Accident Details
Probable Cause and Findings
The pilots' decision to land at Cherry Capital Airport (TVC), Traverse City, Michigan, without performing a landing distance assessment, which was required by company policy because of runway contamination initially reported by TVC ground operations personnel and continuing reports of deteriorating weather and runway conditions during the approach. This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions. Contributing to the accident were 1) the Federal Aviation Administration pilot flight and duty time regulations that permitted the pilots' long, demanding duty day and 2) the TVC operations supervisor's use of ambiguous and unspecific radio phraseology in providing runway braking information. The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-08-02.
Aircraft Information
Registered Owner (Historical)
Analysis
The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-08-02.
On April 12, 2007, about 0043 eastern daylight time, a Bombardier/Canadair Regional Jet (CRJ) CL600-2B19, N8905F, operated as Pinnacle Airlines flight 4712, ran off the departure end of runway 28 after landing at Cherry Capital Airport (TVC), Traverse City, Michigan. There were no injuries among the 49 passengers (including 3 lap-held infants) and 3 crewmembers, and the aircraft was substantially damaged. Weather was reported as snowing. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and had departed from Minneapolis-St. Paul International (Wold-Chamberlain) Airport (MSP), Minneapolis, Minnesota, about 2153 central daylight time (CDT). Instrument meteorological conditions prevailed at the time of the accident flight, which operated on an instrument flight rules (IFR) flight plan.
The accident occurred on the fifth and final scheduled flight segment on the first day of a scheduled 4-day trip for the flight crew. The flight was scheduled to depart MSP about 2030 CDT for a scheduled arrival time at TVC of 2251. However, when the pilots arrived at the gate for the accident flight, the gate agent advised them that the flight release paperwork was not available and that the flight might be cancelled. About 2022 CDT (about 8 minutes before the accident flight was originally scheduled to depart), the Pinnacle dispatcher provided the captain with details, indicating that the flight could not be dispatched to TVC because the forecast winds at TVC resulted in a tailwind component that exceeded the CRJ's 10-knot landing tailwind component limitation. However, about 22 minutes later, the dispatcher advised the captain that the flight could be dispatched because a new forecast predicted a smaller tailwind component for the landing at TVC. Postaccident interviews indicate that Pinnacle's system operations control (SOC) duty manager had reviewed the observed conditions and forecast for TVC (from Northwest Airline's [NWA] meteorology department) and approved the release.
The flight's dispatch documentation, which listed Detroit Metropolitan Wayne County Airport (DTW) as a destination alternate airport, was subsequently issued about 2043 CDT. However, because the flight was delayed, an update of the airplane's flight management system database software was required before the airplane could depart. After installation of this software, the airplane was pushed back from the gate at MSP about 2144 CDT. The pilots taxied the airplane to the runway 30R deice pad, where it was deiced and the departure clearance was issued. About 2153 CDT, an MSP air traffic control tower (ATCT) controller issued a takeoff clearance, and the accident flight departed for TVC.
Postaccident crew interviews and review of the cockpit voice recorder (CVR) transcript indicated that the departure, climb, and en route portion of the flight from MSP to TVC was routine. The captain/check airman was the flying pilot and was overseeing the first officer's initial operating experience (OE); the first officer performed the duties of the monitoring pilot. The CVR recorded several instances during the accident flight in which the pilots indicated that they were tired. For example, the CVR recorded the following statements on the captain's channel: 1) about 2332:12, "yeah, just tired. Too late for this...;" 2) about 2341:53, "aw I'm tired dude, just (expletive) worn out;" and 3) about 0018:43 "...a wet dog ready to go to sleep tonight dude." Additionally, about 0020:41, the CVR recorded the first officer stating, "jeez, I'm tired." Further, several yawns were recorded on the captain's channel (about 2340:00, 0001:06, 0004:00, and 0009:47).
Because the TVC ATCT had closed at 2200 the night of the accident (consistent with its normal operations), the captain briefed the first officer regarding landing at TVC at night, after the tower closed, in snowy windy weather conditions. Records indicate that the Pinnacle dispatch personnel who were providing flight-following services for the accident flight occasionally provided the pilots with updated TVC weather information during earlier portions of the flight. Specifically, the aircraft communications addressing and reporting system (ACARS) log showed that about 2354, dispatch personnel sent weather updates to the accident airplane indicating IFR conditions with restricted visibility in light snow. After reviewing the weather information (about 2357), the captain made a public address statement advising the passengers that the winds at TVC were "dying down significantly...so it looks like we're gonna have no problems gettin' in this evening."
