KILLEEN, TX, USA
N353SB
Saab 340B
The captain was the flying pilot for the night landing on runway 01 in instrument meteorological conditions (IMC), with a right cross wind from 110 degrees at 14 gusting 18 knots, drizzle, and a wet runway. Prior to starting the approach, the flightcrew determined that the landing approach speed (Vref) and the approach speed (Vapp) were 122 and 128 knots, respectively. DFDR data showed the airplane flying on autopilot as it passed the middle marker at 200 feet AGL at 130 knots on the ILS approach. Approximately 3 seconds after the first officer called "runway in sight twelve o'clock," the captain disconnected the autopilot, while at a radio altitude of 132 feet and on a heading of approximately 18 degrees. Within approximately 11 seconds after the autopilot disconnect, the glideslope and localizer deviation increased. The first officer called "runway over there." Approximately 5 seconds before touchdown, the airplane rolled right, then left, then right. DFDR data-based performance calculations showed the airplane crossed the threshold at an altitude of 35 feet and 130 knots. The airplane touched down 2,802 feet from the approach end of the 5,495-foot runway (844-foot displaced threshold) at 125 knots on a heading of 10 degrees. The airplane overran the runway and struck a ditch 175 feet beyond the departure end of the runway. Landing roll calculations showed a ground roll of 2,693 feet after touchdown, consisting of 1,016 feet ground roll before braking was initiated and 1,677 feet ground roll after braking was initiated until the airplane exited the pavement. According to Saab, for a wet runway, the aircraft would have needed 1,989 feet from the time of braking initiation to come to a complete stop. The American Eagle Airlines, Inc., FAA approved aircraft operating manual (AOM), states in part: Stabilized approaches are essential when landing on contaminated runways. Landing under adverse weather conditions, the desired touch-down point is still 1,000 feet from the approach end of the runway. Touchdown at the planned point. Cross the threshold at Vapp, then bleed off speed to land approximately Vref -5. Use reverse, if needed. To achieve maximum braking effect on wet runway, apply maximum and steady brake pressure. In 1992, the City of Killeen submitted a proposal that included extending the north end of runway 01 by 194 feet. The FAA originally disapproved the proposal, in part, because the runway extension decreased the length of the runway safety area (RSA) which was already shorter than the recommended 1,000 feet for a 14 CFR Part 139 certificated airport. The proposal was subsequently approved and a drainage ditch was installed in the north RSA, perpendicular to the runway and approximately 175 feet north of the departure end of runway 01. In 1993, the airport received FAA Part 139 certification. The 1998 and 1999, FAA airport certification inspection reports noted the inadequate RSA; however, neither letter of correction, sent from the FAA to the City of Killeen following the inspections, mentioned the RSA. Following this accident, the ILS runway 01 was flight checked by the FAA and all components were found to be operating within prescribed tolerances. Examination of the airplane found no anomalies that would have prevented it from operating per design prior to departing the runway and encountering the ditch.
HISTORY OF FLIGHT On March 21, 2000, approximately 1914 central standard time, a Saab 340B twin turboprop airplane, N353SB, operating as Eagle Flight 3789, sustained substantial damage upon impact with a drainage ditch following a runway overrun during the landing roll on runway 01 at the Killeen Municipal Airport (ILE), Killeen, Texas. (All times in this report are central standard time, based on a 24-hour clock). The airplane was operated by American Eagle Airlines, Inc., and was registered to AMR Leasing Corporation of Fort Worth, Texas. The scheduled domestic passenger/cargo flight was operating under 14 Code of Federal Regulations (CFR) Part 121. The 3 crewmembers and 33 passengers were not injured. One passenger was transported to the hospital for treatment of hypertension. Night instrument meteorological conditions (IMC) prevailed for the flight, and an instrument flight rules (IFR) flight plan had been filed. The flight originated at 1829 from the Dallas/Fort Worth International Airport (DFW), Texas, with a destination of ILE. According to the cockpit voice recorder (CVR) data and flight crew interviews, the captain was the pilot flying (PF) on the flight from DFW to ILE, and the first officer was the non-flying pilot (PNF). The flight crew reported that the takeoff/initial climb from DFW, the en route phase of flight, and the clearance for the instrument landing system (ILS) approach at the destination non-towered airport were routine. At 1854:36, the PNF obtained the ILE automated weather observation: wind from 090 degrees at 11 knots, visibility 1 1/2 miles, ceiling sky overcast at 200 feet, temperature 18 degrees Celsius, dew point 17 degrees