
Role
Co-pilot
Age
41
Injuries
None
Certificates
Commercial, Airline transport, Private, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
November 2, 2000
Seat
Right
Flight hours
11,497 total · 180 in this make and model · 180 in the last 90 days · 44 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
320° at 16 knots
Visibility
2 statute miles
Lowest ceiling
3,300 ft broken
Temperature
23 °F, dew point 19 °F
Altimeter
29.90 inHg
Observed at
JFK, 1 nm away