PILOTS' POOR DECISION MAKING CAUSED PLANE TO OVERRUN RUNWAY IN TRAVERSE CITY

[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: June 10, 2008
SB-08-24

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PILOTS' POOR DECISION MAKING CAUSED PLANE TO OVERRUN RUNWAY 
IN TRAVERSE CITY


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Washington, DC - The National Transportation Safety Board 
said that a regional jet overran the end of a runway in 
Michigan last year because the pilots elected to land on a 
contaminated (snowy) runway without performing the required 
landing distance calculations.  

The Board adopted its final report on the April 12, 
2007 accident in which, a Bombardier/Canadair Regional Jet 
(CRJ) CL600-2B19, operated as Pinnacle Airline 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 and 3 crewmembers and 
the aircraft was substantially damaged.  The weather at the 
time of the accident was reported as snowing.   Instrument 
meteorological conditions prevailed at the time of the 
accident, which was operated on an instrument flight rules 
flight plan.	

"Our recommendations are designed to reduce injuries 
and deaths and prevent accidents like this from occurring," 
said NTSB Chairman Mark Rosenker.
"Piloting an aircraft should not be guess work.  There are 
rules and guidelines that need to be followed at all times 
and it is imperative that the Federal Aviation 
Administration enforce these recommendations."

The probable cause cites the pilots' decision to land 
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 throughout 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. 
	 
Also contributing to the accident were the Federal 
Aviation Administration pilot flight and duty time 
regulations that permitted the pilots' long, demanding duty 
day; and the TVC operations supervisor's use of ambiguous 
and unspecific radio phraseology in providing runway braking 
information.

During its investigation, the Safety Board evaluated 
the pilots' actions and decisions during the flight, 
including their decision to land at TVC, their awareness 
of/attention to the weather and runway conditions at TVC, 
and their actions during the landing roll.  The Safety Board 
concluded that the pilots failed to perform the landing 
distance assessment that was required by Pinnacle's 
Operations Specifications. Had the pilots done so, using 
current weather information, the results would have shown 
that the runway length was inadequate for the contaminated 
runway conditions described. 

The investigation also examined pilot fatigue.  The 
accident occurred after midnight at the end of a demanding 
day during which the pilots had flown over 8 hours, made 
five landings, been on duty more than 14 hours, and been 
awake more than 16 hours.  The Safety Board further notes 
that the pilots had also flown in challenging weather 
conditions throughout the day.

Therefore, the Safety Board concluded that the poor 
decision-making shown by the accident pilots, including 
their failure to account for the changing weather and runway 
conditions during the approach; their failure to perform a 
landing distance calculation; and their failure to reassess 
or discontinue the approach accordingly, likely reflected 
the effects of fatigue.

As a result of the investigation of this accident, the 
Safety Board made recommendations to the Federal Aviation 
Administration in the following areas: the pilots' actions 
and decision-making during the approach, landing, and 
landing roll; landing distance assessment training; pilot 
fatigue; weather and field condition information and ground 
operations personnel communications; criteria for runway 
closures in snow and ice conditions; and alcohol testing. 

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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