JAMAICA, NY, USA
N232AE
Saab-Scania AB (Saab) 340B
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.
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 the approach, the first officer stated "No, I relied on the captain to know what he was doing and know where he was." INJURIES TO PERSONS According to crew statements, passenger statements, and medical records, one passenger was seriously injured. She suffered a fractured fibula while exiting the airplane. All other occupants were not injured. AIRCRAFT INFORMATION The airplane was equipped with two General Electric, GECT7-9B, engines. Before the accident, the airplane underwent a maintenance inspection on May 7, 1999. After the accident, Examination of the airplane by a Federal Aviation Administration Inspector, and company personnel, did not reveal any pre-impact mechanical malfunctions, nor did the pilots report any. METEOROLOGICAL INFORMATION At 0705, the reported weather at JFK was: winds from 090 degrees at 11 knots; visibility less than 1/4 mile; Runway 4R visibility range 1,600 feet, variable 2,000 feet; fog; vertical visibility 100 feet; temperature and dewpoint 55 degrees Fahrenheit; altimeter 29.96 inches of mercury. The flight plan, dispatch release, and weather documents were examined. No deficiencies were found. AERODROME INFORMATION John F. Kennedy International Airport (JFK), Jamaica, New York, was owned by the City of New York, and operated by the Port Authority of New York and New Jersey (PANY&NJ). JFK was served by four runways: 4L/22R, 4R/22L, 13L/31R, and 13R/31L. Runway 4R was asphalt, transverse grooved full length, 8,400 feet long, and 150 feet wide. It was configured for category II/III instrument landings, equipped with high intensity runway edge lights, and centerline lights. Runway 4R was also equipped with an Engineered Materials Arrestor System (EMAS). The EMAS was located approximately 102 feet beyond the end of the runway. It was constructed of cellular cement, and measured approximately 400 feet long, by 150 feet wide. It progressed from approximately 9 to 30 inches in depth. The Thurston Basin was located about 25 feet beyond the EMAS. It was a shallow, mud-based estuary with its bottom about 10 to 15 feet below runway level, and it was subject to tidal changes. At high tide, the shorelines of the basin began about 560 feet beyond the departure end of the runway. Additionally, the Thurston Basin was the site of a previous accident involving Scandinavian Airlines System flight 910 on February 28, 1984. In that accident, the airplane overran Runway 4R and came to rest in the basin. Twelve people were injured, and the airplane sustained substantial damage. Information about the accident was available from NTSB report DCA84AA018. The Safety Board issued Safety Recommendation A-87-37, as a result of Safety Board Safety Study SS-84-02, "Airport Certification and Operations." The Safety Board recommended that the FAA: "Initiate research and development activities to establish the feasibility of soft-ground aircraft arresting systems and promulgate a design standard, if the systems are found to be practical." The FAA and the United States Air Force (USAF) agreed to determine the feasibility of, and develop criteria for, the design of soft-ground arresting systems on December 21, 1984. In 1989, the FAA initiated an experimental program with the U.S. Naval Air Engineering Center, Lakehurst, New Jersey, to conduct experiments on soft-ground materials. The purpose of the experiments was to verify the theoretical calculations of stopping distances. Tests were conducted using a FAA Boeing 727 in July-August 1990, using phenolic foam and cellular cement. The FAA's Technical Center conducted two successful full-scale arrestments using the instrumented FAA Boeing 727 aircraft between June and July, 1993. A phenolic foam bed; 680 feet long, 48 feet wide; and 18 inches deep, was used. During the first arrestment, the instrumented Boeing 727 traveled at 50 knots, and stopped safely, 420 feet into the bed. During the second test, the Boeing 727 traveled at 60 knots, and stopped safely, 540 feet into the bed. From 1994-1996, the FAA and PANY&NJ developed the prototype arrestor bed for runway 4R at JFK. In September 1994, the FAA and Engineered Systems Company of Aston, Pennsylvania, entered into a cooperative research and development agreement to test new materials and methods related to the practical aspects of soft-ground arresting systems. By November 1994, a cast-in-place arrestor bed, comprised of cellular cements, was constructed and tested at the FAA William J. Hughes Technical Center. A second test bed, built with pre-cast cellular cement block, was tested in June 1995. The PANY&NJ installed the prototype aircraft arrestor bed at JFK in 1996. The $2.6 million bed was fully funded by the PANY&NJ. Another EMAS was installed at the departure end of Runway 13 at LaGuardia Airport (LGA), and five other EMAS were being considered for New York City area airports, by the PANY&NJ. While the FAA tested the feasibility of EMAS with a Boeing 727; no test was ever completed with a Saab 340, or an aircraft of similar weight. The accident was the first operational use of the EMAS. Additional information pertaining to the EMAS was found in FAA Advisory Circular AC 150/5220-22 - Engineered Materials Arresting Systems for Aircraft Overruns. After the overrun, repairs to the system took 15 days, and cost approximately $900,000. Repairs to the airplane cost approximately $ 984,000. While the EMAS at JFK was successful, the system at LGA experienced a breakup due to the proximity of the system to the runway end. In August, 1999, PANY&NJ removed the EMAS at LGA. PANY&NJ suspected that vibration may have been involved, and that the foam panels had to be strengthened. Additional testing was being performed at the FAA Technical Center. FLIGHT RECORDERS Cockpit Voice Recorder The airplane was equipped with a Fairchild model A-100A cockpit voice recorder. The CVR was transported to the NTSB, Office of Research and Engineering, on May 13, 1999. The CVR committee convened on May 20, 1999, and a transcript was prepared of 9:56 minutes of the 31:04 minute recording. According to the CVR Group Chairman's report, the exterior of the CVR showed no evidence of structural damage. The interior of the recorder and the tape sustained no apparent heat or impact damage. The recording consisted of four channels of good quality audio information. Flight Data Recorder The airplane was equipped with a Loral F800 model (S/N 4307) Digital Flight Data Recorder (DFDR). The DFDR was transported to the NTSB Office of Research and Engineering on May 13, 1999. A DFDR readout was performed. The DFDR recorded data in a digital format on six separate tracks contained on a 1/4 inch Mylar based magnetic tape. The recording process consisted of tape being drawn from one reel to another, through a set of read/write heads, as well as erase heads. The DFDR was examined upon receipt, and during tape removal, was found to be in good condition. The DFDR data were transcribed from the DFDR magnetic tape medium to hard disk for further analysis using the NTSB laboratory readout equipment. The DFDR tape was a continuous loop. In order to maintain the loop, the ends of the tape were physically spliced together. Immediately following the splice in the tape, was a transparent section called a "window". The window let the recorder know to switch to the next track to continue the recording. The timing of the incident was such that the final approach and landing of the flight in question occurred at that point physically on the tape. The result was a very "messy" readout with many data dropouts and blank spots. A good portion of the data was irretrievable because of the set of circumstances. The spots were noticeable upon analysis of the graphical and tabular data. In addition to the loss of data associated with the normal track change and splice, the recording was subjected to a random track change. The F800 recorder model had a tendency to randomly change tracks. Additionally, American Eagle had experienced problems with the make and model DFDR in the past. According to a letter from the Manager of Flight Safety at American Eagle: "...In the past we have downloaded the information from several FDR's following minor inciden
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.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