Celsius, altimeter 29.96 inches Hg. At 1855:34, the PNF made initial contact with the Gray Approach Control controller and reported the flight descending to 8,000 feet. At 1855:39, the flight crew was advised by the controller to expect an ILS runway 01 approach at ILE. The flight crew performed the descent and approach checklist during which the altimeters were set to 29.96 inches of Hg, and the speeds were briefed as 122 [Vref-red], 128 [V-approach green], and 130 [V-minimum maneuvering or V-clean configuration] knots, respectively. At 1857:55, the controller cleared the flight to descend to 3,000 feet. At 1859:22, the PNF identified the Morse code for the IRESH NDB/OUTER MARKER. At 1859:59, the controller began vectoring the flight for the ILS approach to runway 01 at ILE and assigned an initial heading of 190 degrees. The PF briefed on the missed approach procedures, and the PNF tuned and identified the Morse code for the localizer for runway 01 at ILE. After a series of turns the flight was cleared at 1908:42 for the ILS runway 01 approach. Subsequently, the glideslope and localizer were intercepted, and the flight crew performed the before landing checklist. At 1910:22, the controller issued a frequency change, and requested that the flight crew report when the airplane was on the ground. At 1910:41, the PNF transmitted that Eagle flight 789 was on the ILS runway 01 Killeen, five miles out. At 1912:33, the PNF called approaching minimums. At 1912:40, the PNF called intermittent ground contact. At 1912:46, the PNF called runway in sight twelve o'clock. At 1912:49, there was a sound similar to autopilot disconnect, and the PF called going visual. At 1913:01, the PNF called "runway over there". At 1913:28, there was a sound of loud noise. At 1913:37, the captain gave the command to evacuate the aircraft. The airplane was evacuated through the main cabin door, and the passengers were transported to the terminal via vans. The captain notified the controller that the airplane went off the end of the runway. The first officer notified American Eagle Operations/Dispatch that the airplane ran off the end of the runway. During interviews and in written statements, the captain reported that he "did not have the condition of the runway prior to the touchdown or he would not have landed the airplane at ILE." There were no aircraft discrepancies in flight. During the ILS approach, the airplane was on glideslope and on localizer at Vref 122 or less. Touchdown was in the touchdown zone (TDZ) and before glideslope intersect of the runway. The landing was "firm" on the right main landing gear followed by the left main landing gear and nose landing gear. Upon seconds after touchdown, the airplane was slipping forward and left (diagonal) toward the left side and felt like it was skidding along and accelerating. The captain described it as "like stepping on a banana." He said he did not lose 100% directional control; however, as he attempted to maintain centerline alignment, the airplane veered right, departed the runway onto the grass, and into the ditch. The captain described the runway as contaminated: glassy, slick, lots of water, braking action NIL. The last weather report obtained by the crew was from the ILE Automated Weather Observation System (AWOS), which was recalled as 1 1/2 miles visibility, 200-foot overcast, with the wind from 090 degrees at 11 knots. During interviews and in a written statement, the first officer (FO) reported that he did not observe any aircraft discrepancies during the preflight inspection at DFW or en route to ILE. The FO stated the touchdown at ILE was 500 feet beyond the displaced threshold, and the aircraft was slipping after touchdown. He recalled a lack of deceleration. He observed the power levers moving aft toward beta; however, he did not recall full reverse before departing the runway. The FO did not recall puddles of water on the runway or constant precipitation at the time of the landing. He described the runway as glassy. The weather was mist in the air and the visibility was good. He recalled the anti-skid working, deceleration, and braking. One witness, an Army Aviation Safety Officer and pilot, who was waiting for a passenger on the flight, first sighted the airplane on final approach "approximately 600 feet agl. On short final the [air]plane making sharp corrections to first the left, and then to a lesser correction to the right." The airplane was "still making corrections when it touched down on the runway, abeam the witness's position near the terminal, approximately mid field before taxiway Delta. The aircraft was still traveling at a high rate of speed at touchdown and did not appear to slow as it continued down the runway." This witness reported the weather conditions were "overcast with light rain and drizzle." He further stated that the wind was from "090 degrees (windsock abeam my position approximately 500 feet away). The wind sock was fully extended." A second witness was one of the airport rescue and fire personnel, who also observed the aircraft's approach