About 0010, the pilots listened to the TVC automated surface observation system (ASOS) for updated airport weather information, which indicated, in part, that winds were out of 040º at 7 knots and visibility of 1 1/2 miles in light snow. About 0021, the MSP Air Route Traffic Control Center (ARTCC) controller confirmed that the accident pilots had received the current TVC weather and began to issue radar vectors for the instrument landing system (ILS) approach to runway 28 at TVC. About 0025, the captain sent a message to dispatch indicating that the TVC weather looked good for the approach, citing winds out of 040 degrees at 8 knots. Company dispatch personnel responded, stating, "[w]e show that too, looks like we should be good."
The weather data subsequently recorded by the TVC's ASOS showed that the conditions at TVC began to deteriorate rapidly after 0025, with visibility of 1/2 mile in moderate snow, sky obscured, and vertical visibility of 400 feet. The pilots did not listen to the ASOS again as they continued to follow ATC-provided radar vectors for the ILS approach to TVC; however, they did obtain information regarding runway conditions from TVC airport operations personnel. For example, beginning about 0025, the CVR recorded a radio conversation between the captain and the TVC airport operations supervisor regarding the runway condition and ongoing snow removal operations. The airport operations supervisor indicated that he had "multiple pieces of [snow removal] equipment" on runway 28 and that he was "running numbers for you as we speak." The captain indicated that they would be landing in about 13 minutes.
According to the CVR, about 0026:56, the airport operations supervisor radioed the pilots, advising that the braking action on runway 28 was "40 plus," with "thin wet snow [over] patchy thin ice...give us about [5 to 8] minutes to clear the runway...when you're ready to land." About 0029:10, the CVR recorded the captain stating, "there's snow removal on the field yet they're showing forty or better sounds like a contaminated...runway to me." During the next 4+ minutes, the CVR recorded additional conversation between the pilots, TVC operations, and MSP ARTCC personnel regarding the status of the snow removal equipment on the runway and the timing of the approach. About 0032:16 (about 6 minutes before the captain's estimated arrival time), the airport operations supervisor contacted the pilots to indicate that the last snow plow was off the runway. The captain responded, advising that the accident flight would be turning inbound and requesting additional airport traffic advisories if applicable.
About 0033, the captain advised the MSP ARTCC controller that the TVC runway was clear of snow removal equipment; the controller advised him that it would "be about another...2 minutes 'til I get you out far enough to turn you back onto the ILS." The pilots then discussed the length of the landing runway, and, about 0033:46, the captain stated, "...and at night it'll feel short too...with contaminant...more than likely." About 0034, the airport operations supervisor contacted the accident pilots again regarding their proximity to the airport. The captain replied that they expected an inbound turn clearance from the controller in about 1 minute, and the airport operations supervisor responded, "okay, roger that...it's comin' down pretty good here so ahhh (guess) I'll see you on the ground here." About 1 minute later, the airport operations supervisor queried the pilots about their progress, indicating "it's comin' down pretty good guys, just to give you a heads up." About 7 seconds later (about 0035:42), the controller issued the first of a series of heading changes, vectoring the accident pilots towards the approach to runway 28.
About 0036:19, the captain commented to the first officer, "...says it's comin' down good, which means its snowing...and we probably won't see the runway, so be ready for the missed [approach]." About 1 minute later, the airport operations supervisor contacted the pilots, stating 'I need to know if [you] guys are gonna be landing soon 'cause I gotta...this is fillin' in pretty quick down here...so, ah, how far are you guys out?" The captain replied that they were intercepting the approach course inbound and anticipated landing in "4 1/2, 5 minutes at the most."
According to the CVR, at 0038:03.2, the airport operations supervisor stated, "...I don't know what the ah conditions [are] like...the runway, but I'm gonna call braking action nil now. 'Cause it's fillin' in real hard." However, during that transmission, beginning at 0038:04.3, the controller also contacted the pilots, issuing another heading change for the approach. CVR information and postaccident interviews indicated that the pilots did not recognize or acknowledge the airport operations supervisor's nil braking action report. About 0038:30, the controller cleared the pilots for the ILS runway 28 approach at TVC. Postaccident evaluation of the CVR revealed that the first officer was initially monitoring both the common traffic advisory frequency (CTAF) and MSP ARTCC frequencies but ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# DCA07FA037