NYC02LA013

NTSB accident investigation · Embraer 145LR · Roanoke, VA · October 17, 2001

Accident · No injuriesLimited investigationFinal report
Date
October 16, 2001, 22:14 local (Oct 17, 2001, 02:14 UTC)
Place
Roanoke, VA
Injuries
33 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N825MJEmbraer 145LR
Weather
Visual (VMC) · Night/dark
Status
Completed · report June 25, 2003
Report
Approved by Office Director
Parties
Embraer Aircraft Company, Mesa Airlines, Federal Aviation Administration
FAA report
20011016036509A
Case key
53643

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 captain's failure to maintain airspeed which resulted in an inadvertent stall/mush, and hard landing. Factors were the failure of both pilots to follow company CRM and flight manual procedures, and the captains improper approach briefing.

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 - in flightLanding
ContinuedPilot in commandCause
Airspeed - not maintainedPilot in commandCause
Procedure inadequateCompany/operator management
Inadequate surveillance of operationFaa(organization)
Stall/mush
Procedures/directives - not followedFlightcrewFactor
Crew/group briefing - improperPilot in commandFactor
Hard landingLanding - flare/touchdown

Analysis

The captain briefed a "no go-around" for a night visual approach to a "Special Airport." The approach was not stabilized, and the airspeed decreased to the point of a stall. The airplane struck the runway in a nose high pitch attitude, on the aft fuselage, and settled on the landing gear. The first officer made initial callouts of slow airspeed and then stopped when the captain failed to respond to her callouts. After landing, the airplane was taxied to the gate where a post flight inspection limited to the main landing gear did not find the damage. When interviewed, the captain reported that she briefed "no go-around" because no takeoffs were authorized on the runway at night or in IMC conditions; however, the first officer knew this was incorrect, but did not challenge the captain. Both pilots had received CRM training, which included crewmember assertiveness, methods of fostering crew input, and situational awareness, and training on special use airports; however it was not followed by either pilot. The captain's handling of the airplane was outside the parameters specified in the company manuals. Both pilots were described to having good flying skills. The captain said the first officer was passive and quiet. The first officer reported the captain was defensive and did not take criticism very well. A definition of stabilized approach criteria was not found in the company manuals. An FAA Advisory Circular dated August 10, 2000 defined stabilized approach criteria, and actions to be taken if the approach was not stabilized.

Factual narrative

History of flight

On October 16, 2001, at 2214 eastern daylight time, an Embraer 145LR, N825MJ, operated by Mesa Airlines as US Airways Express flight 5733, was substantially damaged while landing at Roanoke Regional/Woodrum Field Airport (ROA), Roanoke, Virginia. The 2 certificated pilots, 1 flight attendant, and 30 passengers were not injured. Night visual meteorological conditions prevailed for the scheduled passenger flight. The flight was conducted on an instrument flight rules (IFR) flight plan under 14 CFR 121.

According to the pilots, the flight originated at Pittsburgh International Airport (PIT), Pittsburgh, Pennsylvania. No problems were reported with the en route or approach phases, and the flight was radar vectored for a visual approach to runway 33.

According to the captain:

"While on short final approach to landing at Roanoke "(...[reported winds] of 280 at 25 [knots] gust to 40 [knots]), there was an abrupt drop in indicated airspeed. Upon simultaneous notification of the stick shaker, I applied power accordingly and landed without apparent incident.

As the landing was more firm than usual, the first officer and I mutually agreed to visually inspect the aircraft upon arrival at the gate. The visual post flight inspection noted nothing unusual, nor any damage to the aircraft.

As the occurrence noted no damage to aircraft, passengers, or crew, no further action was taken."

According to the first officer:

"We arrived into the Roanoke area approximately 9:45 PM, and began a visual approach to runway 33. The captain briefed that a go-around was not an option due to hills on the other side of the runway. Takeoffs were not authorized on 33 during night and IFR operations. Although we had a quartering crosswind at 15 mph gusting to 21 mph, I do not think there was any wind shear. The approach was normal until approximately 300 feet AGL, when I called that we were one dot high on the PAPI and Ref +5. The captain appeared to pull the thrust levers to idle and placed both hands back on the yoke. At 200-300 feet I called Ref -5, Ref -10, then the stick shaker activated for one second and we began to sink rapidly. I saw the airspeed reach 110 KIAS, the captain pushed the thrust levers up, but the engines did not spool up in time, and the stall stick shaker went off [again]. At this point, approximately 100 feet AGL, the aircraft seemed to stall and within seconds hit the end of the runway. The main gear hit the runway very hard, then the nose gear followed quickly. I do not recall the pitch attitude. The events happened very quickly, and by the time I thought about going around it was too late.

Immediately upon deplaning, I inspected the entire aircraft with a flashlight, paying particular attention to the landing gear. I did not notice any damage to the aircraft, and if I had, I would have reported it immediately. The captain verified that there was no damage and said that it was not necessary to have maintenance inspect the aircraft. I felt uneasy but complied."

