Accident Details
Probable Cause and Findings
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.
Aircraft Information
Registered Owner (Historical)
Analysis
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 ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# FTW00FA101