Crash During Landing, Executive Airlines Flight 5401, Avions de Transport Regional 72-212, N438AT, San Juan, Puerto Rico, May 9, 2004

Crash During Landing

Executive Airlines (doing business as

American Eagle) Flight 5401

Avions de Transport Regional 72-212, N438AT

San Juan, Puerto Rico

May 9, 2004

Aircraft Accident Report

NTSB/AAR-05/02

PB2005-910402

Notation 7650A

National

Transportation

Safety Board

Washington, D.C.

THE CORRECTION BELOW IS INCLUDED

IN THIS VERSION OF THE PUBLISHED REPORT

AIRCRAFT ACCIDENT REPORT

NTSB/AAR-05/02 (PB2005-910402)

Crash During Landing

Executive Airlines (doing business as American Eagle) Flight 5401

Avions de Transport Regional 72-212, N438AT

San Juan, Puerto Rico

May 9, 2004

• Page number 100.1 between 100 and 101 in Appendix B has been added. (17 November 2005)

The page was originally missing from the report.

Aircraft Accident Report

Crash During Landing

Executive Airlines (doing business as

American Eagle) Flight 5401

Avions de Transport Regional 72-212, N438AT

San Juan, Puerto Rico

May 9, 2004

NTSB/AAR-05/02

PB2005-910402 National Transportation Safety Board

Notation 7650A 490 L’Enfant Plaza, S.W.

Adopted September 7, 2005 Washington, D.C. 20594

National Transportation Safety Board. 2005. Executive Airlines (doing business as American Eagle)

Flight 5401, Avions de Transport Regional 72-212, N438AT, San Juan, Puerto Rico, May 9, 2004.

Aircraft Accident Report NTSB/AAR-05/02. Washington, DC.

Abstract: This report explains the accident involving Executive Airlines (doing business as American

Eagle) flight 5401, an Avions de Transport Regional 72-212, which skipped once, bounced hard twice, and

then crashed at Luis Muñoz Marin International Airport, San Juan, Puerto Rico. Safety issues discussed in

this report focus on flight crew performance, the lack of company bounced landing recovery guidance and

training, and malfunctioning flight data recorder potentiometer sensors. Safety recommendations

concerning these issues are addressed to the Federal Aviation Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2005-910402 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report

Contents

Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.5.2.1 The First Officer’s Medical History and Prescription Drug Use . . . . . . . . . . . . . 7

1.5.3 The Flight Attendants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.6.1 Pitch Control System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.6.2 Landing Gear System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.6.3 Cockpit Seats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.7.1 Airport Weather Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.7.2 Additional Wind Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.11.2.1 Validation of Flight Data Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.11.2.2 Aileron Surface Position Sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.12.1 General Wreckage Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.12.2 Fuselage, Wings, and Engines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.12.3 Landing Gear System and Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.12.4 Elevator and Rudder Control Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.12.5 Cockpit Seats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.15.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.15.2 Evacuation of Passengers and Crewmembers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.15.3 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Contents iv Aircraft Accident Report

1.16.1 Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.16.2 Air Traffic Control Radar Data Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.16.3 Cockpit Seat Assembly Metallurgical Examinations . . . . . . . . . . . . . . . . . . . . . . . 23

1.16.3.1 Accident Airplane Cockpit Seat Assemblies . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1.16.3.2 FAA Vertical Drop Test of ATR-42 Cockpit Seats . . . . . . . . . . . . . . . . . . . . . . 24

1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1.17.1 Flight Crew Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1.17.1.1 Simulator Flight Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1.17.1.1.1 Observations of Simulator Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.17.1.2 Crew Resource Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.17.1.3 Bounced Landing Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.17.2 Operational Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

1.17.2.1 Approach Airspeed Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

1.17.2.2 Before Landing Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

1.17.2.3 Evacuation Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.18.1 Additional Information About Ipeco Cockpit Seats . . . . . . . . . . . . . . . . . . . . . . . . 31

1.18.1.1 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.18.1.2 Ipeco Cockpit Seat Tensile Strength Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1.18.1.3 Ipeco’s Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1.18.2 Previous Bounced Landing Recovery Guidance and

Training-Related Safety Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

1.18.3 Previous Flight Data Recorder Potentiometer

Sensor-Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.3 Bounced Landing Recovery Guidance and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

2.4 Quality of Data Provided by Flight Data

Recorder Potentiometer Sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

2.5 The First Officer’s Medical Condition and Prescription

Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2.6 Uncoupling of the Pitch Control Uncoupling Mechanism . . . . . . . . . . . . . . . . . . . . . . 43

