EMB 170 overrun at KCLE

[bomarc]

sunday an EMB 170 over ran the runway at Cleveland Ohio during a snow event.

plane appears to have landed on the shorter runway, 28, some 6017feet long...and it SLOPES DOWNHILL some 29 feet.

no injuries.

[Zeffy]

http://www.cnn.com/2007/US/02/18/runway.mishap/

[mutt]

I cant understand why Embraer operate this aircraft without the use of thrust reversers for landing on contaminated surfaces:confused:

Mutt

[GBALU53]

WHAT ARE THE ON BOARD LIBARY USE FOR.

Is it commercial pressure that the aircrarft perfomance libary is not used fully and understood?? (If this is the case could the bood figures be missinterpretated?

At least no loss of life but how many more times will this happen.

Commercial pressures plays a big part in these low cost carriers.

[WHBM]

As so often the aircraft is operated by an airline few of its passengers will have heard of, in this case "Shuttle America".

It had a Delta Airlines DL flight number. You check in at the Delta desk and it is shown in the Delta departures. The aircraft is painted in Delta livery. The FAs wear DL uniforms. There's the Delta magazine in the seatbacks. The pax will be on DL tickets.

Yet when an accident happens it is immediately announced as a carrier nobody has heard of. To the pax it would seem a technicality that it was some different operator, as far as they are concerned it's a Delta flight.

[Vapor]

The reversers seem to be deployed in the video clip. Are you sure you are not confusing the 170 with the 145 on which reversers are an optional extra?

[bomarc]

I am not saying that the EMB 170 couldn't land on a 6017' runway...if anyone has the data I hope they will post it.

HOWEVER, when it is snowing and the runway slopes downhilll that much, a pilot who hasn't checked the slope of the runway (and it isn't readily available, one must compare the difference between elevation on both ends of runway, which is available) will FLARE and if not done in a way to counter the slope effect will end up floating away quite a bit of runway.

Even if the winds were more favorable for runway 28, I would have used the longer runways 24 and accepted the greater, but still safe, crosswind.

I am pretty sure the thrust reversers were used, but my computer isn't up to the task of the video clip, if anyone can post the still photo that would be nice.

[Angryfool]

HOWEVER, when it is snowing and the runway slopes downhilll that much, a pilot who hasn't checked the slope of the runway (and it isn't readily available, one must compare the difference between elevation on both ends of runway, which is available) will FLARE and if not done in a way to counter the slope effect will end up floating away quite a bit of runway.

Bomarc, are you implying that the pilot's in this accident didn't perhaps check the runway slope or that it would have perhaps been more prudent to use runway 24? I'm sure you appreciate that with a contaminated runway there are different crosswind limitations for aircraft. Perhaps they were not able to land on 24 because of this restriction, who knows? Doesanyone have the actual weather at the time of the accident and the runway braking coefficients?

If in terms of performance they were able to 'legally' land on runway 28, then what needs to be determined are the factor(s) for the overrun, and i'm sure no amount of 'guessing' will be able to determine that until the data from the FDR and pilot's information is analysed.

[Huck]

This was posted over on Flightinfo.com - in no way am I vouching for it, but one other poster said he was flying into CLE that day and this was applicable:

its a cat I runway, and this notam was active:

!FDC 7/3107 (KCLE A0785/07) CLE FI/T CLEVELAND-HOPKINS INTL, CLEVELAND, OH. ILS RWY 28, AMDT 22.... DUE TO EFFECTS OF SNOW ON THE GLIDE SLOPE MINIMUMS TEMPORARILY RAISED TO LOCALIZER ONLY FOR ALL CATEGORY AIRCRAFT. GLIDE SLOPE REMAINS IN SERVICE. HOWEVER, ANGLE MAY BE DIFFERENT THAN PUBLISHED.

[bomarc]

Huck

you have some points, however here is the wx, the first just prior to the landing and the second just after:

SPECI KCLE 181956Z 30016KT 1/4SM +SN BKN006 BKN015 OVC041 M07/M11 A3001 RMK AO2 P0000 $

SPECI KCLE 182017Z 33013G19KT 1/4SM +SN BKN003 BKN010 OVC015 M08/M11 A3003 RMK AO2 P0000 $


The information about the situation with glideslope is very interesting.

the 300 degrees at 16 knots should have been fine for runway 24, which is longer.

even with braking action as medium or fair.

do you have the operational x wind limits for the EMB?

8 minutes prior to landing a braking action with no problems was reported (whatever that means).

[Lucifer]

As so often the aircraft is operated by an airline few of its passengers will have heard of, in this case "Shuttle America".

It had a Delta Airlines DL flight number. You check in at the Delta desk and it is shown in the Delta departures. The aircraft is painted in Delta livery. The FAs wear DL uniforms. There's the Delta magazine in the seatbacks. The pax will be on DL tickets.

Yet when an accident happens it is immediately announced as a carrier nobody has heard of. To the pax it would seem a technicality that it was some different operator, as far as they are concerned it's a Delta flight.
And your point is? It carries FAA authorisation and submits itself to the relevant safety audits. Sounds like pseudo-unionist BS to me.