and landing from his location at midfield. He observed the airplane landing on the runway "about the 2,000 feet remaining marker." Further, this witness "thought it was going too fast and was not going to make it." The witness stated that the weather had been drizzling "off and on all day [and] the runway and taxiways were very wet." A third witness, the aircraft line technician, observed the airplane coming in on runway 01 with all landing lights on, and the aircraft "appeared to touchdown midfield" and "traveling faster than normal and the right wing dipped upon touchdown." Toward the end of the runway, "it appeared the tail section was moving up and down as if brakes were being applied at high speed. The aircraft turned right and the tail section raised to about a 45 degree angle and came back down" as the aircraft struck the ditch. The runway lights were on and the rotating beacon was operational. This witness reported the "wind was calm to light, low clouds and solid, not raining but damp and misty." Passenger Statements (NTSB Form 6120.9) were sent to twenty-two passengers. Nine passengers returned their Passenger Statements to the NTSB investigator-in-charge (IIC). On their statements, the passengers reported the following information: Seat belts were fastened during the entire flight, and the flight attendant expedited the evacuation in an orderly fashion. The passengers had to jump about 2-3 feet from the doorway to the ground. Passengers reported that it was 20-30 minutes to about 1 hour, standing in light drizzle and rain, before they were bused to the terminal. One passenger, a student pilot with 32 hours who stated he flew into ILE about 15 times per year on the airlines, reported the pilot brought the airplane in "high, hot, and long and quite simple run out of runway. The engine noise coming in didn't cut back much, we were higher than normal crossing the south border of the runway, we did land longer down runway, and the prop[ellers] trim was harder and more abrupt than normal." The pilot "waved the airplane on final several times" prior to touchdown. This passenger described the airplane as banking left just prior to touchdown, leveling before touchdown, and landing "normally." The landing was "quite a ways down the runway though [and] we rolled out quite a ways before the props [propellers] were trimmed and when this occurred it was substantially harder jolt than normal." A second passenger, who was also a pilot and had landed as a pilot at the airport many times, reported dark night conditions with a strong crosswind. Further, he stated the airplane was "coming in too fast and were too high, touchdown seemed to be farther down the runway than normal. Prop[ellers] reversal was not engaged for several seconds after touchdown. Full reverse thrust and full braking then occurred." Additionally, two passengers recalled "halfway past the runway as the airplane was landing." Other passengers reported the airplane was high and fast on the approach. The airplane did not touchdown on the first part of the runway. The touchdown was very bumpy. After touchdown, tires were grabbing, the engines were roaring loudly, and the airplane started shaking and the vibration got worse until the airplane stopped. Passengers described the conditions as dark night, sky overcast with low ceilings, fog, freezing drizzle, light drizzle, light rain, and rain. Some passengers reported there was good visibility below the cloud layer. PERSONNEL INFORMATION Neither the captain nor the first officer had any Federal Aviation Administration (FAA) record of airplane accidents, incidents, or enforcement actions. The accident flight occurred on the 2nd day of a 4-day trip sequence. On the day of the accident, the accrued crew duty time was 5 hours 35 minutes with an accumulated flight time of 2 hours and 29 minutes. Reviews of the flight and duty time records and crew interviews disclosed no evidence of any activities that would have prevented either flight crewmember from obtaining sufficient rest in the 72 hours before the accident. The Captain The captain held an airline transport pilot certificate with the ratings and limitations of airplane multiengine and single-engine land; and type ratings for the Saab 340 and L-382. The captain obtained his Saab 340 type rating on June 6, 1995. His most recent FAA first-class medical certificate was issued on November 18, 1999, with the limitation that he possess glasses for near and intermediate vision while acting as a pilot. During a review of company records, the completed Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2), interviews with company personnel, and an interview with the captain, the following information was revealed. The captain, hired in March 1989 by Simmons Airlines as a first officer, was upgraded to captain in August 1995 when American Eagle, Executive, Simmons, Wings West, and Flagship merged with AMR. The captain was designated as a company line check airman, and he was current and qualified (ground, emergency, flight, line) as captain for the CFR Part 