2.7 Failure of the Left Main Landing Gear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

4. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

5. Appendixes

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

v Aircraft Accident Report

Figures

1. Ground track of the accident flight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2. Altitude profile of the accident flight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3. Main landing gear assembly.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

4. Ground scrape marks and the main wreckage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

5. Interior configuration of the airplane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

6. Schematic of the cockpit seat assembly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1a.

vi Aircraft Accident Report

Abbreviations

AFFF aqueous film forming foam

ALAR approach and landing accident reduction

AOM Airplane Operating Manual

ARFF aircraft rescue and firefighting

ASOS Automated Surface Observing System

ATC air traffic control

ATIS automatic terminal information service

ATR Avions de Transport Regional

BEA Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation

Civile

c.g. center of gravity

CAM cockpit area microphone

CF center field

CFR Code of Federal Regulations

CLB climb

CRM crew resource management

CRZ cruise

CVR cockpit voice recorder

DFDAU digital flight data acquisition unit

DFW Dallas/Fort Worth International Airport

FAA Federal Aviation Administration

FARs Federal Aviation Regulations

FDR flight data recorder

fps feet per second

GPWS ground proximity warning system

HBAW flight standards handbook bulletin for airworthiness

IOE initial operating experience

KIAS knots indicated airspeed

LOFT line-oriented flight training

MAZ Eugenio Mariá de Hostos Airport

MDCRS Meteorological Data Collection and Reporting System

Abbreviations vii Aircraft Accident Report

mg milligram

MLG main landing gear

msl mean sea level

NLG nose landing gear

PA public address

PIC pilot-in-command

SB service bulletin

SJU Luis Muñoz Marin International Airport

SNPRM supplemental notice of proposed rulemaking

STC supplemental type certificate

STT Cyril E. King International Airport

TO takeoff

VA S I visual approach slope indicator

viii Aircraft Accident Report

Executive Summary

On May 9, 2004, about 1450 Atlantic standard time, Executive Airlines (doing

business as American Eagle) flight 5401, an Avions de Transport Regional 72-212,

N438AT, skipped once, bounced hard twice, and then crashed at Luis Muñoz Marin

International Airport, San Juan, Puerto Rico. The airplane came to a complete stop on a

grassy area about 217 feet left of the runway 8 centerline and about 4,317 feet beyond the

runway threshold. The captain was seriously injured; the first officer, 2 flight attendants,

and 16 of the 22 passengers received minor injuries; and the remaining 6 passengers

received no injuries. The airplane was substantially damaged. The airplane was operating

under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger

flight. Visual meteorological conditions prevailed for the flight, which operated on an

instrument flight rules flight plan.

The National Transportation Safety Board determines that the probable cause of

this accident was the captain’s failure to execute proper techniques to recover from the

bounced landings and his subsequent failure to execute a go-around.

The safety issues in this report include flight crew performance, the lack of

company bounced landing recovery guidance and training, and malfunctioning flight data

recorder potentiometer sensors. Safety recommendations concerning bounced landing

recovery guidance and training and flight control surface position sensors are addressed to

the Federal Aviation Administration.

1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

On May 9, 2004, about 1450 Atlantic standard time,

Executive Airlines (doing

business as American Eagle) flight 5401, an Avions de Transport Regional (ATR) 72-212,

N438AT, skipped once, bounced hard twice,

and then crashed at Luis Muñoz Marin

International Airport (SJU), San Juan, Puerto Rico. The airplane came to a complete stop

on a grassy area about 217 feet left of the runway 8 centerline and about 4,317 feet beyond

the runway threshold. The captain was seriously injured; the first officer, 2 flight

attendants, and 16 of the 22 passengers received minor injuries; and the remaining

6 passengers received no injuries. The airplane was substantially damaged. The airplane

was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a

scheduled passenger flight. Visual meteorological conditions prevailed for the flight,

which operated on an instrument flight rules flight plan.

Flight 5401 departed Eugenio Mariá de Hostos Airport (MAZ), Mayagüez, Puerto

Rico, for SJU about 1415. The captain was the nonflying pilot for the flight, and the first

officer was the flying pilot. The flight crew stated that the takeoff, climb, and en route

portions of the flight were uneventful.

At 1437:05, as the flight approached the SJU traffic area, the cockpit voice

recorder (CVR) recorded the first officer confirming with the captain that automatic

terminal information service (ATIS) Juliet, which reported that winds were 060° magnetic

at 17 knots and gusting at 23 knots, was current.

Shortly thereafter, the captain briefed a

ref

(the minimum approach airspeed in the landing configuration before the airplane

reaches the runway threshold) of 95 knots and told the first officer to “stand by for

winds.”

The first officer asked the captain if he should set his airspeed bug

to 95 knots,

and the captain replied, “yeah.”

At 1443:03, a controller from the SJU Terminal Radar Approach Control

cautioned the pilots of possible wake turbulence from a preceding Boeing 727.

The

Unless otherwise indicated, all times in this report are Atlantic standard time.

For the purposes of this report, the term “skip” refers to a landing airplane that momentarily becomes

airborne after contact with the runway. A bounce is similar to a skip; however, the airplane reaches a higher

altitude after contact with the runway. A skip or a bounce is typically caused by excessive airspeed or

excessive back pressure being applied to the flight controls by the pilot.

ATIS information Juliet was based on a 1356 meteorological aerodrome report. For more information

about the meteorological conditions that existed before and after the time of the accident, see section 1.7.

For information about Executive Airlines’ wind additive to approach airspeed procedures, see

section 1.17.2.1.

An airspeed bug is an orange reference marker on the inside of the airspeed indicator that is set to

ref

by the pilot before the approach.

Factual Information 2 Aircraft Accident Report

captain then told the first officer to “get your speed back. You do not want to take wake

turbulence from a seven five.” At 1443:44, the approach controller told the flight crew to

reduce the airspeed to 160 knots. After this instruction, the captain again told the first

officer to slow down because of the preceding airplane. The first officer replied,

“[approach control] said one sixty though I thought.” The captain stated, “yeah, slow it

down even more though…just go about one forty.”

At 1446:17, the captain stated, “San Juan tower Eagle four zero one ILS

[instrument landing system] runway one zero, with eight in sight.” The SJU air traffic

control (ATC) tower local controller stated, “one departure prior to your arrival…seven

twenty seven, mile final just reported loss of ten knots.” At 1446:33, the local controller

cleared the airplane to land on runway 8. The captain acknowledged the clearance. At this

time, the first officer turned the airplane left toward runway 8 and transitioned to the

visual approach slope indicator (VASI), which is located near the approach end of the

runway for glideslope guidance.

At 1449:07, during the approach to landing, the captain stated, “you better keep

that nose down or get some power up because you’re gonna balloon.”

The captain then

told the first officer to “bring the power back.” About 2 seconds later, the ground

proximity warning system (GPWS) alerted “minimums,” and the captain instructed the

first officer to get the airplane’s nose up. Four seconds later, the GPWS alerted

“glideslope,” and the captain stated, “below the glideslope.” The first officer responded,

“correcting.”

The 727 landed on runway 10. The accident airplane was initially on approach to runway 10 but was

later vectored to runway 8. For information about the Safety Board’s air traffic control (ATC) radar data

study, see section 1.16.2.

The term “balloon” refers to a landing airplane that rises slightly before touching down. Ballooning is

typically caused by excessive airspeed or excessive back pressure being applied to the flight controls by the

pilot during the landing flare.

Factual Information 3 Aircraft Accident Report

At 1449:28, the captain told the first officer to “power in a little bit.” Flight data

recorder (FDR) data indicated that the airplane was about 45 feet above ground level

and

traveling at 110 knots indicated airspeed (KIAS) when it crossed the runway 8 threshold 2

seconds later. After the airplane crossed the runway threshold, the captain stated, “power

in a little bit, don’t pull the nose up, don’t pull the nose up.” At 1449:39, the captain

stated, “you’re ballooning,” and the first officer replied, “all right.”

CVR and FDR information indicated that the airplane touched down for the first

time about 1449:41 and about 1,600 feet beyond the runway 8 threshold. At this time, the

FDR recorded vertical and lateral loads of about 1.3 Gs and -0.10 G, respectively.

1449:41, the captain stated, “get the power,” and, 1 second later, “my aircraft.” The first

officer responded, “your airplane.” FDR data indicated that, by 1449:43, the airplane had

skipped to an altitude of about 4 feet.

CVR and FDR information indicated that the airplane touched down a second time

about 1449:45 and about 2,200 feet beyond the runway 8 threshold. FDR data indicated

that the airplane then pitched up to an angle of 9° while climbing to an altitude of 37 feet

and that the engine torque increased from 10 to 43 percent. About 1449:49, the pitch angle

decreased to -3°, and the engine torque started to decrease to 20 percent. The pitch angle

continued to decrease to -10°.

CVR and FDR information indicated that the airplane touched down a third time

about 1449:51 at a bank angle of 7° left wing down and about 3,300 feet beyond the

runway 8 threshold. Concurrently, the FDR recorded vertical and lateral loads of about

5 Gs and 0.85 G, respectively. By 1449:54, the pitch angle was 11°, and the airplane had

bounced to an altitude of about 24 feet.

CVR and FDR information indicated that the airplane touched down a fourth time

about 1449:56 (about 15 seconds after the initial touchdown) and about 4,000 feet beyond

the runway 8 threshold. FDR data indicated that the airplane pitched down to -7° and that

it was banked 29° left wing down. The airplane came to a complete stop about 4,317 feet

from the runway threshold. Figure 1 shows the ground track of the accident flight, and

figure 1a shows the altitude profile of the accident flight.

Unless otherwise indicated, altitudes referenced in this report are reported as height above ground

level.

One G is equivalent to the acceleration caused by the earth’s gravity (32.174 feet/second

). The

Safety Board conducted an airplane performance study, which included airplane trajectory, load, and

standard performance calculations. For more information about the Board’s airplane performance study, see

section 1.16.1.

Factual Information 4 Aircraft Accident Report

Figure 1. Ground track of the accident flight.

Figure 1a. Altitude profile of the accident flight.

Factual Information 5 Aircraft Accident Report

1.2 Injuries to Persons

Table 1. Injury chart.

Note: Title 14 CFR 830.2 defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours,

starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple

fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves

any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body

surface. A minor injury is any injury that does not qualify as a fatal or serious injury.

1.3 Damage to Airplane

The airplane was substantially damaged.

1.4 Other Damage

None.

1.5 Personnel Information

1.5.1 The Captain

The captain, age 33, was hired by Executive Airlines on January 11, 1999. He held

a multiengine airline transport pilot certificate with an ATR-42/-72 type rating.

(The

Federal Aviation Administration [FAA] denotes both airplane models on a pilot’s airman

certificate regardless of which simulator or airplane model the pilot used to qualify for the

type rating.) The captain’s most recent FAA first-class airman medical certificate was

issued on February 10, 2004, and contained the limitation that he “must wear corrective

lenses.”

According to the captain’s employment application for Executive Airlines, from

October 1996 to November 1997, he worked as a pilot-in-command (PIC) at Westwind

Aviation, Phoenix, Arizona. From December 1997 to February 1998, the captain held

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal

0 0 0 0 0

Serious

1 0 0 0 1

Minor

1 2 16 0 19

None

0 0 6 0 6

Total

2 2 22 0 26

On August 17, 2001, the captain received a notice of disapproval from the Federal Aviation

Administration (FAA) after a checkride for his ATR-42/-72 type rating. The notice of disapproval stated that

the entire flight check would have to be repeated, except for the portions involving stalls and steep turns. On

September 2, 2001, the captain was rechecked successfully, and he received his ATR-42/-72 type rating.

Factual Information 6 Aircraft Accident Report

nonaviation-related jobs. From March 1998 to January 1999, he worked as a PIC at

Sunrise Airlines in Phoenix.

Executive Airlines records indicated that the captain had accumulated a total flight

time of about 6,071 hours, about 3,814 hours of which were with the company in its

ATR-42 and -72 airplanes, including about 1,120 hours as PIC. The captain had flown

about 177, 134, 72, and 3.5 hours in the last 90, 60, and 30 days, and 24 hours,

respectively. The captain’s last ground training occurred on October 10, 2003; his last PIC

proficiency check occurred on October 15, 2003; and his last PIC line check occurred on

October 20, 2003.

On May 7, 2004, the captain flew the first leg of a 2-day trip sequence, which was

a roundtrip between SJU and Flamingo Airport, Antilles Islands, the Netherlands, where

he remained overnight. On May 8th, the captain flew the return flight to SJU. He stated

that he felt “well rested” for the flights to and from the Antilles Islands. On May 9, the

captain reported for standby duty at SJU about 1000. The captain stated that he had slept

well the night before. The captain stated that he did not smoke, drink alcohol, or take any

medications.

1.5.2 The First Officer

The first officer, age 26, was hired by Executive Airlines on March 15, 2004. He

held a commercial pilot certificate with single-engine and multiengine land and

instrument airplane ratings. The first officer’s most recent FAA airman first-class medical

certificate was issued on February 10, 2004, and contained the limitation that he “must

wear corrective lenses.”

According to the first officer, his only previous aviation-related employment was

as a flight instructor in Cessna 172 and Baron airplanes at Windy City Flyers, Wheeling,

Illinois. Executive Airlines records indicated that the first officer had accumulated a total

flight time of about 2,000 hours, about 20 hours of which were with the company as first

officer in its ATR-42 and -72 airplanes. About 18.5 hours of the first officer’s flight time,

which included eight landings in the ATR-72, were accumulated during his initial

operating experience (IOE).

Flight 5401 was the first officer’s first scheduled flight since

he completed IOE on May 4, 2004. The first officer had flown about 20 hours, all of which

were flown in the last 30 days. The first officer’s last recurrent ground training occurred

on April 10, 2004, and his last first officer proficiency check occurred on April 26, 2004.

On May 8, 2004, the first officer was assigned standby duty at SJU from 0600 to

1400. He was not assigned any flights during this period. On May 9, the first officer

reported for standby duty at SJU about 1100.

IOE consists of revenue flights flown by pilots after they complete their initial simulator training.

These flights are conducted in the presence of a company check airman. Federal regulations require that Part

121 pilots have 20 hours of IOE, which can be reduced by 1 hour (up to 10 hours) for each landing that they

have completed.

Factual Information 7 Aircraft Accident Report

1.5.2.1 The First Officer’s Medical History and Prescription Drug Use

A review of the first officer’s medical records from his personal psychiatrist

revealed that, in July 2001, he began seeing the psychiatrist for treatment of various

anxiety-related symptoms. The psychiatrist prescribed alprazolam to treat the first

officer’s condition.

Common side effects of alprazolam include drowsiness and

light-headedness.

The first officer noted on his psychiatric patient information form that he was

employed as a part-time flight instructor and that his ambition was to become a

commercial airline pilot. In March 2004, the psychiatrist noted in the first officer’s

medical records that they discussed the following:

heightened anxieties surrounding…his intensive ‘wind-down’ training for full

commercial jet pilot licensure….we looked at creative as needed manipulation of

alprazolam being mindful of…the need to stay alert.

The first officer’s pharmacy refill records indicated that he filled prescriptions for

60 0.25-milligram (mg) alprazolam tablets on July 15, August 19, and November 3, 2001,

and on March 28 and May 4, 2004. The first officer stated that he typically took one-half

of a 0.25-mg tablet and that he took that dosage about once every 2 or 3 days. He stated

that he did not take any alprazolam on the day of the accident and that he thought that the

only time he took a whole 0.25-mg tablet in the 72 hours before the accident flight was on

May 8 about 2000.

A review of the first officer’s three most recent FAA airman medical certificates

(dated August 13, 2001; August 7, 2003; and February 10, 2004) revealed that he did not

indicate that he was taking alprazolam or being treated by a psychiatrist for anxiety.

Specifically, the first officer checked the “no” box in response to item No. 18 on the

airman medical certificate application, which asks, “Have you ever in your life been

diagnosed with, had, or do you presently have any of the following…Mental disorders of

any sort, depression, anxiety, etc.?” Further, the first officer did not provide any

information about his psychiatric visits in response to item No. 19 on the application,

which asks the applicant to list any “visits to health professional within last 3 years.”

The Executive Airlines Flight Manual, Chapter 3, “Crew Qualification and

Responsibility,” Section 12.5, “Use of Medication (FARs [Federal Aviation Regulations]

91.17),” states, in part, the following:

The prescription was for 60 0.25-milligram (mg) tablets with instructions to take one to two tablets

every 2 to 3 hours, as needed, and not to exceed 8 mg per day.

The National Transportation Safety Board is aware that, after the accident, the FAA revoked the first

officer’s airman medical certificate because he allegedly falsified his application.

Factual Information 8 Aircraft Accident Report

FARs prohibit [a person from] acting or attempting ‘to act as a crewmember of a

civil aircraft while using any drug that affects the person’s faculties in any way

contrary to safety…’ Crewmembers who are unsure of the side affects of a

particular prescription or non-prescription drug are advised to consult their FAA

Aeromedical Examiner, or [company] Corporate Medical Director.

Although 14 CFR 61.53, “Prohibition on Operations During Medical Deficiency,”

does not specifically note anxiety as a disqualifying condition, the FAA “Guide for

Aviation Medical Examiners,” dated September 2003, states, “the use of a psychotropic

drug is disqualifying for Aeromedical certification purposes. This includes

all…anxiolytics [that is, medications used for the treatment of anxiety.]”