[WHBM]

And your point is? It carries FAA authorisation and submits itself to the relevant safety audits. Sounds like pseudo-unionist BS to me.Sorry you are down the wrong path. From the passengers point of view there is all the emphasis by the main carrier about their vast network, which includes their commuter affiliates. Fine, it is all being operated in a seamless manner. But when something goes wrong there is this grand distancing operation, all prepared in advance, along the "nothing to do with Delta" lines. Look this one up in the accident stats for Delta and it won't appear. Yet it was operating entirely as a Delta flight.

It's no comment on the flying aspects of the incident, but on the corporate distancing that seems to happen in these cases. Shuttle America say it was a Delta flight involved; Delta say it was a Shuttle America flight involved.

[West Coast]

"Shuttle America say it was a Delta flight involved; Delta say it was a Shuttle America flight involved"

Both are correct.

[FE Hoppy]

if anyone knows the % slope LDA and contamination type or WED and the landing weight I will run the numbers but I can tell you it's well within the types capabilities except that contamination=50%guesswork+50%science and that applies to every aircraft.

[bomarc]

I am sure the landing was "legal". Fe Hoopy and Angry fool, I am raising a question in terms of pilot knowledge of different illusions with sloping runways and their effect on landing distance. We all would aim for touchdown where the glideslope brings us or the 1000' fixed distance marks...

My point about the downslope of the runway isn't for calculating the stopping.

instead it is to warn pilots that a normal "flare" on a downsloping runway will likely result in a prolonged float and thereby reduce the runway available for stopping.

if there are any questions, I will be happy to explain further...ask yourselves if the slope is always considered in terms of the visual illusion during flare in your cockpit?

[e-flier]

Dear Mutt, there are no limitation on the use of thrust rev. for landing. What is worth noting as regards its ops. is that the rev. must reach fully deployed position before the thrust can be increased above idle.

[bomarc]

e flier

thanks for telling us all you can about the emb170. any other views are appreciated. what do you think happened?

[Doors to Automatic]

The type is well capable of operating onto a 6000ft runway. In fact its landing requirement at MLW and Sea Level is 4117ft so it must have touched down late or suffered some sort of braking problem

[RatherBeFlying]

shorter runway, 28, some 6017feet long...and it SLOPES DOWNHILL some 29 feet.makes for a slope of 0.5%

[Angryfool]

My point about the downslope of the runway isn't for calculating the stopping.

instead it is to warn pilots that a normal "flare" on a downsloping runway will likely result in a prolonged float and thereby reduce the runway available for stopping.


Fair enough. I would hope that most professional pilots are aware of these factors, especially where the gradient may be significant and have landed on these types of runway before. There are numerous airfields/runways around Europe where the same phenomenum might occur ie Zurich r/w 14, Lisbon r/w 03.

Bomarc, with reference to your point, what I believe may be of interest, is whether this crew were familiar with the airfield and in particular, this runway. The other point(s) is the 'visual perception' of landing on a snow covered runway. What effect can it have on the touchdown point? Is the tendancy to over flare or have a shallow flare if there are less visual cues due to the snow?

The type is well capable of operating onto a 6000ft runway. In fact its landing requirement at MLW and Sea Level is 4117ft so it must have touched down late or suffered some sort of braking problem


It may have been fast as well, thrust reversers deployed later than normal. On 'shorter' runways and in instances of snow/water reducing the braking, speed over the threshold becomes even more critical than normal.

[bomarc]

angry fool

being aware of book learning, doesn't always translate to real flying...add to this NO ILS glideslope and one might have been a bit fast a bit high and a bit long...if not down in the first third, go around is still a good rule

[Angryfool]

angry fool

being aware of book learning, doesn't always translate to real flying...add to this NO ILS glideslope and one might have been a bit fast a bit high and a bit long...if not down in the first third, go around is still a good rule

In hindsight, yes it is. I'm sure we've all landed and later on thought that perhaps we should have gone around or thought we would have gone around a second later.

As with most accidents, as might be found out later on in this investigation, there are usually a number of causes. I know that this is a rumour forum, but how about we wait for the prelim findings otherwise this speculation could and will run into several pages.

[bomarc]

angryfool

I think we miscommunicated...the book learning I was talking about was reference the visual illusion of landing on a downsloping runway...you mentioned, I think, that you felt professional pilots would know that...I am not so sure.

yes, the investigation will take a year, but we will hear something within a week like touchdown point, airspeed on touchdown etc.

[bomarc]

did you all see that DELTA doesn't consider this an accident?

I also read that a prelim report will be issued within a week.

[Angryfool]

I can't remember the definition for an accident or incident. I could be incorrect, but if an aircraft is damaged then I believe it's an accident. Most probably wishful thinking from Delta.

[alf5071h]

Time to read Managing the Threats and Errors during Approach and Landing (www.flightsafety.org/ppt/managing_threat.ppt) again.

Also see the article on the perception of risk. ( www.time.com/time/magazine/printout/0,8816,1562978,00.html) In particular note "People call these crises wake-up calls …. but they're more like snooze alarms. We get agitated for a while, and then we don't follow through." Isn’t this accident another one that is likely to join the list but there is no follow through action?

Other relevant links:
Landing Performance Assessments at Time of Arrival. (http://web.nbaa.org/public/ops/safety/SAFO06012.pdf)
Runway Friction Accountability Risk Assessment. (www.tc.gc.ca/tdc/publication/pdf/13900/13941e.pdf)
Slippery when wet. (www.casa.gov.au/fsa/2000/sep/index.htm)
Benefit-Cost Analysis of Procedures for Accounting for Runway Friction on Landing. (www.tc.gc.ca/tdc/summary/14000/14082e.htm)

[nmejiab]

Certenly the 170 has reversers and the creww of Delta use them.

