NYC97FA098

NTSB accident investigation · Boeing 767-300 · Newark, NJ · May 22, 1997

Accident · No injuriesField investigationFinal report
Date
May 22, 1997, 14:38 local (18:38 UTC)
Place
Newark, NJ
Injuries
168 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
IDEILBoeing 767-300
Weather
Visual (VMC) · Day
Status
Completed · report July 23, 1999
Report
Approved by Office Director
Case key
39275

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

On this page

Probable cause

The improper landing flare by the co-pilot and the inadequate supervision of the flight by the pilot-in-command. Other related factors were the gusty crosswind, windshear, and the lack of familiarity with the airplane by both pilots.

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.

Hard landingLanding
Weather condition - crosswindFactor
Weather condition - gustsFactor
Weather condition - windshearFactor
Flare - improperCopilot/second pilotCause
Elevator - improper use ofCopilot/second pilotFactor
Lack of familiarity with aircraftCopilot/second pilotFactor
Supervision - inadequatePilot in commandFactor
Lack of familiarity with aircraftPilot in commandFactor

Analysis

During landing with a gusty crosswind, the pilot received an onboard wind shear alert about 5 seconds prior to touchdown, and the airplane touched down with a 1.8 G load on the main landing gear, followed 2 seconds later by a 2.8 G spike on the nose landing gear. After touchdown, the first officer, the operating pilot, continued to push the control column forward, and the airplane pitched nose down, as the main landing gear alternately lifted off the ground and the ground spoilers retracted. The nose landing gear and surrounding structure were damaged. The captain and first officer had 150 hours and 68 hours respectively, in make and model. The ATIS contained, '...Low level windshear advisories are in effect...' which was acknowledged by the flight crew. The local controller had advised preceding flights prior to the airplane's arrival on frequency that, '...gain or loss of 15 knots below 300 feet reported by several aircraft...' He also gave this information to his relief about 1 minute prior to the airplane landing. However, it was not given to the accident flight. ATC controllers were not required to repeat the warning when it was on the ATIS.

Factual narrative

History of flight

On May 22, 1997, at 1438 eastern daylight time, a Boeing 767-300, I-DEIL, operated by Alitalia Airlines as flight 600 (AZA 600), was substantially damaged while landing at Newark International Airport (KEWR), Newark, New Jersey. The 10 crewmembers, and 158 passengers were not injured. Visual meteorological conditions prevailed for the scheduled international passenger flight that originated at Milano, Italy. Flight 600 was operated on an instrument flight rules (IFR) flight plan under 14 CFR Part 129.

According to air traffic control records, from the Federal Aviation Administration (FAA), the following Automatic Terminal Information Service (ATIS) was in effect at the time that flight AZA 600 arrived in the New York terminal area, and remained in effect through the time of the accident.

"Newark tower information whiskey one seven five one zulu, wind three five zero at two four [knots], visibility one zero [miles], ceiling seven thousand broken, temperature one seven [Celsius], dewpoint one [Celsius], altimeter two niner niner four, i l s four right approach in use, landing runway four right, departing runway four left...low Level windshear advisories are in effect...."

Flight 600 made initial contact with the New York Terminal Radar Approach Control (TRACON) at 1412, and was told to expect an ILS Runway 4R approach, and was issued the current altimeter. About 10 second after the initial contact, the crew from flight 600 reported they had information WHISKEY, which was acknowledged by the controller.

Examination of the air/ground voice communications tape from Newark Air Traffic Control Tower revealed that at 1427:55, and again at 1428:09, the local controller reported to arriving airplanes:

"...gain or loss of fifteen knots below three hundred feet reported by several aircraft."

At 1432:47, Flight 600 made initial contact with Newark air traffic control tower and transmitted, "newark tower good afternoon alitalia six hundred heavy intercepting zero four right I l s."

At 1432:52, the local controller replied, "alitalia six hundred heavy newark tower good afternoon runway four right number five wind three four zero at one seven gusts two niner cleared to land."

Flight 600 replied, "cleared to land number five alitalia six hundred copy wind."

At 1434:02, the local controller transmitted to a departing flight, "...wind three four zero at one six...."

At 1434:27, flight 600 was advised of a nearby helicopter which was acknowledged.

At 1434:57, the local controller transmitted as part of a landing clearance to a preceding flight, "...wind three three zero at one seven...."

At 1435:16, the local controller began a relief briefing which was not transmitted outside of the facility, but was recorded on the air/ground communications tape. The relief briefing was interrupted twice, and continued at 1435:52, and again at 1437:25, when it was completed. The controller being relieved stated in part, "...two nine belongs to you its active its available...just waiting for your use...some guys been requesting [it] as the wind gusted up...your weather is v f r the winds have been doing this I've been getting gusts up to 40...[there] was a loss gain or loss of fifteen knots below three hundred by several aircraft maybe about fifteen minutes ago...."

