New York, NY, USA
N278EA
BOEING 737 7L9
Automatic terminal information service (ATIS) "Bravo" was current when the first officer, who was the pilot flying, began to brief the instrument landing system approach for runway 22. The ATIS indicated visibility 3 miles in rain, ceiling 1,500 ft broken, overcast at 2,200 ft, wind from 130º at 9 knots, and that braking action advisories were in effect. The approach briefing included the decision altitude and visibility for the approach and manual deployment of the speed brakes by the captain, with the captain stating "you're gonna do these. I'm gonna do this" to which the first officer replied "[that] is correct." (The airplane's automatic speed brake module had been deactivated 2 days before the incident and deferred in accordance with the operator's minimum equipment list, which was appropriate). The flight crew completed the approach briefing after descending through 18,000 ft mean sea level and completed the landing checklist when the airplane was near the final approach fix. The airplane was configured for landing with the autobrake set to 3 and the flaps set to 30º. ATIS information "Charlie" was current at that time and indicated visibility 3 miles in rain, ceiling 900 ft broken, overcast at 1,500 ft, and wind from 120º at 9 knots. Flight data recorder (FDR) data and postincident flight crew statements indicate that the airplane was stabilized on the approach in accordance with the operator's procedures until the flare. The airplane crossed the runway threshold at 66 ft radio altitude at a descent rate of 750 ft per minute. When the airplane had traveled about 2,500 ft beyond the runway threshold, its descent rate decreased to near zero, and it floated during the flare. Its pitch attitude started to increase in the flare from 2.8° at a radio altitude of about 38 ft, which is high compared to the 20 ft recommended by the Boeing 737 Flight Crew Training Manual. Further, the first officer didn't fully reduce the throttles to idle until about 16 seconds after the flare was initiated and after the airplane had touched down. The initiation of the flare at a relatively high altitude above the runway and the significant delay in the reduction of thrust resulted in the airplane floating down the runway, prompting the captain to tell the first officer to get the airplane on the ground, stating "down down down down you're three thousand feet remaining." The airplane eventually touched down 4,242 ft beyond the runway threshold. According to the operator's procedures, the touchdown zone for runway 22 was the first third of the 7,001-ft-long runway beginning at the threshold, or 2,334 ft. Touchdown zone markers and lights (the latter of which extended to 3,000 ft beyond the threshold) should have provided the flight crew a visual indication of the airplane's distance beyond the threshold and prompted either pilot to call for a go-around but neither did. The point at which the airplane touched down left only about 2,759 ft remaining runway to stop. The airplane's groundspeed at touchdown was 130 knots. The captain manually deployed the speed brakes about 4.5 seconds after touchdown and after the airplane had traveled about 1,250 ft down the runway. Maximum reverse thrust was commanded about 3.5 seconds after the speed brakes were deployed, and, with fully extended speed brakes and maximum wheel brakes (which were applied at main gear touchdown) the airplane achieved increasingly effective deceleration. Its groundspeed was about 35 knots when it entered the EMAS. With the effective deceleration provided by the fully extended speed brakes, maximum wheel brakes, and reverse thrust, the flight crew would have been able to safely stop the airplane if it had touched down within the touchdown zone. The captain later stated that he had considered calling for a go-around before touchdown but the "moment had slipped past and it was too late." He said that "there was little time to verbalize it" and that he instructed the first officer to get the airplane on the ground rather than call for a go-around. He reported that, in hindsight, he should have called for a go-around the moment that he recognized the airplane was floating in the flare. The first officer said that he did not consider a go-around because he did not think that the situation was abnormal at that time. Training and practice improve human performance and response time when completing complex tasks. In this case, the operator's go-around training did not include any scenarios that addressed performing go-arounds in which pilots must decide to perform the maneuver rather than being instructed or prompted to do so. Thus, the incident flight crew lacked the training and practice making go-around decisions, which contributed to the captain's and first officer's failure to call for a go-around. Following the incident, the operator incorporated go-around training scenarios in which flight crews must decide to go around rather than being instructed to do so. The company's director of operations also stated that the company has incorporated scenarios in which go-arounds are initiated from idle power and rejected landings are performed after touchdown with the automatic speed brake inoperative. It also added a training module emphasizing that "if touchdown is predicted to be outside of the [touchdown zone], go around" and intended to require a go-around if landing outside of the touchdown zone were predicted. The operator also intended to incorporate go-around planning into the approach briefing. Flight crews would determine the cues for the touchdown zone using the airport diagram and decide at which point they would initiate a go-around if the airplane had not touched down. Given the known wet runway conditions and airplane manufacturer and operator guidance concerning "immediate" manual deployment of the speed brakes upon landing, the captain's manual deployment of the speed brakes was not timely. NTSB analysis of FDR data for previous landings in the incident airplane determined an average of 0.5 second for manual deployment of the speed brakes. Using the same touchdown point as in the incident, postincident simulations suggest that, if the speed brakes had been deployed 1 second after touchdown followed by maximum reverse thrust commanded within 2 seconds, the airplane would have remained on the runway surface. Therefore, the captain's delay in manually deploying the speed brake contributed to the airplane's runway departure into the EMAS. During the landing roll, the captain did not announce that he was assuming airplane control, contrary to the operator's procedures, and commanded directional control inputs that countered those commanded by the first officer. The captain later reported that he had forgotten that an EMAS was installed at the end of runway 22 and attempted to avoid the road beyond the runway's end by applying right rudder because he thought it would be better to veer to the right. However, the first officer applied left rudder to maintain alignment with the runway centerline and to counter the airplane pulling "really hard" to the right because of the captain's inputs. The breakdown of crew resource management during the landing roll and the captain's failure to call for a go-around demonstrated his lack of command authority, which contributed to the incident. At the time of the incident, EMAS training was not part of the operator's pilot training program, but such training was added after the incident. The circumstances of this event suggest that the safety benefit of EMASs could be undermined if flight crews are not aware of their presence or purpose.
HISTORY OF FLIGHT**This report was modified on September 18, 2017. Please see the docket for this accident to view the original report.** On October 27, 2016, about 1942 eastern daylight time, Eastern Air Lines flight 3452, a Boeing 737-700, N923CL, overran runway 22 during the landing roll at LaGuardia Airport (KLGA), Flushing, Queens, New York. The airplane traveled through the right forward corner of the engineered materials arresting system (EMAS) at the departure end of the runway and came to rest off the right side of the EMAS. The 2 certificated airline transport pilots, 7 cabin crewmembers, and 39 passengers were not injured and evacuated the airplane via airstairs. The airplane sustained minor damage. The charter flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night instrument flight rules conditions prevailed at the airport at the time of the incident, and an instrument flight rules flight plan was filed for the flight, which originated at Fort Dodge Regional Airport (KFOD), Fort Dodge, Iowa, about 1623 central daylight time. The first leg of the trip began on October 14, 2016, and the captain and first officer were paired from then to the incident. In postincident statements, the flight crew indicated that the captain was the pilot monitoring (PM) for the incident flight, and the first officer was the pilot flying (PF). The first officer reported that the autopilot and autothrottles were engaged beginning about 2,500 ft after their takeoff from KFOD. Both pilots stated that the en route portion of the flight and the descent into the terminal area were uneventful but they encountered moderate-to-heavy rain during the final 15 minutes of the flight. According to information from the airplane's cockpit voice recorder (CVR), the first officer partially briefed the instrument landing system (ILS) approach for runway 13 beginning about 1848, indicating an autobrake setting of 3 and a 30º flap setting. ATIS information "Bravo" was current at that time and indicated visibility 3 miles in rain, ceiling 1,500 ft broken, overcast at 2,200 ft, wind from 130º at 9 knots, and that braking action advisories were in