NYC03FA035

NTSB accident investigation · Embraer ERJ-145LR · Cleveland, OH · January 6, 2003

Accident · No injuriesField investigationFinal report
Date
January 6, 2003, 12:48 local (17:48 UTC)
Place
Cleveland, OH
Injuries
50 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N16571Embraer ERJ-145LR
Weather
Instrument (IMC) · Day
Status
Completed · report June 2, 2004
Report
Approved by Office Director
Parties
ALPA, Continental Express, Federal Aviation Administration, Embrear Aircraft Co.
FAA report
20030106000139A
Case key
56284

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 attain a proper touchdown on runway, and his subsequent failure to perform a go-around, both of which resulted in a runway overrun. Factors were the company's inadequate dispatch procedures with their failure to provide all NOTAMS for the airport to the flight crew, 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.

OverrunLanding - roll
Dispatch procedures - inadequateCompany/operator managementFactor
Terrain condition - snow coveredFactor
Proper touchdown point - not attainedPilot in commandCause
Go-around - not performedPilot in commandCause
On ground/water collision with objectLanding - roll
Object - antenna

Analysis

The pilots initiated an approach to runway 6L, which was snow covered, and had a useable landing distance of 6,000 feet. The last winds from the tower were 340 degrees at 22 kts, with gusts to 35 knots. The maximum demonstrated crosswind for the airplane was 30 knots. The ATIS contained runway condition data that was 1 hour old. Inside the final approach fix, the captain elected to land with the wing flaps set at 22 degrees, rather than 45 degrees due to the wind. The Vref was adjusted to 138 kts, however, the final 38 seconds of flight was above 138 kts, and the final 7 seconds of flight was above 150 kts. In the final eight seconds of flight, the radar altimeter was less than 15 feet. However, the pilot continued with the landing and did not go-around. Touchdown occurred at an airspeed of 150 kts, about 1,523 feet from the departure end of the runway, and 2,308 feet from the ILS localizer antenna, which the airplane struck after it overran the runway. According to the company flight manual, with flaps set at 22 degrees, and a wet runway, the actual landing distance would have been 4,260 feet. When interviewed, the flight crew reported they had not checked landing distance. The FAA had published a NOTAM 26 days prior to the accident, which raised the landing minimums for the runway from 4,000 ft RVR to 5,000 ft RVR. The NOTAM was not in the airline's data base, and the company had no backup method for determining if they had all NOTAMS. The last RVR transmitted to the flight crew was 4,000 ft. The local controller did not update the flight crew with the latest RVR, or braking action reports as required. There was no requirement for the local controller to notify the pilots that the airport was below landing minimums even though the controllers were required to be aware of the approach minimums.

Factual narrative

History of flight

On January 6, 2003, at 1248 eastern standard time, an Embraer ERJ-145LR, N16571, operated by ExpressJet Airlines, Inc., dba Continental Express as flight 2051, was substantially damaged when it overran the departure end of the runway while landing at Cleveland-Hopkins International Airport (CLE), Cleveland, Ohio. There were no injuries to the certificated airline transport pilot, and commercial rated pilot, flight attendant, and 47 passengers. Instrument meteorological conditions prevailed for the scheduled, domestic flight that last departed from Bradley International Airport (BDL), Windsor Locks, Connecticut. Flight 2051 was conducted on an instrument flight rules (IFR) flight plan under 14 CFR Part 121.

The flight sequence for the crew started at Cleveland. They flew the airplane to Windsor Locks, and then initiated the return trip to Cleveland. This was the first time the pilot and first officer had flown together. While on the ground at Windsor Locks, the captain received and signed the flight release. The flight release contained a computerized flight plan for the flight, and appropriate notices to airmen (NOTAMS), and weather. The designated alternate airport was Detroit Metropolitan Wayne County Airport (DTW), Detroit, Michigan.

The flight release showed a fuel load of 7,802 pounds, and the captain increased the fuel load to 8,100 pounds. According to the flight release, the computed fuel for the trip was 3,872 pounds with the remainder to be allocated to flight to alternate airport, reserve and contingency fuel.

Flight 2051 departed the gate at 1025, and was airborne at 1049. According to the flight crew, there were no problems with the en route or approach phases of the flight.