[mutt]

FAA certified E170's do not have ANY information in either the ECAFM or AOM regarding the use of thrust reversers on contaminated runways! This applies for takeoff and landing!

Have any of you read OB-170-001-06??

Mutt

[Flyer 1492]

Every one is talking about the runway slope. With vis @ 1/4, I wonder what the runway friction index was? How much snow was on the runway at the time? Both of those factors will contribute to a longer roll out, or in this case being stopped by the perimeter fence.

[bomarc]

I think when you couple no glideslope, poor visibility, a relatively short runway, visual illusion with downsloping runway, snow etc on runway you have a strong possibility of a long landing.

I don't know anyone who hasn't been taught...if you don't touchown in the first third, go around.

my guess is:

we will find out that runway touchdown was with 3000 feet remaining or so.

the real tragedy is how badly delta treated the passengers who trusted their lives to the odd mix of delta and their contracted emb carrier.

[FE Hoppy]

I have mutt!!!!;)

[None]

Looking at Bomarc's post concerning the weather makes me wonder if the crew had this information:
"you have some points, however here is the wx, the first just prior to the landing and the second just after:
SPECI KCLE 181956Z 30016KT 1/4SM +SN BKN006 BKN015 OVC041 M07/M11 A3001 RMK AO2 P0000 $
SPECI KCLE 182017Z 33013G19KT 1/4SM +SN BKN003 BKN010 OVC015 M08/M11 A3003 RMK AO2 P0000 $ "
Did tower update them with the special, inluding the term "heavy snow?" What braking action report did tower give them? How old was it?
Decision-making is only as good as the accuracy of the information we receive and use to choose a course of action.

[mutt]

Bomarc,

Talk about hanging the crew out to dry before the investigation :( Are you qualified on the E170? Do you know anything about the aircraft? Have you read OB-170-001-06 regarding thrust reversers??

e-flier, remember this was an FAA certified aircraft, not JAA!

Mutt

[bomarc]

mutt:

no, the EMB 170 is not high on my list of planes to fly and I don't fly it.

please send me a copy of the ops bulletin on the thrust reversers so I can read it.

My point is this: any pilot, not just these pilots, who did not take into account the items I mentioned might have gone off the end. Let us all ask ourselves right now, what would we have done differently?

wx, visual illusion with downsloping runway, no glideslope...how would you have handled that approach?

tell me, honestly now, how many of you out there in internet land brief the slope of the runway? be honest now.

I've written the slope on my apch charts since 1994. try landing at binghamton, new york some time.

[Zeffy]

Bomarc,

Agree that slope is an important component of approach briefing and planning for landings. Jeppesen spot elevations on their airport charts frequently provide clues about slopes, but the information is not as complete as it could be.

Mutt -- would you mind sharing the Ops Bulletin with me via email or PM?

Fortunately, (for operations in the U.S.), runway slope information is now available in the online AF/D:
http://www.naco.faa.gov/index.asp?xml=naco/online/d_afd


"...try landing at binghamton, new york some time."
http://www.naco.faa.gov/pdfs/ne_131_18JAN2007.pdf
Runway 16-34: 0.9% up NW

Runway 28 at KCLE.
http://www.naco.faa.gov/pdfs/ec_202_18JAN2007.pdf (http://www.naco.faa.gov/pdfs/ec_202_18JAN2007.pdf)
RWY 10.28: 0.5% up E.

But, what exactly is the crew to do with the slope data? Experience and intuition tell us that slope can be very significant to stopping distances, especially when the runway is not clear and dry. But I've not found approved performance data (for that matter neither have I found "advisory data") that take into account the effects of runway slope.

Why is that?

[bomarc]

what can the crew do with slope data...

first off, the slope is part of the airline's calculations and I am sure they meet approval.

the real thing for me is the pilot's handling of the flare. you must create a mindset for a downsloping runway of flaring less...if you flare the normal amount the runway is going away from you and you float.

going uphill if you flare normally, you will get a harder landing as the runway is coming up to meet you.

(over simplified, but useful)

and yes, JEPPS don't show slope, but one can calculate difference between touchdown zone elevations for both sides of the same runway.


landing at binghamton new york really got my attention...fortunately I landed up hill the first time.

the first time I landed downhill there, I pretty much didn't flare and got on the brakes right away.

remember, it is not the landing calculation I am talking about...that must be ok or your airline would not be approved to use it.

BUT all calculations assume no prolonged float...so be careful.

[Zeffy]

"...first off, the slope is part of the airline's calculations and I am sure they meet approval."

Oh?

And what data would be used for those calculations? :confused:

To my knowledge, AC 25-7A does not require slope values to be included in stopping distances.

Do certain OEM's included it anyway?

[bomarc]

sadly I don't have my airport analysis data at home...it is carried aboard our planes and there is a calculation made by our engineeering department and approved for each runway at our normal airports.

