# NTSB NYC99FA110: Saab-Scania 340B, N232AE, Jamaica, NY, May 8, 1999 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: May 8, 1999, 07:01 local (11:01 UTC) - Place: Jamaica, NY - Location: 40.6399° N, 73.7787° W: Placed by OpenAirDocs at JOHN F KENNEDY INTL (JFK), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=40.6399&lon=-73.7787&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 29 uninjured - Status: Completed, report December 4, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 51312 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC99FA110 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51312/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=51312 - Page: https://openairdocs.org/ntsb/NYC99FA110 ## Probable cause The pilot-in-command's failure to perform a missed approach as required by his company procedures. Factors were the pilot-in-command's improper in-flight decisions, the pilot-in-command's failure to comply with FAA regulations and company procedures, inadequate crew coordination, and fatigue. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Overrun, landing - roll - missed approach - not performed, pilot in command (cause) - crew/group coordination - inadequate, flightcrew (contributing factor) - fatigue, flightcrew (contributing factor) - procedures/directives - not complied with, pilot in command (contributing factor) - in-flight planning/decision - inadequate, pilot in command (contributing factor) - On ground/water collision with object, landing - roll - object - other ## Analysis The RVR went below minimums, and the flightcrew was issued holding instructions. While flying toward the holding fix, the RVR increased. The ATC specialist offered the flightcrew the ILS approach, but advised that they might be too high. The captain accepted the approach clearance, and the ATC specialist asked if the flightcrew would be able to make the approach from their position. The captain gave an affirmative reply. He continued the entire approach with excessive altitude, airspeed, and rate of descent; while remaining above the glide slope. This was contrary to the company procedures, the instrument approach procedure, Federal Aviation Regulations 91.175, and four audible warnings from the airplane GPWS. During the approach, the first officer failed to make the required callouts, including a missed approach callout. The airplane landed approximately 7,000 feet beyond the approach end of the runway, at 157 knots; and subsequently overran the runway. During interviews, both pilots stated that they were fatigued. The flightcrew was working a continuous duty overnight schedule. The previous day, they both awoke during the morning hours, did not sleep during the day, and reported for duty about 2200 for a flight scheduled at 2246. The flight was delayed, and arrived at BWI about 0100. They were asleep about 0130, and awoke about 0445 for the accident flight, which was scheduled to depart at 0610. ## Factual narrative HISTORY OF FLIGHT On May 8, 1999, at 0701:39 Eastern Daylight Time, a Saab 340B, N232AE, sustained substantial damage during landing at John F. Kennedy International Airport (JFK), Jamaica, New York. The airplane was owned by AMR Leasing Corporation, and operated by American Eagle Airlines Inc. as flight 4925. There were no injuries to 3 crewmembers and 26 passengers, while 1 passenger sustained a serious injury. Instrument meteorological conditions prevailed for the flight that originated from Baltimore-Washington International Airport (BWI), Baltimore, Maryland. An instrument flight rules flight plan was filed for the air carrier flight conducted under 14 CFR part 121. According to pilot interviews, Air Traffic Control (ATC) data, and the cockpit voice recorder (CVR), the departure from BWI, and cruise flight to JFK was uneventful. The captain completed an approach checklist and briefing, and ATC gave the flightcrew a vector for the instrument landing system (ILS) approach to Runway 4R. Later, ATC advised the flightcrew that the runway visibility range (RVR) was 1,600 feet. The controller asked if the flightcrew could proceed with the approach, or if they were going to have to hold until the RVR was at 1,800 feet. The captain stated that they needed 1,800 feet RVR to initiate the approach. ATC then cleared the flight to turn to 010 degrees and intercept the Runway 4R localizer, and hold southwest of the EBBEE intersection, on the localizer, at 4,000 feet. The airplane had not reached EBBEE, but was on the localizer course, when the controller stated, "Eagle flight nine twenty five, runway four right RVR is eighteen hundred if, if you want to make it from there, or you might be too high. Just let me know..." The captain replied "we can take it." The controller then cleared flight 4925 for the ILS approach to Runway 4R. At that time, the airplane was approximately 4,000 feet mean sea level (MSL), and 6.6 miles from the approach end of the runway. The first officer began the approach descent, but the captain extended the landing gear and took control of the airplane. Approximately 24 seconds after issuing the approach clearance, the controller stated, "Eagle flight nine twenty five, you good for the approach from there?" The captain replied, "We're gonna give it our best." During the descent, the flightcrew received four audible warnings, including one "sink rate", and three "too low terrain" warnings. According to a Saab 340 manual, a "too low terrain" warning would cancel a flap warning. At 0701:12, the first officer stated "okay, there's