While being radar vectored for the approach, the runway visual range was given as 4,500 feet, and then 4,000 feet.

A review of the CVR revealed that the flight crew did not discuss runway conditions or the amount of runway required to land during the approach briefing, nor was it a requirement. The final runway visual range (RVR) given to the flight crew was 4,000 feet.

At 1241:30, the approach controller advised flight 2051 that their position was 9 miles from SASCO, cleared them for the approach to runway 6 L, and stated the RVR for the runway was 4,000 feet.

At 1242:40, approach control reported to the flight 2051, that they were at SASCO, and were instructed to switch frequencies to the control tower.

At 1244:40, the first officer reported the flight inbound from SASCO, and the control tower told the flight to continue with the approach.

At 1244:48, the first officer asked the captain if he wanted to be vectored back to the same runway in the event that they had to abandon the approach, or would he want to go to Detroit. The captain replied that they would proceed to Detroit.

At 1245:04, the tower controller cleared the flight to land, and stated that the winds were from 340 degrees at 22 knots, gusting to 35 knots. The flightcrew acknowledged the transmission.

At 1245:12, the captain stated that he was going to land the airplane with the 22-degree flap setting, and would add 5 knots to the reference speed. The first officer subsequently updated the captain with a new reference speed of 138 knots. There was no discussion of runway conditions, or runway required to stop the airplane, nor was it required by the Continental Express Operating Manual.

At 1247:15, the CAWS alerted the flightcrew, "approaching minimums."

At 1247:21, the CAWS alerted the flightcrew, "minimums, minimums," followed by the captain asking the first officer, "see anything?" The first officer replied that she observed the approach lights in sight, and instructed the captain to "continue."

At 1247:26, the CAWS alerted the flightcrew that they were 200 feet above the ground.

At 1247:30, the captain stated that he had the runway environment in sight. The first officer replied, "no you're left."

At 1247:36, the CAWS alerted the flightcrew that they were 100 feet above the ground.

At 1247:44, the first officer stated, "dude, you might need to, need to get it down." The captain replied, "I know."

At 1247:54, the cockpit voice recorder recorded a sound similar to an airplane touching down on the runway.

At 1247:58, the cockpit voice recorder recorded a sound level increase, similar to engine reverse thrust being operated.

At 1248:01, the captain stated, "max reverse...it won't stop."

At 1248:05, the first officer said, "I got full brake."

At 1248:15, the cockpit voice recorder recorded the sound of an impact, followed 1 second later with the sound of the airplane coming to a stop.

At 1248:18, the first officer reported to the control tower, that flight 2051 had run off the departure end of the runway, and then the captain called for the rejected takeoff quick reference handbook (QRH), and evacuation checklist. The engines were shut down, and the airplane was secured. The passengers exited the airplane through the main cabin door, and were taken to the terminal via vehicles.

When interviewed, the captain reported that he had landed in similar conditions before. He picked up the flight release in operations and reviewed the material. He brought the departing fuel load up to 8,100 pounds. The minimum fuel to transit to the alternate airport was 3,100 pounds. He made the decision to conduct the landing with the flaps set at 22 degrees due to the winds. He did not seek any braking action report from the control tower. His contingency plan was to proceed direct to Detroit, if he could not land. He said the actual visibility was between 4,000 feet and 5,000 feet when he became visual. He could define the runway by the edge lights that were visible. However, the visibility was obstructed by snow blowing across the runway. Further, he reported that he did not experience any whiteout conditions, and that he maintained visual reference with the runway at all times during the landing. The touchdown speed was close to Vref. Upon touchdown, the speed brakes deployed, and he applied reverse thrust. There were no problems with directional control on the runway. The braking action was poor initially, and progressed to NIL during the rollout. He thought the airspeed was less than 60 knots as the airplane departed the runway. He reported that he considered a missed approach prior to hearing the aural warning for minimums and had visual reference with the runway. He added that he would have executed a rejected landing if the airplane floated a lot.

When asked about landing distance, he said a rule of thumb for landing with the wing flaps set at 22 degrees, and a wet runway was 5,000 feet of runway required. He said he did not ask the first officer to compute the landing distance because he did not have the time to ask her to compute it.