121 flight. The captain's most recent recurrent ground and flight training was accomplished in June 1999 at the facilities of American Airlines, Inc., of Dallas, Texas. On June 14, 1999, the captain satisfactorily completed his most recent line check during a 1.08-hour flight from TXK to DFW. He had accumulated 12,518 total flying hours of which 9,251 (3,574 captain; 5,677 FO) were in the Saab 340. He had flown 74, 154, and 787 hours in the past 30 days, 90 days, and 1 year, respectively. The captain had accumulated 2,155 total night flying hours, and 1,186 actual instrument flight hours of which he estimated 750 hours were in the Saab 340. He had accumulated an estimated 106 flights into ILE during which he had performed the ILS runway 01 approach on several flights in IMC. The captain was previously dispatched on the DFW to ILE route on March 6 and March 7 in the Saab 340 airplane, where he landed the airplane at 2316 and 1831, respectively. The First Officer The first officer held a commercial pilot certificate with the ratings and limitations of airplane multiengine land, single-engine land, and instrument. He also held a flight instructor certificate with the ratings and limitations of airplane single-engine land and instrument. His most recent FAA first-class medical certificate was issued on June 23, 1999, with the limitation that he must wear corrective lenses for distant vision. During a review of company records, the completed Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2) and an interview with the first officer, it was revealed that the first officer was hired by American Eagle in June 1998 as a flight crewmember on the Saab 340 airplane. The first officer was current and qualified to act as second-in-command of the Saab 340B airplane for the CFR Part 121 flight. He had accumulated 2,105 total flying hours of which 1,040 hours were in the Saab 340. He had flown 70, 215, and 840 hours in the past 30 days, 90 days, and 1 year, respectively. The first officer had accumulated 436 total night flying hours, and 193 actual instrument flight hours. The first officer estimated that he had been a crewmember on 15 flights into ILE; however, this was the first flight in night IMC on the approach to minimums. AIRCRAFT INFORMATION N353SB, a Saab 340B, serial number (S/N) 353, was issued an airworthiness certificate on December 3, 1993. The airplane was configured to carry 35 passengers, two pilots, and one flight attendant. The airplane was equipped with two General Electric, model CT7-9B, engines rated at 1,750 shaft horsepower for maximum continuous and normal takeoff. The airplane was equipped with two Hamilton Standard, Model 14 RF-19, four bladed composite propellers. According to a Saab Aircraft engineer, the "power lever angles are 90 degrees maximum, 42 degrees flight idle, 19 degrees ground idle, and 0 degrees maximum reverse." Further, the engineer stated the "power lever angle at ground idle can not be adjusted and is not affected by A/C rigging. Position for the ground idle is 18-22 degrees measured from the surface of the control quadrant, or as an alternate measurement: 18.5 +-1 degrees aft rig point in the control quadrant." DFDR data for the previous flight indicated a left power lever angle of 14.1 degrees; right 15.2 degrees, respectively, when the aircraft was parked at the gate. Weight and Balance Eagle flight 3789 departed DFW with 2,794 pounds of fuel. The subsequent de-fueling at the accident site was calculated at 2,200 pounds. Landing field length with flaps 20 degrees, temperature 18 degrees Celsius, winds 100/9, wet asphalt and landing weight of 28,170 pounds calculated as 4,200 feet with good braking. Medium to good braking (4,560 feet) add 360 feet, medium braking (4,974 feet) add 774 feet. If reverse is not available, add 4,017 feet to landing field chart length. Utilizing the SAAB 340B center of gravity calculator, the airplane's landing weight of 28,170 pounds and its center of gravity (CG) were within landing limits. According to the American Eagle Airlines, Inc., FAA approved operating manual, the landing approach speed (Vref) for the calculated landing weight was 120 knots. V approach (minimum Vref
the captain's failure to follow standard operating procedure for landing on a contaminated ruway in that he touched down long, which combined with his delayed braking resulted in a runway overrun. Contributing factors were the captain's failure to maintain runway alignment following his disconnect of the autopilot, the gusty crosswind and the wet runway. In addition, the following were contributing factors: (1) the airport operator's failure to fill in a ditch in the runway safety area, (2) the FAA's granting of 14 CFR Part 139 approval to the airport when the runway safety area (RSA) did not meet the recommended length for a Part 139 airport, and (3) the FAA's continued lack of acknowledgement to the airport of the inadequate RSA following their annual airport inspection checks.
Source: NTSB Aviation Accident Database
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