# NTSB NYC06LA033: Boeing 737-800, N734MA, State College, PA, November 20, 2005 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 19, 2005, 22:18 local (Nov 20, 2005, 03:18 UTC) - Place: State College, PA - Coordinates: 40.849166, -77.848609 - Nearby events: https://openairdocs.org/map.md?lat=40.8492&lon=-77.8486&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 127 uninjured - Status: Completed, report September 27, 2007 - Report: Approved by Office Director - Parties: The Boeing Company, FAA/FSDO, MAPA - NTSB case key (mKey): 62856 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC06LA033 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62856/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=62856 - Page: https://openairdocs.org/ntsb/NYC06LA033 ## Probable cause The pilot's improper touchdown and recovery from a bounced landing. Factors to the accident were the operator's failure to provide sufficient information on the use of autothrottles and bounced landing recovery techniques, along with the Federal Aviation Administration's failure to require the inclusion of mixed-mode flight control guidance and bounced landing recovery techniques in operator pilot training programs and flight manuals. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, approach - insufficient standards/requirements, faa(organization) (contributing factor) - information insufficient, company/operator management (contributing factor) - autopilot/flight director - disengaged - throttle/power control - improper use of, pilot in command - Hard landing, landing - flare/touchdown - touchdown - improper, pilot in command (cause) - Dragged wing,rotor,pod,float or tail/skid, landing - recovery from bounced landing - improper, pilot in command (cause) ## Analysis During the approach, the captain had disconnected the autopilot, but had left the autothrottles engaged in what is known as "mixed-mode" method of flight control in which control of the flight path is mixed between manual and automatic means. During this time, the autothrottle began to track an airspeed which had been previously selected in the mode control panel speed window. The captain disconnected the autothrottles, but did not retard the throttles to idle. Therefore, automatic speedbrake deployment did not take place during the first touchdown. During the resultant bounce, the captain then retarded the thrust levers to idle, the speedbrakes deployed, there was a loss of lift and nose up pitching moment, and a tailstrike resulted. The airplane manufacturer recommended autothrottle use only when the autopilot was engaged. They also advised if the airplane bounced while landing, the pilot should hold or re-establish a normal landing attitude and add thrust as necessary to control the rate of descent, and that thrust need not be added for a "shallow skip or bounce," however, if a "high, hard bounce" occurred, the pilot should initiate a go-around. Information concerning the dangers of mixed-mode operations and bounced landing recovery was available to the operator and Federal Aviation Administration (FAA); however there were no prohibition on mixed-mode operations, nor were bounced landing recovery guidance required to be listed in any of the operator's FAA approved manuals. Two months prior to the accident, the Safety Board issued a recommendation to the FAA; to require air carriers to incorporate bounced landing recovery techniques in their flight manuals and to teach these techniques during training. As a result the FAA issued a Safety Alert for Operators (SAFO), which "recommended" each airline, include bounced landing recovery techniques in their manuals and training; however since the SAFO was not mandatory, the Safety Board requested the FAA survey air carriers to establish how many had adopted the SAFO. The Safety Board advised the FAA that until the results of the SAFO were known, the Safety Board's recommendation would remain classified; Open Acceptable Response. ## Factual narrative HISTORY OF FLIGHT On November 19, 2005, at 2218 eastern standard time, a Boeing 737-800, N734MA, operated by Miami Air International as flight 622, was substantially damaged while landing at University Park Airport (UNV), State College, Pennsylvania. The 2 certificated pilots, 1 flight mechanic, 4 flight attendants, and 120 passengers were not injured. Night visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight that departed Capital City Airport (LAN), Lansing, Michigan. The nonscheduled passenger flight was