The first officer stated that he was not taking alprazolam at the time of his last

FAA medical examination in February 2004. The investigation determined that the first

officer did not consult either an FAA aeromedical examiner or executive airlines’ medical

director regarding his use of alprazolam.

1.5.3 The Flight Attendants

The flight attendant assigned to the forward jumpseat

had worked for Executive

Airlines as a flight attendant for 6 weeks. This flight attendant had been employed by the

company for 6 years in another capacity. On May 8, 2004, she was assigned a 2-day trip

sequence, which included flight 5401. On May 9, she began duty at Cyril E. King Airport

(STT), St. Thomas, Virgin Islands, about 1130.

The flight attendant assigned to the aft jumpseat, who was the lead flight attendant

on the accident flight, had worked for Executive Airlines for 4 months and had no

previous airline experience. This flight attendant was off duty during the 2 days before the

accident. On May 9, 2004, she began duty at STT about 1210.

1.6 Airplane Information

The ATR 72-212 is a high-wing, twin turbopropeller, pressurized airplane. The

airplane has an overall length of 89 feet 1.5 inches and a wingspan of 88 feet 9 inches. The

accident airplane, serial number 438, was delivered new to AMR Leasing Corporation,

Dallas, Texas, from ATR, Toulouse, France, on March 27, 1995. At the time of the

accident, the airplane had 19,276 total flight hours and 18,086 total cycles.

The airplane was equipped with two Pratt & Whitney 127 PW turbopropeller

engines and two Hamilton Standard four-blade propellers. The time since new for the left

For a description of the airplane’s interior configuration, see section 1.15.1 and figure 4.

AMR Leasing Corporation is owned by AMR Eagle Holding Corporation, which also owns

Executive Airlines.

An airplane cycle is one complete takeoff and landing sequence.

Factual Information 9 Aircraft Accident Report

engine was 18,208 hours, and the time since overhaul was 11,709 hours. The time since

new for the right engine was 15,637 hours, and the time since overhaul was 8,435 hours.

According to the load manifest for flight 5401, the airplane’s takeoff weight was

about 36,590 pounds, including 3,960 pounds of passenger weight and 770 pounds of

baggage weight,

and its takeoff center of gravity (c.g.) was -11 inches.

1.6.1 Pitch Control System

Two elevators (left and right) perform pitch control of the airplane. The elevators

are movable control surfaces attached to the rear spar of the horizontal stabilizer, which is

mounted on top of the vertical stabilizer in a T-tail configuration. Each elevator has a trim

tab with an actuator. The elevators are controlled either by manual inputs from the captain

or first officer control columns,

which are not directly mechanically linked, or the

autopilot system.

Each control column is connected through a dynamometric rod

to a cable tension

regulator located under the cockpit floor. The cable tension regulator maintains constant

cable tension and transmits column movement to two cables that run the length of the

fuselage to the aft fuselage elevator cable quadrant, which converts cable movement to

pushrod and elevator control bellcrank movement. Rotation of the elevator control

bellcrank deflects one elevator, and the pitch uncoupling mechanism (located in the

horizontal stabilizer between the left and right elevator bellcranks) moves the other

elevator.

Pitch uncoupling occurs when opposing rotational forces exist between the left and

right elevator control bellcrank shafts. When the pitch control system becomes uncoupled

or experiences a malfunction (such as jamming) that restricts one side of the pitch control

system, the independent operation of both elevators from either pilot’s control column is

allowed. Also, when the pitch control system becomes uncoupled, a microswitch located

on the pitch uncoupling mechanism closes, which illuminates the master warning and

pitch uncoupling warning lights located on each pilot’s instrument panel and activates a

repetitive aural chime.

Average passenger weights were used to calculate the total passenger weight. According to the load

manifest for flight 5401, 290 pounds of cargo were stowed in the forward cargo area, and 480 pounds of

cargo were stowed in the aft cargo area. The airplane’s maximum certificated gross takeoff weight was

48,501 pounds.

The airplane’s takeoff c.g. limits were from -14.4 inches to -0.2 inch.

Each dynamometric rod has two microswitches, which change state when 22.48 pounds are applied

to the control column. One microswitch indicates that the control column has been pushed downward, and

the other microswitch indicates that the control column has been pushed upward. When the microswitches

change state, the autopilot might disengage and trigger the “effort on pitch axis” FDR parameter.

According to ATR, recent ATR model airplanes incorporate a device (a switch installed on the first

officer’s maintenance panel) that allows the pitch control system to be recoupled. Because recoupling the

pitch control system is considered a maintenance action, recoupling can only be performed on the ground.