effect. About 1852, the first officer began briefing the ILS approach for runway 22 after the captain clarified, based on the ATIS recording, that runway 13 was being used for departures. About 1902, as the airplane descended through 18,000 ft msl, the flight crew completed the approach briefing for runway 22, with the same autobrake and flap setting as indicated earlier, as well as the decision altitude and visibility required for the approach, the touchdown zone elevation, and a reference speed (Vref) of 137 knots. ATIS information "Charlie" was current at that time and indicated visibility 3 miles in rain, ceiling 900 ft broken, overcast at 1,500 ft, and wind from 120º at 9 knots. The flight crew also discussed the captain manually deploying the speed brakes (the airplane's automatic speed brake module had been deactivated 2 days before the incident and deferred in accordance with the company's minimum equipment list (MEL), with corrective action scheduled for November 4, 2016). In reference to the manual deployment of the speed brakes, the captain stated at 1902:44.5 "you're gonna do these. I'm gonna do this" to which the first officer replied "[that] is correct." About 1927, the flight was provided vectors to the final approach course for the ILS approach to runway 22. About 1936, the flight was cleared for the approach. The first officer then called for the landing gear to be extended and the flaps set at 15º. About 1937, the captain stated that the localizer and glideslope were captured. About 1938, as the airplane neared the final approach fix, the flight crew completed the landing checklist and configured the airplane for landing, with flaps set to 30º. The CVR indicates that the captain pointed out the approach lights about 1939. The first officer reported, and flight data recorder (FDR) data indicate, that about 1940:12, he disconnected the autopilot when the airplane's altitude was about 300 ft radio altitude, as required by Eastern Air Lines standard operating procedure. FDR data indicate that the first officer disconnected the autothrottles about 1940:19. FDR data indicate that, shortly after the first officer disconnected the autopilot and autothrottles (about 300 ft radio altitude), the airplane began to increasingly deviate above the glideslope beam and crossed the threshold at a height consistent with the threshold crossing height of the VGSI, which was not coincident with the glide slope beam. CVR data indicate that between 1940:35 and 1940:46, the enhanced ground proximity warning system alerted the decreasing altitude in increments of 10, beginning at 50 ft. The pitch attitude started to increase in the flare from 2.8° at a radio altitude of about 38 ft. After the 20-ft alert, the captain stated "down" at 1940:43.3. After the 10-ft alert, the captain stated, "down down down down you're three thousand feet remaining" at 1940:46.6. There was no callout of spoilers or thrust reversers during the rollout on the CVR. FDR data and performance calculations indicate that the airplane crossed the runway threshold at a radio altitude of 66 ft, with an increasing glideslope deviation and a descent rate of about 750 ft per minute. When the airplane had traveled about 2,500 ft beyond the runway threshold, its descent rate decreased to near zero, and it floated before touching down. The captain later reported that the descent to the touchdown zone was normal until the flare. He stated that the airplane floated initially in the flare, which prompted the captain to tell the first officer to "get it down." The first officer recalled hearing the captain's instruction to "put [the airplane] down" during the flare but was not certain how far down the runway the airplane touched down. FDR data indicate that, at 1940:51.8, the airplane's main landing gear touched down; maximum manual wheel brakes were applied at main gear touchdown. The throttles were not fully reduced to idle until about 16 seconds after the flare was initiated, and after the airplane had touched down. The touch down point was about 4,242 ft beyond the threshold of the 7,001-ft-long runway. The nose gear initially touched down about 2 seconds after the main landing gear but rebounded into the air due to aft control column input. The nose gear touched down a second and final time at 1940:56.8. The captain reported that, as briefed, he manually deployed the speed brakes, which FDR data indicate were manually extended to full at 1940:56.3, about 4.5 seconds after the main landing gear touched down and the airplane had traveled about 1,250 ft farther down the runway from the touchdown point. At 1940:59.8, when the airplane had traveled about 1,650 ft down the runway from the touchdown point (and 5,892 ft from the threshold), maximum reverse thrust was commanded. The captain reported that he saw the end of the runway approaching and began to apply maximum braking, as well as right