I don't know how your airline does it...mine is a big airline, very big airline that begins with a vowell, that is all I will say.

there is even a formula for penalites using slope for both landing and takeoff for non routinely used airports.

again I don't have it in front of me.

and again, if you aren't down in the first third of a runway, go around...that goes back to private pilot days ( of course there are exceptions...15,000 feet of runway, I suppose most planes could overfly the first half and still be ok, but let's keep it real)

[Zeffy]

"...a formula for penalites using slope for both landing and takeoff for non routinely used airports."

Thanks.

One would assume that those penalties are predicated on approved landing data.

I just ran an analysis for 10-28 at CLE for my Dassault trimotor (F900EX).

The limiting weights (wet) are the identical in both directions, so I am inferring that the absence of OEM-provided corrections for slope is at the root of the dilemma.

AC 25-7A doesn't require much in the way of published landing data - obviously, the following directly states "as a minimum":

g. Airplane Flight Manual Landing Distances.
(l) As a minimum, the AFM must include data for standard temperature and zero runway gradient showing the variation of landing distance with weight (up to maximum takeoff weight), altitude, and wind. If the airplane is intended for operation under Part 121 of the FAR, the distances presented should include the operational field length factors for both dry and wet runways required by § 121.195.

Does anyone know if the E-170 performance data includes corrections for slope?

How unusual is the case of the F900 performance data not providing corrections for slope?

[bomarc]

zeffy

I think that most runways fall in the acceptable catagory of slope and that there is not a correction for actual performance (at least runways that most airline would use) certainly corporate planes are much more flexible in their destinations.

check your limitations section in your manual and you will find something of interest. I checked the nearest manual I had, a bae 146 and there is a limit to runway slope +- 2%


in this way you are covered...but again, my discourse is on the prolonged float and visual illusion part of the slope.

smack it down on the 1000' marker, hit the brakes and thrust reversers and you should stop (ice...well)

but indulge in a prolonged float due to visual illusion, and you might not stop on the runway (think air france yyz)

[Zeffy]

Fully agree with your discourse, bomarc -- the F900 AFM does indeed contain a runway slope limit of (+/-) 2.5%.

And of course the slope number provided by the airport authority is by itself probably just a net rise/run calculation and may not reflect the challenges in any one portion of an irregularly sloped pavement.

For example, Telluride, Colorado features a runway 6078 feet in length with threshold elevations of 9078' (rwy 27) and 9061' (rwy 09). One might assume that the landing slope is pretty close to flat. However, the gradient to midpoint of 09 is 1.9% downhill, then 1.9 back up to the opposite threshold.

<Back to Ohio...>

If the prevailing vis at the time of the accident at CLE was indeed 1/4 mile with snow and blowing snow, it's certainly possible that it would have been quite difficult to obtain an adequate sight picture (one that would reveal the slope) via the partial obscurations out the cockpit windows.

Absent prior knowledge, briefing and discussion of the downslope, an extended float might not be a very surprising result.

[bomarc]

zeffy

it has been of interest discussing this with you...perhaps if one person reads our chat, one less plane will go off the end.

another thought...if a runway is being used for takeoff and landing, the deice /anti ice fluid will shear off near the END of the runway, running downhill also perhaps compromising stopping a bit. while the cleveland incident/accident may not have had that aspect, it is something professional pilots should think about.

happy landings

[Zeffy]

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20070223X00215&key=1

------------------------------------------------------------------

NTSB Identification: CHI07MA072

Scheduled 14 CFR Part 121: Air Carrier operation of Shuttle America (D.B.A. Delta Connection)

Accident occurred Sunday, February 18, 2007 in Cleveland, OH

Aircraft: Embraer ERJ-170, registration: N862RW

Injuries: 74 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

On February 18, 2007, at 1506 eastern daylight time, an Embraer ERJ-170, N862RW, operated by Shuttle America, as Delta Connection flight 6448, was substantially damaged when it overrun the end of runway 28 (6,017 feet by 150 feet, snow covered) while landing at the Cleveland Hopkins International Airport (CLE), Cleveland, Ohio. The airplane contacted the localizer antenna and a fence prior to coming to rest approximately 150 feet off the end of the runway. The captain, first officer, 2 flight attendants, and 70 passengers were not injured. Instrument meteorological conditions prevailed and the flight was operating on an instrument flight plan. The scheduled passenger flight was operating under 14 Code of Federal Regulations Part 121. The flight originated from the Hartsfield-Jackson Atlanta International Airport (ATL), Atlanta, Georgia, at 1331.

The first officer was flying the airplane at the time of the accident. The captain reported they were cleared for the ILS runway 24R approach. He stated that approximately 10 minutes prior to landing, air traffic control changed the landing runway to runway 28. The captain stated they were informed that the runway visual range (RVR) was 6,000 feet and that the braking action was fair. He reported that after passing the final approach fix, they were informed that the RVR had decreased to 2,000 feet. The captain stated he had the approach lights in sight and at 50 feet above the ground, he had the runway in sight. He stated the first officer then turned off the autopilot to land. The captain stated that at 30 feet above the ground he momentarily lost sight of the runway. He stated he then regained sight of the runway and the airplane was landed. He stated they encountered strong gusty winds during the landing flare and after touchdown they could barely see the runway lights and taxiway turn-offs. The captain reported that despite the use of full reverse and braking, the airplane did not seem to slow down. The airplane traveled off the runway and into the snow covered grass where the nose gear collapsed and the airplane came to rest. The crew and passengers deplaned using a ladder with assistance from the fire department.