conducted under 14 CFR 121. According to the flight crew, the en route phase was uneventful. During a "VNAV approach backed up with ILS" to runway 24 at UNV, with the flaps set to 40 degrees, the captain noticed that after the autopilot was disconnected at approximately 1,000 feet above ground level (agl), the airplane appeared to be a "little low on the glideslope." Then after correcting, the airplane appeared to "go a little high" in reference to the precision approach path indicator, as it crossed the runway threshold. Approximately 30 feet agl, the captain began the landing flare and the airplane touched down "a little firm." The airplane then became airborne again, but the captain did not add power. The airplane "floated for a little bit," the spoilers deployed, and the captain tried to arrest the descent rate by adding "flare." The airplane then touched down for a second time. During the postflight inspection it was determined that the tailskid and the lower portion of the aft fuselage had contacted the ground. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the captain held an airline transport pilot certificate with multiple ratings including airplane multi-engine land, and a type rating for the Boeing 737. According to records provided by Miami Air International, the captain had a total flight time of 8,141 hours, with 4,954 hours in multi-engine airplanes and 1,258 hours in the Boeing 737. His most recent FAA first-class medical certificate was issued on October 28, 2005. According to FAA records, the first officer held a commercial pilot certificate with ratings for airplane single engine land, airplane multi-engine land, and airplane instrument. According to records provided by Miami Air International he had a total flight time of 3,072 hours, with 2,281 hours in multi-engine airplanes. His most recent FAA first-class medical certificate was issued on June 16, 2005. AIRCRAFT INFORMATION According to FAA and company maintenance records, the airplane was manufactured in 2000. The airplane's most recent continuous airworthiness inspection was completed on September 29, 2005, and at the time of the accident, it had accumulated 17,022 total hours of operation. METEOROLOGICAL INFORMATION A weather observation taken at the airport about 2 minutes after the accident, included winds from 260 degrees at 4 knots, 10 miles visibility, clear skies, temperature 37 degrees Fahrenheit, dew point 21 degrees Fahrenheit, and an altimeter setting of 30.24 inches of mercury. AIRPORT INFORMATION According to the Airport Facility Directory, UNV was located at an elevation of 1,239 feet msl. Runway 24 was 6,701-feet-long, 150-feet-wide, and constructed of grooved asphalt. In addition, runway 24 was equipped with an instrument landing system, precision instrument markings, a 4-light precision approach path indicator, and a medium intensity approach lighting system with runway alignment indicator lights. FLIGHT RECORDERS Cockpit Voice Recorder Information The 30-minute recording began after the crew had started the descent from cruise altitude for landing at UNV. After performing the descent approach checklist, the crew was assigned a visual approach by air traffic control. After descending through 5,000 feet, the crew received traffic and weather information from University Park Traffic (Common Traffic Advisory Frequency - CTAF). Two minutes later, the first officer reported runway 24 in sight and canceled the IFR flight plan. The crew next reported right downwind on the traffic frequency, and received a wind and altimeter advisory. The captain requested first flaps 1 degree and then 2 minutes later, flaps 5 degrees. After the first officer reported right base for runway 24, the captain stated he had the field in sight. At a position 5 miles from the runway, the captain turned onto final approach and requested gear extension, 15 degrees flaps, and the final landing checklist. The first officer reported passing "PENUE" at 3,090 feet as the captain requested flaps 40 degrees. As the aircraft approached "minimums," the first officer told the captain that they were above the glideslope. The airplane touched down on the runway and after the first officer uttered a comment, impacted the runway a second time. As the airplane was slowing, both pilots commented about the landing. The first officer then asked about "manual speed brake." The first officer reported clearing the runway and the captain then made a comment about "the worst landing of his life." After arriving