rudder because he thought it would be better to veer to the right rather than continue straight to the road beyond the end of the runway. The first officer reported that the captain did not, as required in the operator's procedures, tell him that he was attempting to brake and steer the airplane during the landing rollout, and no such callout is recorded on the CVR. The first officer stated that the airplane was pulling to the right "really hard," which prompted him to apply left rudder. He reported that the left rudder input was counter to his expectation due to a 9-knot crosswind from the left, which he expected to counteract with right rudder input. He attempted to maintain alignment with the runway centerline by applying left rudder and overriding the autobrakes with pressure on the brake pedal. At 1941:08.3, the CVR recorded the sound of rumbling, consistent with the airplane exiting the runway. The airplane then entered the EMAS about 35 knots groundspeed and came to rest 172 ft beyond the end of the runway and to the right of the EMAS. Review of the CVR recording revealed that, after the airplane came to a stop, the first officer twice remarked that they should have conducted a go-around, and the captain agreed. The first officer later reported that he did not believe the approach or landing were abnormal at the time. The captain later stated that he should have called for a go-around when the airplane floated during the flare. PERSONNEL INFORMATIONThe Captain The captain, age 58, held an airline transport pilot (ATP) certificate with a rating for airplane single- and multiengine land with commercial privileges, with type ratings on the Boeing 737, DC-10, DC-8, and MD-11, Bombardier CL-65, BAE Systems HS-114, and Lockheed Martin L-188. He also held a Federal Aviation Administration (FAA) first-class medical certificate dated July 20, 2016, with a limitation for glasses or corrective lenses for near and intermediate vision. He was hired by Eastern Air Lines in June 2015 as a first officer and upgraded to captain in February 2016, when he received captain leadership training. At the time of the incident, he was based in Miami, Florida. Before joining Eastern Air Lines, the captain was a pilot at Centurion Cargo, where he was hired as a first officer on the DC-10 in 2005 and subsequently upgraded to captain on the MD-11 in 2010. According to Eastern Airlines personnel records, the captain had 20,638 hours of flight experience, 14,767 hours pilot-in-command (PIC) time, with 3,000 hours on 737s and 202 hours as PIC on 737s. He flew 75 hours, 28 hours, and 11 hours during the 90-, 30-, and 7-day periods, respectively, preceding the incident. He also reported flying 1.5 hours during the 24-hour period before the incident. His most recent 737 proficiency check occurred March 16, 2016. A review of FAA records found no prior accident, incident, or enforcement actions. 72-Hour History On Monday, October 24, the captain flew from Indianapolis, Indiana, to Charlotte, North Carolina; Charlotte to Greensboro, North Carolina; and Greensboro to Indianapolis, arriving at 2119 EDT. He went to bed about 0030 EDT and slept until 1100 EDT. On Tuesday, October 25, he and the first officer flew commercially to Salt Lake City, Utah, via Minneapolis, Minnesota. After arriving about 1700 mountain daylight time (MDT), he went to dinner with his son. He watched television for about an hour and went to sleep about 2230 MDT. On Wednesday, October 26, he slept until 0800 MDT and went to breakfast about 1000 MDT. He met his son briefly in the morning and flew from Salt Lake City to Colorado Springs, Colorado, then Colorado Springs to Omaha, Nebraska. He was off duty at 2356 CDT and went to bed about 0130 CDT on October 27. On Thursday, October 27, he awoke about 0830 CDT. He reported having no difficulties sleeping that night and stated that, when he awoke, he felt as rested as could be expected with "normal flying" 14 days into a trip (the first leg of the captain's trip began on October 14). He took a shuttle to the airport about 1000 CDT. He flew to KFOD from which he departed for the incident flight to KLGA. The First Officer The first officer, age 49, held an ATP certificate with a rating for airplane single- and multiengine land with commercial privileges and with type ratings on the Boeing 737, Cessna Citation CE-500, and Embraer ERJ-170 and ERJ-190. He also had an FAA first-class medical certificate dated October 11, 2016, with a limitation for glasses for near vision. His date of hire with Eastern Air Lines was December 1, 2015. At the time of the incident, he was based in Miami, Florida. Prior to Eastern Air Lines, he was employed by Republic Airlines as a pilot flying the ERJ-170. In 2007, he began working as a flight instructor, which he did for about 5 years. He began flight training in 2002. According to Eastern Airlines personnel and FAA records, the first officer had 6,200 hours of flight experience, 3,137 hours PIC time, and 225 hours on 737s. He flew 57 hours, 35 hours, and 11 hours during the 90-, 30-, and 7-day periods, respectively, preceding the incident. He also reported flying 1.5 hours during the 24-hour period before the incident. The first officer's most recent 737 proficiency check occurred February 2, 2016. A review of FAA records found no prior accident, incident, or enforcement actions. 