The glideslope for the ILS runway 28 approach was unusable at the time of the accident due to the snow. The crew stated they were made aware of this by air traffic control when they were cleared for the approach to runway 28.

The weather reported at CLE at 1456 was: wind 300 degrees at 16 knots, 1/4 mile visibility, heavy snow, broken clouds at 600 feet, broken clouds at 1,500 feet, overcast clouds at 4,100 feet, temperature -7 degrees Celsius, dewpoint - 11 degrees Celsius, altimeter 30.01 inches of mercury.

The weather reported at CLE at 1517 was: wind 330 degrees at 13 knots gusting to 19 knots, 1/4 mile visibility, heavy snow, broken clouds at 300 feet, broken clouds at 1,000 feet, overcast clouds at 1,500 feet, temperature -8 degrees Celsius, dewpoint - 11 degrees Celsius, altimeter 30.03 inches of mercury.

-------------------------------------------------------

[bomarc]

zeffy

thanks for posting this. interesting.

before I put out my take, I would like to hear everyone elses

I believe the EMB 170 would be a catagory C for straight in mins...does anyone know for sure?

I hope you will all take a look at the localizer only mins for runway 28 at CLE.
one might want to review FAR 121.651 C etc. and review the meaning of the word : momentarily

[alf5071h]

It is interesting to compare the initial report with similar overrun accidents. Like most accidents and incidents, there are many potential contributors to the cause, not at least opportunities for error. As usual, questions will arise as to why the safety defenses failed.
One aspect of interest, as in Toronto, is why the crew did not associate the reducing visibility with heavy precipitation and then associate it, with it (the precipitation) being on the ground when they arrived.
Too often we over focus on the weather minima for a decision – ‘are we legal?’ ‘can we get in’? We assume that if we can see the runway then the landing will be safe; not so, just survey the ever increasing number of overrun accidents.
A good approach briefing should discuss the runway conditions and consider possible changes; the latter setting a limit, which if reached, then the approach is discontinued. This aids decision making if unforeseen conditions are encountered. The briefing should include the runway length required in deteriorating conditions, i.e. in winter precipitation, always plan for a contaminated runway.
Another question, also applicable to Toronto and Bangkok (QF1), is why didn’t the crew consider a go-around, particularly if one or both crew lost contact with the runway?
Perhaps the reasons for this are within human factors; a mind set – to land, or you think that are in control of the situation (but you don’t have all of the information), or you have done this (risky operation) before successfully (but in different circumstances). Whatever the reason, these mindsets can be broken with good monitoring and call outs, a good briefing to set the scene (a briefing is the flight plan for the mind), and thinking beyond the immediate objective (DH) – think ahead, how / where do we stop – what if.
We should keep thinking about the landing until we have turned off, thinking about the aircraft until its shut down, and about operating until we have debriefed (at least ourselves).
Controlled and reasonable speculation on accident reports such as this one provides opportunity for thinking.
For another opportunity for thinking, see “Long float to land – landing in heavy rain” Flight Safety Australia Sept – Oct 06 ( www.casa.gov.au/fsa/2006/oct/index.htm )

[Angryfool]

The captain stated he had the approach lights in sight and at 50 feet above the ground, he had the runway in sight. He stated the first officer then turned off the autopilot to land.
Assuming that the aircraft was over the threshold at 50', if that is when the captain saw the runway it seems a bit late? It would be interesting to know what was seen at MDA for the localiser only approach. Did the captain see the visual requirements at decision, if not then why not go around?
One final note, I found it strange that the autopilot be turned off so late; in my company on the airbus 320, for a cat 1 manual landing, the autopilot is not to be used below 160' R, and for a non-precision approach not lower than MDA - 100'.

[FE Hoppy]

AUTOPILOT
- Minimum Engagement Height.........................400 ft
- Minimum Use Height (MUH):
Cruise and Descent............................................... 1000 ft
Approach.................................................... ........... 50 ft

Embraer AFM.


I found it strange that the autopilot be turned off so late;

Thats because you don't have an ERJ170 type rating and are making ASSumptions.

[Angryfool]

Thats because you don't have an ERJ170 type rating and are making ASSumptions.

Apologies FE Hoppy, I perhaps should have made it clearer, yes I was making assumptions. 'I found it strange' was perhaps not the correct phrase to use.

AUTOPILOT
- Minimum Engagement Height.........................400 ft
- Minimum Use Height (MUH):
Cruise and Descent........................................... .... 1000 ft
Approach.......................................... ..................... 50 ft

Embraer AFM.

Thank you for bringing this to my attention.

Of course part of the reason why certain companies operate a 'minimum autopilot disengagement height' for a manual landing is perhaps deeper than you appreciate FE Hoppy, and wouldn't necessarily be based on the aircraft capabilities alone. That is why i was suprised by the fact that the autopilot was disengaged at 50'

[bomarc]

IT doesn't take an EMB 170 type rating to wonder, what if the approach had been hand flown...would somehow the "touch" of someone who had the "feel" of the plane for more than the last few seconds from 50' afe to touchdown have kept the plane on the runway?

my thoughts:

no ILS glide slope

visual illusion with downsloping runway, contributing to prolonged flare.

delay in touchdown due to "losing sight" of the runway at 30'

additional speed of aircraft over and above vref due to no glideslope and diving from MDA to the runway? gusty winds etc?

