On 27 Oct 2016 at 23:40z, an Eastern Airlines, 737-700, N278EA, 28006/26, overran Runway 22 during a landing at La Guardia (KLGA) in rain. The aircraft continued onto the Engineered Materials Arresting System (EMAS) where it was stopped 200 feet past the runway end.
KLGA 272351Z 10010G15KT 3SM RA BR OVC010 13/12 A3010 RMK AO2 SFC VIS 4 SLP192 P0032 60061 T01330117 10139 20072 58018 $
The NTSB has said that the approach had been stable and the crew became visual at 700ft above the runway. The aircraft floated in the flare and the main landing gear touched down about 912m (2992ft) past the threshold of Runway 22 (LDA 7001ft). The pilots manually engaged the speed brakes about 4s after touchdown and the thrust reversers deployed about 7s after touchdown. Furthermore, the flight crew did not report any mechanical irregularities or abnormal braking action, which was corroborated by the flight data recorder.
The aircraft was carrying Presidential VP candidate Mike Pence at the time which made the event high profile in the media.
31 May 2017 - The NTSB released the Docket of the incident (DCA17IA020) containing 28 factual documents pertaining to the event at the following link.
02 Aug 2017 - The NTSB published their factual report into the incident here.
22 Sep 2017 - The NTSB published their final report into the incident in which they determined that determines the probable cause(s) of this incident as follows:
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.
*** Updated 18 Apr 2019 ***
This report (excerpts reproduced below) is well worth a read. It brings together a landing on a 7000ft runway in a 10kt tailwind with a long flare and late touchdown followed by late deployment of speedbrake and reverse thrust followed by a confusion of handover of control and both crew applying opposite rudder force, one trying to turn and the other trying to keep straight.
HISTORY OF FLIGHT
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 (the first third of the 7,001-ft-long runway), 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. 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 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.
TESTS AND RESEARCH
An analysis of the FDR data performed by Boeing and reviewed by the NTSB showed that the airplane was in a turbulent atmosphere with an increasing tailwind as it approached runway 22. At touchdown, the tailwind was about 10 knots (which is the maximum specified in the Boeing 737 Flight Crew Operations Manual), and the airplane's airspeed was 123 knots, its groundspeed was 130 knots, and its sink rate was 3.3 ft per second. Boeing's analysis indicated that (the eventual) full deflection of the speed brakes, maximum wheel brakes, and maximum reverse thrust provided effective deceleration. From the time the nose gear touched down to the time the airplane entered the EMAS, the airplane's braking coefficient varied between 0.2 and 0.4. The increasing left control wheel input, which reached 50º by 1941:09, reduced the spoiler deflections on the right wing, in accordance with the airplane's design.
Boeing conducted a simulation of the airplane's stopping performance at the request of the NTSB. The simulation revealed that, had the speed brakes been manually deployed within 1 second of touchdown (the criteria for automatic deployment), followed by thrust reverser deployment 7 seconds later, the airplane's CG would have remained on the runway surface and only the nose of the airplane would have exited the runway surface. If, in addition to the prompt deployment of the speed brakes, the thrust reversers had been deployed about 2 seconds (instead of 7 seconds) after manual speed brake deployment, the entire airplane would have remained on the runway surface. NTSB review of FDR data for previous landings of the incident airplane determined an average of 0.5 second for manual deployment of the speed brake.
The autobrake and antiskid systems were tested and no faults were found. In addition, no pre-existing faults were recorded.
Crew Resource Management (CRM) and EMAS Training
The manager of flight operations training at the time of the incident was also a check airman. He had been manager of training for about 1.5 years and had been with the company for 2 years. The airline provided three courses on CRM: new hire, captain's upgrade, and recurrent. The new hire CRM course consisted of a 2-hour segment covering CRM background, communications processes and decision behavior, team building and leadership, workload management and situational awareness, individual factors and stress reduction, and error management. The upgrade training included 1 day of ground school in which 1 hour was dedicated to CRM. Upgrade training also incorporated a captain's leadership course that included content on the captain's authority, briefings, workload management, and sterile cockpit procedures in accordance with 14 CFR 121.542, "Flight Crewmember Duties." The recurrent training included a 3.5-day ground school for captains and first officers in which 1 hour was devoted to CRM training. All courses were taught using presentation slides, open discussion, and videos created by contracted training organizations.
The captain reported after the incident that he believed he and the first officer were working well as a crew during the trip. He stated that he did not call for a transfer of controls during the landing rollout and that, in hindsight, he should have. He further mentioned that he thought it was "OK" for both crewmembers to be applying brakes. The first officer reported a "lack of communication" during the landing rollout because the captain did not say that he was taking control of the airplane. Another Eastern Air Lines first officer who had flown with the captain before the incident described the captain's CRM as "good."
At the time of the incident, EMAS training was not part of Eastern Air Lines' pilot training program. The captain stated during postincident interviews that he had forgotten that an EMAS was installed at the end of runway 22, that he had read about the systems, but had not had any training on them.
The Final Report
NTSB investigators used data provided by various sources and may have traveled in support of this investigation to prepare this aircraft incident report.
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.
The National Transportation Safety Board determines the probable cause(s) of this incident as follows: