N732MA

HISTORY OF FLIGHTOn May 3, 2019, at 2142 eastern daylight time, Miami Air International flight 293, a Boeing 737-81Q, N732MA, departed the end of runway 10 while landing at Jacksonville Naval Air Station (NIP), Jacksonville, Florida, and came to rest in shallow water in St. Johns River. Of the 2 pilots, 4 flight attendants, 1 mechanic (in the jumpseat), and 136 passengers onboard, one minor injury was reported; the rest were not injured. The airplane was substantially damaged. The flight was operated as a Title 14 Code of Federal Regulations Part 121 supplemental nonscheduled passenger flight from Leeward Point Field (MUGM), Guantanamo Bay, Cuba, to NIP. Marginal visual flight rules conditions prevailed at the time of the accident.

According to the flight crew, the day of the accident was the second day of a 3-day pairing; three flight legs were scheduled for the day; however, the schedule was amended before the accident flight to remove the originally scheduled third (last) leg of the day due to earlier maintenance delays. The pairing was the first time the pilots had flown together. The captain was the pilot flying (PF) for the accident flight, and the first officer was the pilot monitoring (PM). The captain was also performing check airman duties for the first officer who was in the process of completing operating experience training.

Before departing MUGM, the flight crew reviewed the dispatch paperwork and weather and noted that thunderstorms were in the forecast for their scheduled time of arrival at NIP; Orlando International Airport, Orlando, Florida, was listed as the alternate airport. The No. 1 (left) thrust reverser was not operational and deferred for the flight in accordance with the airplane’s minimum equipment list (MEL). According to both pilots, the takeoff, climb, and cruise portions of the flight were uneventful.

During postaccident interviews, the flight crew stated that, about 30 minutes before landing at NIP, the flight deviated around weather as it approached the Jacksonville area. According to the captain, the weather was “nothing serious.” Available weather data near this time indicated rain showers or thunderstorm growth over NIP from 2110 onward. Based on the weather forecast information provided in the flight plan, which indicated variable wind at 20 knots with 30-knot gusts, thunderstorms, and rain, the flight crew set up the area navigation (RNAV) GPS approach to runway 10 in the flight management system and briefed setting the autobrake at level 2.

According to data from the cockpit voice recorder (CVR), about 2122, the first officer checked in with the Jacksonville International Airport (JAX) airport traffic control tower radar approach (RP) controller indicating the flight’s altitude at 13,000 ft mean sea level (msl). The RP controller acknowledged and advised the flight to expect the RNAV approach to runway 28 at NIP, which the first officer acknowledged. About 10 seconds later, the JAX RP controller advised the flight crew of moderate-to-heavy precipitation on the final approach to runway 28. The captain acknowledged and asked about the wind conditions and indicated that he could not pick up the NIP automatic terminal information service (ATIS) (see Airport Information).

After checking with NIP airport traffic control tower controllers, the RP controller advised the flight crew that the wind was from 350º at 4 knots. The captain then asked if weather conditions looked better for runway 10. The RP controller responded that, for runway 10, conditions showed moderate-to-heavy precipitation beginning about 5 miles out on the final approach. The captain replied that the flight would continue the approach to runway 28. The RP controller advised the flight crew to descend and maintain at 5,000 ft msl, which the first officer acknowledged.

At 2125:45, the RP controller provided additional weather information to the flight crew, stating that moderate-to-heavy precipitation was present east and west of the airport; he asked the flight crew if they wanted to stay with the RNAV approach for runway 28. The captain replied, “ah yes sir, what- whichever looks better an ah then when I get closer I check how it is.” The RP controller assigned the flight crew heading 010 and instructed the pilots to descend to 3,000 ft msl. The flight crew acknowledged and entered the RNAV approach for runway 28 into the flight management system.

According to information from US Navy and Federal Aviation Administration (FAA) certified audio ATC recordings, about 2129, the RP controller advised the NIP radar arrival (RA) controller that flight 293 was 15 miles southwest of NIP for the RNAV approach to runway 28. The RA controller responded that the flight was radar identified. About 2130, the RP controller advised the flight crew that the previously mentioned precipitation was moving east and asked if they wanted to change to runway 10. After clarifying the runway number, the captain responded, “yeah go ahead let’s do it.” The RP controller assigned the flight heading 270 then heading 250, which the captain acknowledged.