72-Hour History On Monday, October 24, the first officer had a 31-hour rest period in Indianapolis that ended at 1530 EDT. He flew from Indianapolis to Charlotte, Charlotte to Greensboro, and Greensboro to Indianapolis. He reported sleeping well that night but did not indicate when he went to bed. He awoke between 0815 to 0830 EDT on Tuesday, October 25. He flew from Indianapolis to Salt Lake City arriving about 1641 MDT. He estimated he went to bed between 0130 and 0200 MDT on October 26. On Wednesday, October 26, he had a report time of 1540 MDT and flew from Salt Lake City to Colorado Springs then to Omaha. He went to bed around 0100 CDT on October 27. He estimated that he awoke between 0815 to 0830 CDT on Thursday, October 27, and ate breakfast. He could not recall the quality of his rest the night before the incident. He remained in the hotel after breakfast and went to the gym, worked out, and did laundry. He then showered and departed for the airport. He operated the flight to KFOD then departed on the incident flight to KLGA. AIRCRAFT INFORMATIONThe Boeing 737-700 airplane, serial number 28006, was manufactured May 15, 1998, and equipped with two CFM International CFM56-7B22 engines. At the time of the incident, the airplane had accumulated 48,179 hours of operation, the No. 1 (left) engine had 34, 671 hours, and the No 2. (right) engine had 20,456 hours. The airplane was equipped with an auto speed brake system that, when armed, automatically deployed the spoilers after touchdown to reduce the airplane's lift and increase the effectiveness of the wheel brakes. Alternatively, the flight crew could use the speed brake lever to deploy the spoilers manually. As previously mentioned, the system's automatic mode was inoperative; maintenance records indicate that a ground spoiler did not automatically deploy during a previous landing. The status of the automatic mode was indicated by a paper sticker wrapped around the base of the speed brake handle. In addition, the amber SPEED BRAKE DO NOT ARM light above the captain's right display unit illuminated when the automatic mode was unavailable. The flight crew's paperwork for the flight contained the procedures for the MEL item (see Organization and Management Information for more information). Each engine was equipped with a hydraulically operated thrust reverser, which consisted of left and right translating sleeves. Reverse thrust was produced by aft movement of the reverser sleeves, which caused blocker doors to deflect fan discharge air forward through fixed cascade vanes. According to manufacturer guidance, thrust reversers are manually deployed after touchdown to slow the airplane, reducing stopping distance and brake wear. The autobrake system, which is part of the airplane's hydraulic brake system, monitored the airplane's deceleration after landing and metered hydraulic pressure (via the antiskid/autobrake control unit) to the brakes to achieve the level of deceleration selected by the autobrake select switch. The switch on the incident airplane was found positioned at "3." A manual brake application by either flight crewmember would override and disarm the autobrake system. The airplane's antiskid system controlled the brakes to prevent the wheels from skidding during braking action. An antiskid transducer was located in each main landing gear axle to provide the system with rotational wheel speed. The system monitored the speed and metered hydraulic pressure to each brake to prevent skidding (see the Tests and Research section for additional information on this system). Weight and Balance Eastern Air Lines used the Jeppesen JetPlanner and a nomograph as the primary means of producing weight and balance and performance data for
The first officer's failure to attain the proper touchdown point and the flight crew's failure to call for a go-around, which resulted in the airplane landing more than halfway down the runway. Contributing to the incident were, the first officer's initiation of the landing flare at a relatively high altitude and his delay in reducing the throttles to idle, the captain's delay in manually deploying the speed brakes after touchdown, the captain's lack of command authority, and a lack of robust training provided by the operator to support the flight crew's decision-making concerning when to call for a go-around.
Source: NTSB Aviation Accident Database
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