At 1437:29, the voice on local control had changed.

At 1439:05, the local controller transmitted, "alitalia six hundred heavy left turn left turn sir", and flight 600 replied, "...negative negative alitalia six hundred heavy...our gear has collapsed we have to stop this position."

Emergency response equipment was notified, and the passengers were eventually offloaded by the use of portable stairs.

The captain stated:

"We were cleared for the approach (ILS RNWY 04R); our indicated airspeed was 180 knots. We contacted the EWR tower and were cleared to land 04R, number five. Wind was reported 330/19/29. Our reference speed was 135 knots and, based on the reported winds, we adjusted our speed to a target of 150 knots approximately 7 N. miles from the airport."

"We cleared the fence stabilized in all respects on the approach. Well below 50 ft, AGL, the aircraft windshear detection system was activated. Within 2-3 seconds thereafter, the aircraft's left main landing gear touched down, followed by the right main and nose gear in that order. Given our altitude, speed, and power settings, we did not have an opportunity to react. We were, however, able to maintain directional control of the aircraft and prevent further damage to the aircraft and any injury to our passengers, who were safely evacuated via moveable steps."

A follow-up interview with the captain by an NTSB Investigator disclosed:

"...The captain observed the FO leaning forward during the impact, and the captain stated that the hardest impact was on the nose gear. Once the nose gear touched down, the crew kept the airplane on the runway with the yoke. After impact, the captain recognized that the power levers were not at idle, and he reduced the power levers to the idle position and into reverse. The speed brakes, which were in the armed position, deployed once the captain reduced the power levers to idle. Also, after impact, the steering was not working and the nose of the airplane was slightly tilted to the right side...."

The first officer stated:

"...After touchdown and the sudden dropping of the nose-gear to the runway, (as described by Capt. Vincenti), I was pushed forward and in the process, also pushed the yoke forward. Upon recovery, we immediately commenced appropriate roll-out procedures, which included placing the throttle to idle, this stopping the aircraft."

A follow-up interview with the first officer by an NTSB Investigator disclosed:

"When asked what 'target speed' was, the FO stated it was the approach speed (Vref 135 KIAS) plus 15 knots. This is predetermined by Alitalia's policy which calls for adding half the headwind component plus the gust. The minimum and maximum that can be added are 5 and 20 knots respectively. The headwind component was determined to be 5 knots with the wind 60 degrees off of runway centerline, plus the gust factor provided a plus 15 knots component to Vref."

"During the approach, as the airplane descended through 1,000 feet, the airspeed was dropping from 150 to about 145 KIAS. The airspeed then increased from 150 to 160 KIAS, at which time the FO reduced the power levers. There were small corrections made for airspeed throughout the approach. The airplane crossed the runway threshold below 50 feet above ground level (AGL). The airplane then rolled left which the FO corrected. The Ground Proximity Warning System (GPWS) then gave one wind shear warning alert, followed by the airplane's descent and contact with the runway. The airplane contacted the runway with the left main landing gear, followed by the right main landing gear and nose gear. The FO attempted to pull aft on the yoke to minimize the vertical speed prior to contact. The FO stated that the first contact with the runway on the main landing gear was 'very strong,' and he pulled back on the yoke; however, [the] nose came down very hard. The impact was so hard that his headphones fell off falling between his feet, and he found himself looking down on his lap. After the landing, the FO looked up to see that the airplane was on the runway centerline, at which time the captain reduced the power levers to idle and into reverse, while the FO was applying maximum braking with the pedals. The Captain reached for the power levers about one second before the FO."

A witness stated:

"We were positioned in AF 747 at entrance rd. Alitalia A/C appeared to be in a normal landing situation until what appeared to be at about 40-75 Ft above the ground...At that point the aircraft abruptly dipped its right wing and the...[right] main

Aircraft

Registration
IDEIL
Reported as
Boeing 767-300
Category
Airplane
Serial number
28147
Airframe hours
4,917
Engine
GE CF6-80-C2B6F, turbo fan
Damage
Substantial damage
Flight
Part 129
Registered owner
Alitalia Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 15, 1997 · 344 hours before
Departed
LIMC · Milano, Italy, OF
Destination
EWR
Flight plan
IFR
Airport
EWR · Newark International, runway 4R, 9,300 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
9,880 total · 156 in this make and model · 4,196 as pilot in command · 103 in the last 90 days · 42 in the last 30 days · 9 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 16 knots, gusting 25
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 34 °F
Altimeter
29.00 inHg
Observed at
EWR