three hundred feet." Approximately 7 seconds later, the captain stated "okay, before landing checklist is." The first officer replied "three green, flaps zero." During the approach, the first officer made no other callouts. The flaps remained retracted during the approach. However, after the accident, the captain extended the flaps to 20 degrees. According to radar data, and the flight data recorder (FDR), the airplane's descent rate reached a maximum vertical velocity of approximately 2,950 feet per minute. The airplane crossed the runway threshold about 180 knots. It touched down approximately 7,000 feet beyond the approach end of the runway, at 157 knots. The flightcrew applied reverse thrust and maximum braking, but the airplane departed the end of the runway about 75 knots. Approximately 300 feet of skid marks were observed, by a Federal Aviation Administration (FAA) Inspector, at the end of the runway. The airplane traveled off the end of the runway, over a deflector, and onto an Engineered Materials Arresting System (EMAS). The airplane traveled approximately 248 feet across the 400 foot long EMAS, and the landing gear sank approximately 30 inches into the EMAS, at its final resting place. During the overrun, the nose gear, fuselage, and propellers sustained damage. The accident occurred during the hours of daylight; located approximately 40 degrees, 38 minutes north longitude, and 73 degrees, 46 minutes west latitude. FLIGHTCREW INFORMATION Captain The captain held an Airline Transport Pilot Certificate with a rating for airplane multiengine land, and was type rated in the Saab 340. His most recent FAA First Class Medical Certificate was issued on February 19, 1999. The captain was hired by American Eagle Airlines on July 6, 1992, and flew as a first officer on the Saab 340. He was upgraded to captain in October, 1998. He received his six-month simulator training in April, 1999. In March 1999, he completed academic training for initial operating experience check-airman qualifications. According to company records, the captain's total flight experience was approximately 5,577 hours, of which, approximately 2,376 hours were in the Saab 340. Of the 2,376 hours, about 230 were pilot-in-command experience. The captain's base of operation with American Eagle Airlines was JFK. The captain was interviewed by the Safety Board's Operations Group on July 20, 1999. He stated that, when he was cleared for the approach, he thought he was further from EBBEE. He saw "8" displayed on the distance measuring equipment (DME) and thought it was from EBBEE. He added that calling for the Before Landing Checklist was the pilot-flying (PF) responsibility, but should be challenged if not called for appropriately. He further stated, prior to the approach, he might have known in the back of his mind that the flaps were not down, but it did not register. The captain added that the first officer did not make the required approach call-outs, including; OM/FAF, 1,000 feet, approach deviations, 500 feet, and approaching minimums. The captain said his scan should have included the altimeter, but he was focused on the glide slope. He remembered the first officer saying "300 feet, runway in sight."; but did not remember the first officer saying "flaps zero." The captain felt that he was adequately trained for the stabilized approach. The stabilized approach criteria was taught in ground school and the simulator. He recalled a ground proximity warning system (GPWS) alert at the initiation of descent. He added that he could later hear the GPWS alerts, but they did not register. He did not recall canceling the GPWS alerts. The captain stated that a go-around did not enter his mind at 300 feet because he was still trying to process information. First Officer The first officer held an Airline Transport Pilot Certificate with a rating for airplane multiengine land. His most recent FAA First Class Medical Certificate was issued on December 14, 1998. He was hired by the company on February 8, 1999, and received his qualification as a Saab 340 first officer in March, 1999. According to company records, the first officer had a total flight experience of approximately 2,010 hours, of which, approximately 45 hours were in the Saab 340. His base of operation with the company was JFK. The first officer was interviewed by the Safety Board's Operations Group on July 20, 1999. He stated: "We were at 4,000 feet being vectored for the ILS 4R approach. The visibility was below minimums and we were given holding instructions by ATC. Two miles prior to EBBEE the visibility came up and ATC asked if the weather was good enough for us and could we make the approach. Captain Powers answered yes. He put the landing gear down and pushed the condition levers to Max. I was flying with the autopilot engaged and I initiated a 2,000 foot per minute descent. The captain took the aircraft. At that point I fell behind the aircraft. My scan was not 100%. I missed the call at the Outer Marker and the 1,000 foot call. Something prompted me to do the Before Landing Checklist. At around 500 feet, I thought I saw glide slope and called it, gear down, three green, flaps zero, runway in sight." When asked if he felt uncomfortable with th ## Aircraft - Registration: [N232AE](https://openairdocs.org/deregistered/N232AE-2010-06-28), registration cancelled 2010-06-28, S/N 340B-232, built 1991 (OpenAirDocs) - Reported make and model: Saab-Scania AB (Saab) 340B - Registry model: [Saab-Scania SAAB 340B](https://openairdocs.org/model/saab-scania-saab-340b) (registry code 7860101) (OpenAirDocs) - Registry engine: [GE CT7-SER series](https://openairdocs.org/engine/ge-ct7-ser-series) (registry code 30031, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 340B-232 - Airframe hours: 17488 - Engines: GE GECT7-9B 1750 horsepower turbo prop - Damage: Substantial damage - Flight: Part 121 - Operator: American Eagle Airlines, Inc. - Registered owner: Chase Manhattan Bank & Trust - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, May 7, 1999, 2 hours before - Departed: BWI, BALTIMORE, MD - Destination: JFK - Flight plan: IFR - Airport: JFK, John F. Kennedy Intl Apt, runway 4R, 8,400 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 41; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 6,000 total, 2,800 in this make and model, 2,200 as pilot in command, 100 in the last 90 days, 15 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 90° at 11 knots - Visibility: 0.25 statute miles - Lowest ceiling: 100 ft overcast - Temperature: 136 °F, dew point 136 °F - Altimeter: 29.00 inHg - Observed at: JFK ## 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 19990508043689A](https://openairdocs.org/incident/19990508043689A), May 8, 1999: Saab 340B, New York, NY, Substantial damage. (.4) The RVR went below minimums, and the flightcrew was issued holding instructions. While flying toward the holding fix, the RVR increased. The ATC… ## Docket (22 files) The files NTSB released with the investigation on April 27, 2000, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=51312. 19.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 760 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436745&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement E - Second Pilot Information (item 2, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436746&FileExtension=.PDF&FileName=Supplement%20E%20-%20Second%20Pilot%20Information-Redacted.PDF - Supplement S - Aircraft Occupant and Injured Ground Personnel (item 3, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122438&FileExtension=.PDF&FileName=Supplement%20S%20-%20Aircraft%20Occupant%20and%20Injured%20Ground%20Personnel-Master.PDF - Operations 2 - Factual Report of Group Chairman (item 4, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436747&FileExtension=.PDF&FileName=Operations%202%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - ATC 3 - Factual Report of Group Chairman (item 5, .PDF, 997 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436748&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - Meteorology 5 - Factual Report of Group Chairman (item 6, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436749&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - Survival Factors 6 - Factual Report of Group Chairman (item 7, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436750&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - Flight Data Recorder 10 - Factual Report of Group Chairman (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436751&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%2010%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 9, .PDF, 810 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122445&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Aircraft Performance 13 - Factual Report of Group Chairman (item 10, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436752&FileExtension=.PDF&FileName=Aircraft%20Performance%2013%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - Airports/ARFF 16 - Factual Report of Group Chairman (item 11, .PDF, 664 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122447&FileExtension=.PDF&FileName=Airports%2FARFF%2016%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Interview Summaries (item 12, .PDF, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436753&FileExtension=.PDF&FileName=Interview%20Summaries-Redacted.PDF - Excerpt From Saab 340 Manual (item 13, .PDF, 314 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122449&FileExtension=.PDF&FileName=Excerpt%20From%20Saab%20340%20Manual-Master.PDF - Excerpt From American Eagle Operations Manual (item 14, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122450&FileExtension=.PDF&FileName=Excerpt%20From%20American%20Eagle%20Operations%20Manual-Master.PDF - Engineering Order (item 15, .PDF, 815 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436754&FileExtension=.PDF&FileName=Engineering%20Order-Redacted.PDF - Excerpt from NASA Report (item 16, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436755&FileExtension=.PDF&FileName=Excerpt%20from%20NASA%20Report-Redacted.PDF - Correspondence from Party Representatives (item 17, .PDF, 868 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436756&FileExtension=.PDF&FileName=Correspondence%20from%20Party%20Representatives-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436757&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photograph 1 (item 19, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122455&FileExtension=.PDF&FileName=Photograph%201-Master.PDF - Photograph 2 (item 20, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122456&FileExtension=.PDF&FileName=Photograph%202-Master.PDF - Photograph 3 (item 21, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122457&FileExtension=.PDF&FileName=Photograph%203-Master.PDF - Photograph 4 (item 22, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40122458&FileExtension=.PDF&FileName=Photograph%204-Master.PDF From the NTSB's public API. 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