FAILURE TO EXECUTE A MISSED APPROACH CAUSED SHUTTLE AMERICA'S RUNWAY OVERRUN

[NTSB Press Releases <NTSBPressReleases@xxxxxxxx>]

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                      NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: April 15, 2008
SB-08-13

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FAILURE TO EXECUTE A MISSED APPROACH CAUSED SHUTTLE 
AMERICA'S RUNWAY OVERRUN

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Washington, D. C. - The National Transportation Safety Board 
today determined that the probable cause of an Embraer ERJ-
170, operated by Shuttle America, Inc., was the failure of 
the flight crew to execute a missed approach when visual 
cues for the runway were not distinct and identifiable. 

	"Professional pilots have the daunting task of 
operating these passenger aircraft on a daily basis under a 
variety of weather conditions," said NTSB Chairman Mark V. 
Rosenker.  "Their decision making process and training must 
be comprehensive enough to take all conditions into 
account."

	On February 18, 2007, a Delta Connection flight 6448, 
an Embraer ERJ-170, operated by Shuttle America, Inc., was 
landing on runway 28 at Cleveland-Hopkins International 
Airport, Cleveland, Ohio, during snow conditions when it 
overran the end of the runway, contacted an instrument 
landing system (ILS) antenna, and struck an airport 
perimeter fence.  The airplane's nose gear collapsed during 
the overrun.  There were 71 passengers and four crewmembers 
on board.  Three passengers received minor injuries.

	The Board found that contributing to the accident was 
the crew's decision to descend to the ILS decision height 
instead of the localizer (glideslope out) minimum descent 
altitude.  Because the flight crewmembers were advised that 
the glideslope was unusable, they should not have executed 
the approach to ILS minimums; instead, they should have set 
up, briefed, and accomplished the approach to localizer (glideslope out) minimums.

	Also contributing to the accident was the first 
officer's long landing on a short contaminated runway and 
the crew's failure to use reverse thrust and braking to 
their maximum effectiveness.  When the first officer lost 
sight of the runway just before landing, he should have 
abandoned the landing attempt and immediately executed a 
missed approach.  Furthermore, the report states that had 
the flight crew used the reverse thrust and braking to their 
maximum effectiveness the airplane would likely have stopped 
before the end of the runway.  The Board concluded that 
specific training for pilots in applying maximum braking and 
maximum reverse thrust on contaminated runways until a safe 
stop is ensured would reinforce the skills needed to 
successfully accomplish such landings.

	In its final report on its investigation, the Safety 
Board noted that the captain's fatigue, which affected his 
ability to effectively plan for and monitor the approach and 
landing, contributed to the accident. By not advising Shuttle 
America of this fatigue or removing himself from duty, the 
captain placed himself, his crew, and his passengers in a 
dangerous situation that could have been avoided, the Board 
said.

 	Another contributing factor to the accident was 
Shuttle America's failure to administer an attendance policy 
that permitted flight crewmembers to call in as fatigued 
without fear of reprisals.  The policy had limited 
effectiveness because the specific details of the policy 
were not documented in writing and were not clearly 
communicated to pilots, especially the administrative 
implications or consequences of calling in as fatigued.

	As a result of the investigation of this accident, the 
Safety Board made recommendations to the Federal Aviation 
Administration in the following areas:  flight training for 
rejected landings in deteriorating weather conditions and 
for maximum performance landings on contaminated runways, 
standard operating procedures for the go-around callout, and 
pilot fatigue policies.  

	A synopsis of the Board's report, including the 
probable cause and recommendations, is available on the 
NTSB's website, www.ntsb.gov, under "Board Meetings." The 
Board's full report will be available on the website in 
several weeks.
 
Media Contact: Keith Holloway, 202-314-6100







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