I would like to know the exact point of touchdown...and if it was beyond 2000' from the approach end of the runway.

[fokkerjet]

The captain stated they were informed that the runway visual range (RVR) was 6,000 feet and that the braking action was fair. He reported that after passing the final approach fix, they were informed that the RVR had decreased to 2,000 feet. The captain stated he had the approach lights in sight and at 50 feet above the ground, he had the runway in sight. He stated the first officer then turned off the autopilot to land. The captain stated that at 30 feet above the ground he momentarily lost sight of the runway. He stated he then regained sight of the runway and the airplane was landed. He stated they encountered strong gusty winds during the landing flare and after touchdown they could barely see the runway lights and taxiway turn-offs. The captain reported that despite the use of full reverse and braking, the airplane did not seem to slow down. The airplane traveled off the runway and into the snow covered grass where the nose gear collapsed and the airplane came to rest. The crew and passengers deplaned using a ladder with assistance from the fire department.
The glideslope for the ILS runway 28 approach was unusable at the time of the accident due to the snow. The crew stated they were made aware of this by air traffic control when they were cleared for the approach to runway 28.
The weather reported at CLE at 1456 was: wind 300 degrees at 16 knots, 1/4 mile visibility, heavy snow, broken clouds at 600 feet, broken clouds at 1,500 feet, overcast clouds at 4,100 feet, temperature -7 degrees Celsius, dewpoint - 11 degrees Celsius, altimeter 30.01 inches of mercury.
The weather reported at CLE at 1517 was: wind 330 degrees at 13 knots gusting to 19 knots, 1/4 mile visibility, heavy snow, broken clouds at 300 feet, broken clouds at 1,000 feet, overcast clouds at 1,500 feet, temperature -8 degrees Celsius, dewpoint - 11 degrees Celsius, altimeter 30.03 inches of mercury.
The ILS minimums for RWY 28, with Glideslope out, is 429' agl (RVR 40 or 3/4 mile). Let me add that the runway was served with MALSR and PAPI.
I'll paraphase the regulations, but basically, to go below 100' agl, you need to see something other than the approach lights.

[bomarc]

fokkerjet is quite right...100' above touchdown zone is ok with JUST apch lights...but you need more to go lower than that.

this report and the captain's statement leave alot of questions to be asked...I want the copilot's statement someday.

I am guessing, but losing sight of the runway at 30'...well how does one do that?

TCH is usually at about 50'...are we to gather that the captain lost sight of the runway while OVER IT? I could write 1000 words on this but won't. could they have leveled off at 30' waiting to see the runway again? could this have caused a float to a long landing.

I would love to see the data readouts on this one.

[Angryfool]

I am guessing, but losing sight of the runway at 30'...well how does one do that?

Bomarc, it could be lots of reasons; blowing snow reducing the RVR, flying through a small cloud as it passes over the runway threshold. I think you're being a bit critical with regard to them losing sight at 30'. It can happen to any one of us, and in hindsight at that point they should have gone around. You put 100 crews in the sim in the same situation, with a scenario of losing visual contact at 30' for a split second and then seeing the runway again, how many do you think would;

a) Initiate the go-around almost immediately and continue with the go-around even if they saw the runway again.

b) Think about initiating the go-around but as it was going through their minds they saw the runway and continued to land.

c) Chance it and continue hoping to see the runway.

My view is that there would be a mix of a and b, hopefully none in the c department, but i'm sure you'll always get the odd one or two.

Theoretically 'a' is the correct answer, 'a' and 'b' the answers taking into account human factors, and 'c' ?

[bomarc]

and what if they started to go around and then "went for it" slapping the throttles aft and pushing over maybe picking up speed, maybe already too far down the runway.

lets just all be careful out there

[Huck]

Let me get this straight - you're saying that an Embraer crew can disconnect the autopilot at 50' agl on a non-precision approach?

[Angryfool]

Huck

FE Hoppy seems to think that, I don't think anyone else has made a comment on it apart from yourself.

My view is that you can't and shouldn't be able to do that on a non precision approach. But then that is my view based on the SOP's of the airline I fly for combined with Airbus operating procedures.

What needs to be determined are the SOP's for Shuttle America in relation to non-precision approaches. At what point aal' do they require the disengagement of the autopilot for a non-precision approach?

[Huck]

What needs to be determined are the SOP's for Shuttle America

I'm guessing it's in the Limitations section of the aircraft flight manual.

I'm also guessing it says disconnect by 50' below minimums.

[alf5071h]

The technical certification normally determines the value of autopilot minimum use height (MUH) and considers systems failure situations (there might be differences between FAR/JAR in the AFM depiction). For a modern aircraft with Cat 2+ capability, 50 ft MUH on an ILS would be typical. Often the operational certification requires the autopilot to be useable at 80% of the DH.

None of the above appears to tie in with the report that the ILS glideslope was unavailable; thus, the use of the autopilot in the reported conditions would not be authorized – consider that the report might imply flight guidance (FD) which could have different limits.
However, it is unusual that an intermediate MUH is not specified for a NPA, where increased pilot vigilance (quicker reaction time) might be used in the certification of a MUH below 1000ft.