From 2132 to 2133, the JAX RP controller and NIP RA controller coordinated the flight’s change to runway 10. From 2134 to 2137, the RP controller provided the flight crew a series of heading changes to join the final approach course, which the first officer acknowledged. At 2137:34, the RP controller advised the flight crew that they were 7 miles from the final approach fix and cleared the flight for the RNAV runway 10 approach, which the first officer acknowledged. The JAX RP controller also confirmed with the NIP RA controller that the flight was set up for runway 10.

At 2137:48, the RP controller instructed the flight crew to contact NIP ground controlled approach (GCA). The captain requested a VHF frequency, which the RP controller provided. The first officer contacted the NIP GCA at 2138:32; the NIP RA controller responded with the NIP altimeter setting and advised that the RNAV approach would be using precision approach radar monitoring. (Precision approach radar is a fixed-base primary approach aid used by the US Navy during poor visibility conditions to provide vertical and lateral guidance, as well as range, to aircraft on final approach).

The RA controller also provided rollout and missed approach instructions and advised the flight crew that the short-field arresting gear on runway 10 was rigged (according to a Miami Air operations bulletin, arresting gear on runways places no limitations on Boeing 737 takeoff or landing operations; see Airport Information). The first officer acknowledged, then the captain sought clarification, asking the RA controller, “and that’s for the ah first thousand feet, correct?”, which the RA controller confirmed.

While the RA controller was providing arrival instructions, the CVR recorded a sound consistent with an altitude alert at 2139:06. At 2139:38 the NIP radar final (RF) controller assumed control of the flight from the RA controller and advised the flight crew that the “wheels should be down” (ATC procedures at US military facilities require a wheels-down check before descent on final approach for aircraft conducting radar-monitored approaches). The first officer acknowledged, and the CVR recorded sounds consistent with landing gear extension at 2139:48. At the same time, the RF controller cleared the flight to land on runway 10 and indicated a wind direction of 240º at 10 knots. The first officer acknowledged the landing clearance. A sound consistent with an altitude alert was recorded again at 2140:04.

At 2140:15, the RF controller advised the flight crew that they were “well above” the 3º glidepath to runway 10; at 2140:25, the precision approach path indicator (PAPI) lights would have appeared to the flight crew as four white lights, indicating the airplane’s glidepath exceeded 3.5º. Automatic dependent surveillance-broadcast (ADS-B) and flight data recorder (FDR) data indicated that the airplane was about 3.5 nautical miles (nm) from the runway 10 displaced threshold about this time and was descending through 1,390 ft msl (1,369 ft above the touchdown zone elevation of 21 ft) at an indicated airspeed of 158 knots and descent rate of 1,062 ft per minute (fpm). The airplane’s true airspeed about this time was 167 knots, and the groundspeed was 174 knots due to a 7-knot tailwind.

According to the Boeing 737 flight crew operations manual (FCOM), the flaps 30 landing reference speed (VREF30) was 148 knots calibrated airspeed at the airplane’s landing weight of 143,200 lbs, and the target approach speed (VREF30 + 5 knots) was 153 knots calibrated airspeed (which is the indicated airspeed of an aircraft that is corrected for position and instrument error).

At 2140:25, a sound consistent with the autopilot disconnect warning was recorded. The airplane’s descent rate increased from 1,100 to 1,400 fpm at 2140:30. At 2140:31, the captain called for the Landing checklist, and the first officer responded, “ah…speedbrakes ah armed, landing gear down three green, flaps thirty.” At 2140:40, the airplane was about 1,100 ft msl and about 2.8 nm from the runway 10 displaced threshold; its descent rate decreased to 1,000 fpm, its indicated airspeed decreased to the target approach speed of 153 knots, and the groundspeed decreased to 166 knots. The airplane was closer to the nominal 3° glidepath, and the PAPI would have appeared as three white lights and one red light. Between 2140:46 and 2141:39, the indicated airspeed increased steadily from 153 to 170 knots, and the groundspeed increased from 166 to 180 knots. According to the NTSB Performance Study, both groundspeed and airspeed increased during this time at approximately the same rate. Therefore, this increase was a result of pitch control inputs. At 2141:09, at an altitude of about 680 ft msl and about 1.6 nm from the displaced threshold, the airplane deviated further above the 3° glidepath such that ...