at parking, the first officer read the securing checklist. The recording ended at 30:29 when power was removed from the CVR. Flight Data Recorder Information Data from the accident flight was successfully downloaded from the airplane's flight data recorder (FDR). Parameters from the approach and landing phases of the flight were reviewed. On the accident flight, the FDR data indicated that the speedbrake lever was armed at 5,500 feet radio altitude (RA). The wind transitioned from a 40-knot tailwind, to a 6 to 8 knot headwind at approximately 3,000 feet RA. The autopilot was selected off at 575 feet RA, but the autothrottles remained engaged. At approximately 190 feet RA the auto throttle mode changed, to mode control panel (MCP) speed, and began to track the speed that was in the MCP airspeed window. This was recorded by the FDR as a selected speed of 143 knots. The airplane's airspeed degraded below the selected MCP speed, and the autothrottle commanded a thrust advance. This was followed shortly by a reduction in the throttle resolver angle (TRA) and the rate of descent increased to 900 fpm. The autothrottles were selected off at 90 feet RA; however, the TRA remained at approximately 50 degrees, and the 6 to 8 knot headwind diminished to zero. The first touchdown occurred 6 seconds later, at a pitch attitude of 8 degrees nose up. The airplane was at 132 knots ground speed with the TRA still at approximately 50 degrees. The airplane became airborne approximately 0.5 seconds later, and the throttles moved to idle. Approximately, 1.4 seconds later, spoilers 3, 4, 9, and 10 all began to increase while groundspeed remained at 132 knots. Another 1.4 seconds later, the airplane touched down again, the spoiler ground speed brake, transitioned from "Not Up" to "Panels Up," and spoilers 3, 4, 9, and 10 fully extended. During the second touchdown, pitch attitude reached 9.5 degrees nose up, and peak vertical acceleration reached 2.5g's. WRECKAGE AND IMPACT INFORMATION External examination by personnel from the airplane manufacturer revealed that the tailskid cartridge had been compressed to its replacement limits and the shoe had been ground off. An aft drain mast had been ground away on its lower edge, and the airplane had suffered damage to multiple skin panels. Internal examination revealed that multiple frames, doublers, webs, shear ties, stringer ties, clips, splice plates, intercostals, and attach angles had been damaged. Further examination also revealed, that the pressure bulkhead exhibited "oil canning" on the BS1016 web, located just aft between the Y-chord and the circumferential strap inboard of the stiffener. TESTS AND RESEARCH Autospeedbrake Deployment Logic According to ## Aircraft - Registration: N734MA (not matched to a registry record) - Reported make and model: Boeing 737-800 - Category: Airplane - Serial number: 30039 - Airframe hours: 17022 - Engines: CFM International CFM56-7B26 26000 lbs thrust turbo fan; CFM International CFM56-7B26 26000 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Operator: Miami Air International - Registered owner: International Lease Finance Corporation - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, September 1, 2005, 381 hours before - Departed: LAN, Lansing, MI - Destination: UNV, State College, PA - Flight plan: IFR - Airport: UNV, University Park Airport, runway 24, 6,701 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: none; airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 1, with waivers/limitations; last flight review November 1, 2004; seat: left; flight hours: 8,141 total, 1,258 in this make and model, 5,575 as pilot in command, 113 in the last 90 days, 71 in the last 30 days, 4 in the last 24 hours - Co-pilot; age 43; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review November 1, 2005; seat: right; flight hours: 3,072 total, 748 as pilot in command, 105 in the last 90 days, 52 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 260° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 37 °F, dew point 21 °F - Altimeter: 30.23 inHg - Observed at: UNV ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20051119031829A](https://openairdocs.org/incident/20051119031829A), Nov 19, 2005: Boeing 7378Q8, State College, PA, Substantial damage. (-23) Aircraft departed lan with 118 passengers and crew of 7 for unv with captain ^privac^ as the pilot flying (pf). Extra fuel was tankered sinced the price… ## Docket (17 files) The files NTSB released with the investigation on September 3, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=62856. 