The flight attendant stated:

"I strapped in, heard all the necessary commands from the computer in the cockpit: '300', '200', '100'...then right after I heard the computer say the 100...I heard this alarming shaking noise and rapid beeping alarm...The aircraft immediately slammed to the ground."

According to a check captain for Mesa Airlines:

"At approximately midnight on October 16, 2001, I received a phone call from Captain... telling me she thought I was taking her plane the next morning...she told me about her arrival into ROA in strong gusty winds. She described it as a rough ride with a possible stick shaker and a hard landing at the end. I asked her if there was any damage to the aircraft. She said the FO and her had inspected the landing gear and tires during post flight and found no damage. I told her that if she was in doubt, she needed to report it as a hard landing...Upon arrival at the airport the next morning; I discovered that the Charlotte crew had the [accident] airplane and not myself. Wanting to pass on the information to...[that captain], I summarized the story from the night before...."

The check captain further reported that after relaying the information to the flight crew, he departed the airplane. He did not observe the flight crew deplane and conduct a visual check of the airplane.

The accident airplane was subsequently flown to Charlotte, North Carolina, where a crew swap took place. The departing flight crew did not report any damage on the airplane, and the damage was finally discovered by the accepting flight crew at Charlotte during a pre-flight inspection.

Personnel information

The accident occurred on the last flight, of the third day on the flight sequence, following 2 days off for both pilots. The flight sequence was scheduled to continue the following day.

Captain

The captain held an airline transport pilot certificate with a rating for multi-engine land airplanes, and a type rating for the Embraer 145. She also held a commercial pilot certificate with a rating for single engine land airplanes. In addition, she held a flight instructor certificate for single and multi-engine airplanes and instrument airplane. She was last issued a first class Federal Aviation Administration (FAA), airman medical certificate with no limitations on October 2, 2001.

She listed her total flight experience as 2,548 hours, with 1,410 hours in multi-engine airplanes and 213 hours in the EMB-145. Her total pilot-in-command experience was 1,499 hours, which included 174 hours as pilot in command in the EMB-145.

She reported that after college, she had accumulated her flight hours by working as a flight instructor. She was hired by Air Mid-west, a subsidiary of Mesa Airlines on January 24, 2000. Her initial assignment was as a first officer on the Beech 1900. She reported that she had accumulated about 600 hours in the Beech 1900 as a first officer prior to bidding and being accepted for a captain upgrade in the EMB-145 with Mesa Airlines.

First Officer

The first officer held a commercial pilot certificate with ratings for single and multi-engine land airplanes, and instrument airplanes. She was last issued a first class FAA airman medical certificate with no limitations on July 20, 2001.

She listed her total flight experience as 1,919 hours, with 1,531 hours in multi-engine airplanes and 758 hours in the EMB-145. Her total pilot-in-command experience was 356 hours.

The first officer reported that after college, she was employed by Boeing as an analyst, and then was hired by Mesa Airlines. When hired by Mesa Airlines, her total flight experience was about 400 hours. She was initially employed as a Beech 1900 first officer. At the time of the accident, she had been flying the EMB-145 for about 1 year.

During interviews, both pilots reported that they had not received a jet indoctrination course or any specialized training on swept wing aerodynamics.

Aircraft information

There were no entries in the airplane's log sheets regarding a hard landing at either Roanoke or Charlotte. However, the accepting flight crew at Charlotte, which discovered the damage on the airplane, entered a maintenance discrepancy of a tail strike due to overrotation.

Airport information

Runway 33 was 5,800 feet long, 150 feet wide, and had a grooved, asphalt surface. The landing threshold was not displaced, and the runway was painted with precision instrument approach markings.

A 4-light PAPI (precision approach path indicator) was located on the left side of the runway, and the glide slope was set for 3 degrees. A medium approach lighting system was available, and was 1,400 feet long. The useable landing runway beyond the ILS glideslope touchdown point on the runway was 4,849 feet. The touchdown elevation of the approach end of the runway was 1,143 feet. The el

Aircraft

Registration
N825MJ
Reported as
Embraer 145LR
Category
Airplane
Serial number
145179
Airframe hours
3,335.9
Engines
Allison AE3007A1, 7,426 lbs thrust, turbo fanAllison AE3007A1, 7,426 hp, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Mesa Airlines, doing business as US Airways Express
Registered owner
Wells Fargo Bank Minnisota NA Trustee
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · October 16, 2001 · 3 hours before
Departed
PIT · Pittsburgh, VA
Destination
ROA · Roanoke
Flight plan
IFR
Airport
ROA · Roanoke Regional, runway 33, 5,800 × 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
29
Injuries
None
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
June 10, 2001
Seat
Left
Flight hours
2,548 total · 213 in this make and model · 1,499 as pilot in command · 213 in the last 90 days · 62 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
26
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
August 3, 2001
Seat
Right
Flight hours
1,919 total · 758 in this make and model · 356 as pilot in command · 138 in the last 90 days · 48 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
300° at 17 knots, gusting 22
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 30 °F
Altimeter
30.04 inHg
Observed at
ROA, 1 nm away

FAA reports on this event · 1

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