N14171

HISTORY OF FLIGHTOn March 4, 2019, about 1129 eastern standard time, CommutAir flight 4933, an Embraer EMB145XR, N14171, was attempting to land on runway 1 at Presque Isle International Airport  (PQI), Presque Isle, Maine, and impacted terrain to the right of the runway. The first officer and 2 of the 28 passengers sustained minor injuries, and the captain, the flight attendant, and 26 passengers were not injured. The airplane was substantially damaged. The scheduled passenger flight was operating under the provisions of Title 14 Code of Federal Regulations Part 121. Instrument meteorological conditions prevailed at the time of the accident.

The first officer’s most recent flight to PQI before the accident was on February 27, 2019. As part of the predeparture briefing for the accident flight, the first officer mentioned that, during the previous flight, the instrument landing system (ILS) localizer for runway 1 was offset when the airplane was aligned with the runway during a visual approach. (A localizer uses a radio beam to provide pilots of landing aircraft with lateral navigation information to align with the runway and is one of the two main components of an ILS; the glideslope is the other main component.) During a postaccident interview, the first officer, who was the pilot monitoring for that flight, stated that both he and the captain of that flight noticed an “incongruency” between the pink needle (which provides guidance from the airplane’s flight management system) and the green needle (which provides guidance from the ILS localizer signal).

The accident flight departed from Newark Liberty International Airport (EWR), Newark, New Jersey, about 1004. The captain was the pilot monitoring, and the first officer was the pilot flying. The en route portion of the flight was uneventful. According to CommutAir, once the airplane was in range of PQI, the flight crew received an updated airport weather report at the time—a special weather observation at 1031. The observation indicated that the wind was from 090° at 5 knots, visibility was 1/2 mile in moderate snow and freezing fog, and the cloud ceiling was broken at 1,100 ft and overcast at 1,800 ft.

According to the cockpit voice recorder (CVR), at 1101:42, a controller from the Boston Air Route Traffic Control Center (ARTCC) cleared the flight for an ILS approach to runway 1, and the captain acknowledged the instruction. At 1105:35, the controller terminated radar services and instructed the flight crew to change to the PQI common traffic advisory frequency (CTAF); PQI did not have an air traffic control tower. The captain acknowledged this instruction and then announced, over the CTAF, that the flight was 2 miles from FEROG (an approach waypoint) and inbound for the ILS approach to runway 1.

A PQI maintenance staff member (later identified as the maintenance foreman) contacted the flight crew at 1105:59, and the captain responded that the flight was 4 minutes away from the airport. At 1106:14, the first officer stated to the captain, “he said…he was out of the way now, so he’s clear,” indicating that the runway was clear of snow removal vehicles. Flight data recorder (FDR) data indicated that, at 1106:58, the airplane began its first approach to PQI. At 1107:50, the captain announced over the CTAF that the airplane was nearing the final approach fix for the approach.

The ILS approach to runway 1 at PQI had a decision altitude of 678 ft, which was 200 ft above ground level (agl), and a visibility requirement of 1/2 mile. The captain made the 1,000-ft callout (indicating that the airplane was 1,000 ft above the decision altitude) at 1108:38 and stated that the approach was stable and that she had “ground contact.” At 1109:03, the captain asked the first officer if he wanted the airport lights to be turned on. (The runway 1 edge lights, runway end identifier lights, and the approach lighting system were pilot controlled on a published frequency.) The first officer’s reply of “yeah. Turn them on” was preceded and followed by a sound similar to five microphone clicks.

The captain made the 500-, 400-, and 300-ft callouts between 1109:20 and 1109:33. The first officer then stated, “autopilot’s coming off,” which the captain acknowledged. At 1109:40, the captain made the 200-ft callout, which was followed by the “approaching minimums” and “minimums” aural annunciations from the enhanced ground proximity warning system. The CommutAir EMB 145 Aircraft Operations Manual stated that pilots should call for a go-around if the runway environment was not in sight by the decision altitude or if the successful completion of the approach was in doubt.