The first officer reported that she reviewed the flight release, and computed the weight and balance. Initially there were no concerns about fuel, but as the trip progressed, fuel did become a concern. She remembered that they did not receive any braking action reports from the controllers. The captain raised the Vref speed by 5 knots due to the lesser flap setting, but not for the wind. She said that she did not compute a landing distance. There was no forward visibility on the approach; however, she could see the ground from about 1,000 feet. She described the runway condition as patches of snow in the beginning, and around taxiway Romeo, it changed to hard packed snow. The conditions then changed to snow and ice for the remainder of the runway. Overall, the runway conditions deteriorated as they moved down the runway.

The accident occurred during the hours of daylight at 41 degrees, 26.75 minutes north latitude, and 81 degrees, 50.55 minutes west longitude.

Other damage

The airplane struck the localizer antenna, and disabled it.

Aircraft

Registration
N16571
Reported as
Embraer ERJ-145LR
Category
Airplane
Serial number
633
Airframe hours
845.3
Engines
Rolls-Royce 3007-AIP, 7,850 lbs thrust, turbo fanRolls-Royce 3007-AIP, 7,850 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
ExpressJet Airlines Inc., doing business as Continental Express
Registered owner
Wells Fargo Bank, Northwest NA Trustee
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · November 10, 2002 · 378.3 hours before
Departed
BDL · Windsor Locks, CT
Destination
CLE · Cleveland, OH
Flight plan
IFR
Airport
CLE · Cleveland-Hopkins Intl Arpt, runway 6L, 6,000 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Injuries
None
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
August 20, 2002
Seat
Left
Toxicology
Performed
Flight hours
3,765 total · 661 in this make and model · 2,328 as pilot in command · 136 in the last 90 days · 49 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
26
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
October 31, 2002
Seat
Right
Toxicology
Performed
Flight hours
2,550 total · 804 in this make and model · 1,150 as pilot in command · 194 in the last 90 days · 71 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
330° at 19 knots, gusting 29
Visibility
0.5 statute miles
Lowest ceiling
1,100 ft broken
Temperature
27 °F, dew point 25 °F
Altimeter
30.06 inHg
Observed at
CLE

Docket · 23

The files NTSB released with the investigation on March 19, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.8 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 276 KBFlight Data Recorder 10 - Factual Report of Group ChairmanItem 2 · .PDF · 133 KBFlight Data Recorder 10 - Attachment 1, Factual Report PlotsItem 3 · .PDF · 573 KBFlight Data Recorder 10 - Attachment 2, Factual Report Tabular DataItem 4 · .CSV · 185 KBFlight Data Recorder 10 - Study Report of Group ChairmanItem 5 · .PDF · 128 KBFlight Data Recorder 10 - Attachment 1, Study Report PlotsItem 6 · .PDF · 181 KBFlight Data Recorder 10 - Attachment 2, Study Report Tabular DataItem 7 · .CSV · 10 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 8 · .PDF · 110 KBNTSB - Summary of FDC NOTAM 2/2796Item 9 · .PDF · 114 KBNTSB - ATC Handling of FlightItem 10 · .PDF · 196 KBFAA Transcript - Approach ControlItem 11 · .PDF · 392 KBFAA Transcript - Local ControlItem 12 · .PDF · 206 KBFAA - Summary of FDC NOTAM 2/2796Item 13 · .PDF · 50 KBList of Cleveland NOTAMSItem 14 · .PDF · 251 KBCleveland METARSItem 15 · .PDF · 171 KBCleveland Airport Operations LogItem 16 · .PDF · 145 KBCleveland Snow NOTAMSItem 17 · .PDF · 251 KBOperations 2 - Factual Report of Group ChairmanItem 18 · .PDF · 629 KBOperations 2 - Attachment 1Item 19 · .PDF · 2.2 MBPost Accident Brake InspectionItem 20 · .PDF · 165 KBSummary Of Interview With Captain Of Flight 2017Item 21 · .PDF · 44 KBWeather Attached To Flight ReleaseItem 22 · .PDF · 397 KBEmail About Preceding AirplanesItem 23 · .PDF · 25 KB

FAA reports on this event · 1

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