In speculative mode there does appear to been opportunity for the Capt to decline the approach to runway 28 when given the runway change and GS unserviceability was announced, i.e. early threat and error management. Such a decision would avoid the potential for press-on-it is, continuing with an approach once started or mistakenly coupling the autopilot to a ‘glideslope’, whether this was an inappropriately radiated signal, or the mental belief that the coupled pitch mode was GS. The latter mindset being reinforced by the possible annunciation of partial approach mode and the original briefing for an ILS (I’m not type qualified – any comments on potential annunciation weaknesses?). In either event, it reinforces the need to crews to rebrief the approach very carefully following a change of runway (situation) – particularly when involving unservicabilities, the critical issue being that the new situation is understood, which includes thinking ahead to the revised minima (NPA MDA/Vis) and the landing conditions as discussed previously.

It is easy to question why an approach was not discontinued at low altitude in reducing visibility, but far more difficult to understand and prove the mental processes for not doing so in real events - time / workload, stress, etc.
A clear-cut case of a fuel truck on the runway at touchdown was shown by NASA HUD simulation to be far from self evident as many pilots never ‘saw’ the truck – inappropriate mental focus or attention. Often in reduced visibility the brain ‘makes up’ the mental picture, anticipating what is expected to be seen – no truck, no reduction in visibility. This effect is known as streaming and is clearly demonstrated during a low vis takeoff where the pilot ‘sees’ distances greater than the RVR.

[Zeffy]

alf5071h:
It is easy to question why an approach was not discontinued at low altitude in reducing visibility, but far more difficult to understand and prove the mental processes for not doing so in real events - time / workload, stress, etc.

Doesn't training pilots to systematically make appropriate tactical decisions -- even under considerable time pressure -- remain a significant challenge?

According to the preliminary report, the E170 crew had initially prepared to land 24R, a much longer (9000') non-sloping runway with TDZ and CL lighting.

We don't yet know precisely whether the "ten minutes prior to landing" includes the minutes spent conducting the actual approach to the revised runway 28, but obviously there wasn't an abundance of time to collect and assess all of critical information (yes bomarc, certainly including the runway downslope:) ) as well as to set the bottom lines and tolerances necessary to safely conduct the approach and land.

There are many situations in line operations where standard industry/company limits on stabilization gates, airspeed tolerances, touchdown points, etc. will not provide adequate protection for especially challenging conditions.

Is it wise to attempt an approach to a short-ish, slick runway in a jet? Perhaps -- but strict limits will need to be placed on airspeed excursions and touchdown point. Is the need for setting appropriate (tighter) tolerances and acceptable performance gates given sufficient emphasis in courses of training, in manuals, SOP's etc?

It would also be interesting to know if the GS was still on the air. According to a previous post, the following NOTAM was in effect that day.

FDC 7/3107 (KCLE A0785/07) CLE FI/T CLEVELAND-HOPKINS INTL, CLEVELAND, OH. ILS RWY 28, AMDT 22.... DUE TO EFFECTS OF SNOW ON THE GLIDE SLOPE MINIMUMS TEMPORARILY RAISED TO LOCALIZER ONLY FOR ALL CATEGORY AIRCRAFT. GLIDE SLOPE REMAINS IN SERVICE. HOWEVER, ANGLE MAY BE DIFFERENT THAN PUBLISHED.

Was this the NOTAM transmitted to the crew? Verbatim?

Lots of information yet to be revealed, but the aspect of tactical decision making processes is an interesting one.

[Ignition Override]

The Emb-170/190 is a fly-by-wire aircraft.

Does it take a while to develop the right touch, in order to make a decent landing in gusty wind conditions?

Maybe the type of flight control system was not a factor in the incident.

[alf5071h]

Zeffy "Doesn't training pilots to systematically make appropriate tactical decisions -- even under considerable time pressure -- remain a significant challenge?"

Maybe… Poor or inadequate training is often cited as a contributing factor to accidents, but this approach to investigation often represents an unbalanced focus of attention on the ‘sharp end’. It might be just another view of the blame and train mindset.
Crews are well trained, they are checked, approved, monitored, and licensed, so why when there is an accident is training a prime candidate? Humans, on occasion, fail; that’s ‘the ultimate design’ issue, not training.
A balanced investigation should look at all aspects of the operating system – James Reason territory. In this accident, there could be contributions from the operational management, SOPs or crewing, from the corporate organization, culture, the airport, ATC, and even the regulator.
...no matter how hard they try, humans can never be expected to outperform the system which bounds and constrains them. Organisational flaws will, sooner or later, defeat individual human performance.- Gary Parata Air Nelson
With today’s commercial pressures, the industry is probably working very close to the boundary of safety, which in normal operation provides adequate margin for error. Operations are error tolerant and provide sufficient flexibility to keep the system running smoothly. However, in less than ideal circumstances (non-normal circumstances) the system may not cope with error or error provoking situations and often this places great reliance on those at the sharp end to maintain the required level of safety, although the error could be at the ‘blunt end’. Unfortunately, with humans in the system there are inevitably situations where an error gets through the defences, often due to complacency instilled by the ‘safe’ normal operation.
In particular, there is increasing time pressure on crews in critical flight phases i.e. approach and landing. This often involves additional checks, new or changed regulations, SOPs; then add difficult weather, minimum equipment, reduced capability or a significant operational deviation from the norm, … and then everyone is at risk..