At 1109:54, the captain stated, “runway in sight. See it?” to which the first officer responded, “yeah” and “well I got somethin’ [that] looks like a runway up there.” The CVR recorded the aural annunciation “one hundred [ft]” at 1109:59. About 3.5 seconds later, the captain stated, “watch your speed,” which was followed by sounds similar to the stickshaker. At 1110:09, the captain stated, “go missed” twice; less than 1 second later, the first officer stated, “yeah we’re goin’ missed.” During a postaccident interview, the captain stated that she saw the approach lights but that she also saw a tower that looked “very close” to the airplane’s position. The first officer stated that, when he transitioned from looking at the instruments to looking outside, he expected to see the runway but saw what he described as “white on white.” The first officer also stated that he saw a structure with an antenna that was part of the runway environment but not the runway itself, so he executed the go-around. The maintenance foreman stated, during a postaccident interview, that the runway lights were not on after the first approach.

FDR data showed that the airplane had descended to a minimum pressure altitude of 703 ft (169 ft agl) before beginning to ascend. At 1110:33 and 1110:56, the captain stated over the CTAF that the flight was “going missed.” At 1111:05, the captain notified the Boston ARTCC that the flight “went missed…[and] we’re gonna give it another try.” The controller acknowledged the information and then instructed the flight crew to climb to and maintain 3,200 ft. At 1113:28, the captain contacted PQI maintenance and stated that the flight “went missed” and that she would call back again “for another try.”

Between 1113:50 and 1114:08, the captain and the first officer discussed the previous approach. The captain asked the first officer whether he lost the localizer, and he stated, “I don’t think so…I went outside the airplane, too early, and I didn't have the runway.” The first officer continued, “I thought I had the runway then I was like that is not the runway,” to which the captain responded, “yeah I thought that too.” At 1114:13, the first officer stated that, for the second approach, he would “stay inside on the localizer,” and the captain agreed. At 1115:20, the controller provided vectors for the ILS approach to runway 1, which the captain acknowledged.

At 1116:20, the captain contacted PQI maintenance about the second approach to the runway, and the maintenance foreman stated, “we’ll be all clear runway one.” The captain stated, “can you make sure those lights are on for us?” The maintenance foreman replied, “yes we will.” During a postaccident interview, the maintenance foreman reported that he turned on the lights to the high-intensity setting. At 1116:46, the first officer asked the captain, “did you ever see the lights at all last time?” The captain stated that she saw the lights but that “it’s really white down there that’s the problem.” The first officer agreed and stated, “everything is washed out.” The captain also stated, “if we don’t see it we’ll just go to, Vermont.” (The captain was referring to Burlington International Airport, South Burlington, Vermont, which was the alternate airport for the flight.) The first officer replied, “you got it.”

Between 1118:36 and 1118:42, the first officer stated, “so this time I’ll stay on the flight director until things start screaming minimums…then I’ll look up…if there’s nothing there then we’ll go, if there is something there we’ll land.” The captain commented, “yup, sounds good.” The first officer also stated that he would specifically look for the lights that surround the runway and that, during the previous approach, “all I saw was the antennas at the end of the runway.”

Between 1119:00 and 1120:41, the captain and the first officer began discussing the previous approach and the second approach. The captain repeated, “it’s really white down there,” and instructed the first officer to “stay inside and I’ll let you know when you can look up.” The captain also instructed the first officer on the actions to take if she commanded “go missed” again.

The captain contacted PQI maintenance at 1121:46 and stated that the airplane was about 16 miles and 7 minutes away from the airport. The maintenance foreman replied, “we’ll be clear runway one and the lights are on bright.” The maintenance foreman stated he had again activated the lights to high intensity.

At 1123:41, the controller told the flight crew that the airplane was about 8 miles south of the locator outer marker for the ILS runway 1 approach and cleared the flight for the approach. The controller also instructed the flight crew to report when the airplane was established on the localizer. The captain acknowledged this information. At 1125:03, the captain told the first officer, “localizer’s comin’ in alive,” and the first officer responded, “localizer is alive so is the glideslope.” The captain then informed the controller that the airplane was established on the localizer. The controller instructed the flight crew to change to the CTAF, and the captain acknowledged this instruction and notified local traffic that the airplane was inbound for runway 1.

FDR data showed that, at...