The accident airplane was not equipped with a recoupling device.

Factual Information 10 Aircraft Accident Report

1.6.2 Landing Gear System

The ATR-72 is equipped with a retractable, fuselage-mounted, tricycle-arranged

landing gear system. The landing gear system consists of one forward-retracting,

steerable, nose landing gear (NLG) assembly and two inboard-retracting main landing

gear (MLG) assemblies, all of which are hydraulically controlled.

Each MLG assembly

consists of a trunnion leg, a trailing arm, a shock absorber, an actuator, and a side brace.

Figure 2 shows the MLG assembly.

Figure 2. Main landing gear assembly.

The ATR-72 landing gear and associated structure were designed to absorb energy

equivalent to a maximum airplane descent rate of 10 feet per second (fps) when landing at

the airplane’s maximum design landing weight (consistent with the landing design limits

The NLG assembly retracts into the nose wheel well, and the MLG assemblies retract into the

fuselage.

Factual Information 11 Aircraft Accident Report

imposed by 14 CFR 25.473 to 25.487). In addition, in accordance with Section 25.723, the

ATR-72 MLG is designed to absorb reserve energy equivalent to a maximum airplane

descent rate of 12 fps when landing at the airplane’s maximum design landing weight.

1.6.3 Cockpit Seats

The accident airplane’s cockpit seats were designed by Ipeco Europe, Ltd.

According to Ipeco, the accident cockpit seats were manufactured in 1986, and the sleeve

assemblies installed on the seats were manufactured in 2000 and were 2 of 30 assemblies

manufactured in a batch run. Ipeco Test Report No. 1057, issued March 25, 1983,

indicated that the design of the accident airplane cockpit seats met the static load

requirements contained in 14 CFR 25.561 and Technical Standard Order C-39a (9 Gs

forward, 1.5 Gs side, 6 Gs down, and 2 Gs up).

1.7 Meteorological Information

1.7.1 Airport Weather Information

Weather observations at SJU are made every hour by an Automated Surface

Observing System (ASOS),

which transmits an official meteorological aerodrome report

every 56 minutes after the hour. The ASOS is located about 1,900 feet south of the

approach end of runway 8, and its wind measuring equipment is installed 33 feet above the

ground. About 1356 on the day of the accident, the ASOS reported that visibility was

10 statute miles, clouds were scattered at 3,000 and 4,300 feet and broken at 5,000 feet,

and winds were 050° at 17 knots and gusting to 23 knots. At 1456, the ASOS reported that

visibility was 10 statute miles; clouds were few at 2,300 feet, scattered at 3,400 feet, and

broken at 5,500 feet; and winds were 060° at 15 knots and gusting to 22 knots.

The SJU ASOS also provides high-resolution observations that are measured and

stored every 5 minutes. About 1445, the ASOS reported that visibility was 10 statute

miles, clouds were scattered at 2,300 feet and broken at 3,400 feet, and winds were 050° at

15 knots and gusting to 23 knots. About 1450, the ASOS reported that visibility was

10 statute miles, clouds were scattered at 2,300 feet and broken at 3,400 feet, and winds

were 060° at 18 knots and gusting to 22 knots.

1.7.2 Additional Wind Information

The 2000 upper air sounding (that is, a vertical profile of atmospheric conditions)

from SJU showed northeasterly winds aloft from 15 to 24 knots below 4,000 feet mean sea

level (msl).

ASOS is a system that continuously measures weather information, including windspeed and

direction, visibility, precipitation, cloud cover, temperature, dew point, and altimeter setting.

Factual Information 12 Aircraft Accident Report

Center field (CF) wind data,

which report 2-minute average winds, were obtained

from the FAA for the period from 1445:02 to 1452:02. During this 7-minute period, the

CF anemometer indicated wind directions of 060° and 070° magnetic, and the CF

2-minute average windspeed ranged from 12 to 16 knots. No wind gusts were reported for

this period.

A Safety Board meteorologist retrieved Meteorological Data Collection and

Reporting System (MDCRS)

reports from the National Oceanic and Atmospheric

Administration Forecast System Laboratory archive. Two ascent profiles from airplanes

departing STT (about 58 nautical miles from SJU)

before and after the time of the

accident showed 13-knot winds at 1,160 feet msl, 15-knot winds at 1,440 and 1,600 feet

msl, and 13-knot winds at 1,670 feet msl.

1.8 Aids to Navigation

No problems with any navigational aids were reported.

1.9 Communications

No communications problems between the pilots and any of the air traffic

controllers who handled the accident flight were reported.