It is a courageous professional pilot who says ‘No’ to an ATC ‘request’ to change runways (assumes no explanation given). Who is willing to go to the hold to ‘sort things out’, go back into the traffic pattern, deal with the many operational, commercial, and ATC consequences in-flight and after landing?.
In this accident, the safe boundary appears to have been exceeded; could events have been foreseen, avoided?
Who had the ability to do something about it? The crew, yes, but so did many others.
Why was a runway change necessary? Was this an ATC whim to help the crew or to help ATC themselves? ATC have opportunity for good situation awareness, weather, runway state, ILS, but this awareness must include realization of additional crew workload – projecting ahead, not just in the immediate situation. Did ATC anticipate a ‘No’ response – what would they have done if it was No? Inadequate awareness or consideration (judgment) can result in the choice of an unsafe act (J Reason again)..

Did the airport leave the ILS GS transmitting? If a system component is unreliable then turn it off; a crew on final approach cannot determine the GS angle or if the beam is at a stable value. Failure to act opens opportunity for error – an error is an action or inaction resulting in an unexpected result…(Reason?).
Did the crew have the NOTAM information, was it understood? Would the NOTAM have been relevant if the GS was switched off, probably not? A well considered NOTAM could have stated that the GS was inoperative (Off), LOC approaches only, and NPA minima apply, all items that aid the crew to understand the situation and avoid error..

SOPs might mandate that any runway change requires a new approach briefing. However, would more precise wording enable appropriate crew judgment? A crew may not have to rebrief a side-step change to a long runway on a dry VFR day, but from an ILS approach on a long runway to a NPA on a shorter, potentially contaminated runway, then reconsideration, checking, and briefing would be required. Would an SOP encourage a go around if time is insufficient – SOP design, corporate safety culture?.
Then there are the recent recommendations from the regulator on landing distance required on arrival – sufficiently wide ranging to leave the operator (and crew) with the responsibility for safety. The regulator only specifies a minimum factor for safety (less than normal), and the most practical example of compliance refers to a European standard (a mandated regulation). It is wise to expect crew’s to consider all factors and then compute correctly the landing distance required. Even with good computation, would the safety factors have been adequate in the circumstances – who considers the ‘what if’ of these situations – are they really foreseeable? The regulator had opportunity, the operator, airport, ATC, and the crew:-
… of the organisation that claims constitutional authority over us all …
Responsibility lies with those who could act but do not,
it lies with those who could learn but do not and
for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer. - Phillip Capper
I pose questions that search deep into the system, how many investigations go this deep? Are they restricted by the need for ‘factual’ data, information which can be substantiated as if required by law (it isn’t so why be restricted by it). Human factors are not always conducive to such formal investigations and data presentation, they involve judgment. There are many unknown or indeterminate issues in accidents, which could best be considered by appropriate speculation – thus producing something that we could check and all learn from even if it did not apply to that particular accident.
A better understanding of the crew’s contribution or training in this accident could be obtained by considering if we (pilots, managers, operator, airport, ATC, regulator) would be susceptible to error in the same circumstances, … but we never are susceptible, are we!

Beyond the organisational accident. (http://qhc.bmjjournals.com/cgi/reprint/13/suppl_2/ii28)
Human error and organisational failure. (http://qhc.bmjjournals.com/cgi/content/full/14/1/56)
Human error; models and management. (http://bmj.bmjjournals.com/cgi/reprint/320/7237/768)
Achieving a safe culture: theory and practice. (http://scholar.google.com/url?sa=U&q=http://www.shef.ac.uk/~mcn/6810/reading/reason-1998-safety-culture.pdf)
Human Factors in Aviation. (www.lusa.lu.se/upload/Trafikflyghogskolan/TR2004-01_HindsightBias.pdf)
Crossing the Boundaries of Safe Operation: Training for Error Detection and Error Recovery. (www.dsto.defence.gov.au/attachments/crossing%20boundaries.pdf)
Diagnosing "vulnerable system syndrome". (http://qhc.bmjjournals.com/cgi/reprint/10/suppl_2/ii21)
Errors in our understanding of human error. (www.lusa.lu.se/o.o.i.s/6131)
Managing the Threats and Errors during Approach and Landing. (www.flightsafety.org/ppt/managing_threat.ppt)
Landing Performance Assessments at Time of Arrival. (www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo/all_safos/media/2006/safo06012.pdf)
Systems safety in the wake of the cave creek disaster. (www.webresearch.co.nz/docs_public/CaveCreekPaper.pdf)

[bomarc]

pushing the boundries of safety...spell it: PUSHING THE BOUNDRIES OF $AFETY.

[alf5071h]

bomarc, yes, “$$$” may be a contributor or even be the root cause – easy to say, more difficult to provide safety boundaries for the $$ aspects or define safety defences for them.
If a CEO takes a risky decision and succeeds s/he is the investor’s champion. If s/he fails, s/he rarely gets nailed by the Feds or the legal system; s/he might get fired, but with three years or more in the job s/he is set for life including a pension.

The CEO’s involvement in safety contributes to, even defines a company’s safety culture; this should include ‘a Just Culture (www.flightsafety.org/pubs/fsd_2005.html)’.
”An atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.” James Reason.

Who then judges the CEO’s behaviour with respect to this just culture? What are the definitions of acceptable and unacceptable behaviour at the top management levels – again is this judged by investors? If so perhaps they and the CEO should face the penalties when the line is crossed?

Lofty thoughts, but way above my domain to resolve.