10.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278949&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Flight Data Recorder 10 - Specialist's Factual Report (item 2, .PDF, 446 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40276364&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%2010%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Flight Data Recorder 10 - Attachment 1 (FDR tabular data for plots 1, 2, and 3) (item 3, .CSV, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40276365&FileExtension=.csv&FileName=Flight%20Data%20Recorder%2010%20-%20Attachment%201%20(FDR%20tabular%20data%20for%20plots%201,%202,%20and%203)-Master.csv - Flight Data Recorder 10 - Attachment 2 (FDR tabular data for plots 4, 5, and 6) (item 4, .CSV, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40276366&FileExtension=.csv&FileName=Flight%20Data%20Recorder%2010%20-%20Attachment%202%20(FDR%20tabular%20data%20for%20plots%204,%205,%20and%206)-Master.csv - Flight Data Recorder 10 - Attachment 3 (FDR tabular data for plots 7, 8, and 9) (item 5, .CSV, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40276367&FileExtension=.csv&FileName=Flight%20Data%20Recorder%2010%20-%20Attachment%203%20(FDR%20tabular%20data%20for%20plots%207,%208,%20and%209)-Master.csv - Supplemental FDR Data Printout (The Boeing Company) (item 6, .PDF, 576 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278950&FileExtension=.PDF&FileName=Supplemental%20FDR%20Data%20Printout%20(The%20Boeing%20Company)-Master.PDF - Cockpit Voice Recorder 12 - Specialist's Summary Report of Investigation (item 7, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40279009&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Specialist%27s%20Summary%20Report%20of%20Investigation-Master.PDF - Flight Crew Interview Summaries (item 8, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278951&FileExtension=.PDF&FileName=Flight%20Crew%20Interview%20Summaries-Redacted.PDF - Excerpts From Boeing 737NG Flight Crew Training Manual ( Autothrottle Use and Bounced Landing Recovery) (item 9, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278952&FileExtension=.PDF&FileName=Excerpts%20From%20Boeing%20737NG%20Flight%20Crew%20Training%20Manual%20(%20Autothrottle%20Use%20and%20Bounced%20Landing%20Recovery)-Master.PDF - Excerpt from American Institute of Aeronautics and Astronautics Paper, "How Not to Fly" (Mixed-Mode Method of Flight Control) (item 10, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278954&FileExtension=.PDF&FileName=Excerpt%20from%20American%20Institute%20of%20Aeronautics%20and%20Astronautics%20Paper,%20%22How%20Not%20to%20Fly%22%20(Mixed-Mode%20Method%20of%20Flight%20Control)-Master.PDF - Excerpts From FAA Human Factors Team Report on The Interfaces between Flightcrews and Modern Flight Deck Systems (Mixed-Mode Operations) (item 11, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278955&FileExtension=.PDF&FileName=Excerpts%20From%20FAA%20Human%20Factors%20Team%20Report%20on%20The%20Interfaces%20between%20Flightcrews%20and%20Modern%20Flight%20Deck%20Systems%20(Mixed-Mode%20Operations)-Master.PDF - Flight Safety Foundation Bounced Landing Recovery Guidance (item 12, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278956&FileExtension=.PDF&FileName=Flight%20Safety%20Foundation%20Bounced%20Landing%20Recovery%20Guidance-Master.PDF - NTSB Recommendation A-05-30 ( Recommendation, FAA Response, and FAA SAFO) (item 13, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278959&FileExtension=.PDF&FileName=NTSB%20Recommendation%20A-05-30%20(%20Recommendation,%20FAA%20Response,%20and%20FAA%20SAFO)-Master.PDF - Miami Air B737 AOM Bulletin 07-10 (Autothrottle Mixed-mode Flying) (item 14, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40279679&FileExtension=.PDF&FileName=Miami%20Air%20B737%20AOM%20Bulletin%2007-10%20(Autothrottle%20Mixed-mode%20Flying)-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40278962&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photograph of Damage to N734MA (item 16, .PDF, 650 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40279076&FileExtension=.PDF&FileName=Photograph%20of%20Damage%20to%20N734MA-Master.PDF - Photograph of Damage to N734MA (Close-Up) (item 17, .PDF, 649 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40279077&FileExtension=.PDF&FileName=Photograph%20of%20Damage%20to%20N734MA%20(Close-Up)-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.