1.10 Airport Information

SJU is located 3 miles southeast of San Juan at an elevation of 9 feet msl. The

airport has an ATC tower, which provides approach and departure services. SJU has two

precision instrument approach runways: runways 8/26 and 10/28. Runway 8/26 is about

10,000 feet long and 200 feet wide. Runway 10/28 is about 8,000 feet long and 150 feet

wide. The runway surfaces are constructed of grooved asphalt and are accessible by

parallel taxiways.

SJU was certificated under 14 CFR Part 139. A standard two-bar VASI is located

near the approach end of runway 8. SJU maintains an index D aircraft rescue and

firefighting (ARFF) facility, which has six ARFF vehicles.

The National Weather Service typically launches radiosonde balloons about 0700 and 1900. The

2000 upper air sounding was taken shortly after 1900.

According to the FAA, the CF anemometer is located midfield, about 1,500 feet south of runway 8,

and the wind is measured at 48 feet.

According to the FAA, wind gust values are not reported unless the wind gust exceeds the 2-minute

average windspeed by 9 or more knots.

The MDCRS collects, decodes, and disseminates automated weather reports.

No MDCRS data were available for the SJU area.

Factual Information 13 Aircraft Accident Report

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The accident airplane was equipped with a Fairchild model A-100A CVR, serial

number 55031. The exterior of the CVR was not structurally damaged. The tape spool

assembly and other components inside the case were not damaged and were generally in

good condition.

The CVR was sent to the Safety Board’s laboratory in Washington, D.C., for

readout and evaluation. The tape was played back normally and without difficulty. The

recording started at 1422:02 and continued uninterrupted until 1452:54. The recording

consisted of four separate channels of audio information: the cockpit area microphone

(CAM), the captain and first officer audio panels, and the public address (PA) system. Hot

microphone transmissions were also captured on the flight crew’s respective audio

channels. The audio information from all four channels was generally of good quality.

transcript of the 31-minute recording was prepared (see appendix B).

1.11.2 Flight Data Recorder

The accident airplane was equipped with an L3 Communications Fairchild model

F-800 FDR, serial number 3151, which used magnetic tape as the recording medium. The

FDR was found to be in good condition.

The FDR was sent to the Safety Board’s laboratory for readout and evaluation. The

magnetic tape was removed from the FDR, and the data were transcribed directly to a hard

disk. About 25 hours of data were recorded on the FDR, including data from the accident

flight, and 56 parameters that were pertinent to the circumstances of the accident were

verified.

1.11.2.1 Validation of Flight Data Recorder Data

The Safety Board recovered data from the accident flight, the last landing before

the accident flight,

the first recorded landing (made about 25 operational hours before

the accident flight), and the first recorded flight control ground check and subsequent

According to 14 CFR 139.317, an index D ARFF facility is required to have (1) either one

firefighting vehicle with 500 pounds of sodium-based dry chemical or Halon 1211 or 450 pounds of

potassium-based dry chemical and water with a commensurate quantity of aqueous film forming foam

(AFFF) to total 100 gallons and (2) two firefighting vehicles with water and a commensurate quantity of

AFFF so that the total quantity of water for foam production carried by all vehicles is at least 4,000 gallons.

The Safety Board uses the following categories to classify the levels of CVR recording quality:

excellent, good, fair, poor, and unusable. A good quality recording is one in which most of the crew

conversations could be accurately and easily understood. At times during the flight 5401 recording, the

ambient noise level of the CAM channel made it somewhat difficult to discern sounds or conversations

recorded on the other three channels. The transcript that was developed may indicate one to two words that

were not intelligible. Any loss in the transcript can be attributed to simultaneous cockpit/radio transmissions

that obscure each other.

Factual Information 14 Aircraft Accident Report

takeoff. However, the Board could not recover three segments of the event data (8 seconds

total). The Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA)

had developed a program to decode the waveforms from F-800 magnetic tape FDRs. With

the use of this program, the BEA was able to decode two of the three segments of

waveforms; however, because of the very high variation in tape speed, only the last

second of the 4-second third segment could be fully recovered.

1.11.2.2 Aileron Surface Position Sensors

In accordance with 14 CFR 121.344, the accident FDR was required to record left

and right aileron surface positions no later than August 20, 2001. According to Executive

Airlines, the accident airplane was modified on August 7, 2001, in accordance with

Supplemental Type Certificate (STC)

No. ST01310NY, which required adding two new

sensors and associated hardware on each wing.

Although the airplane had been equipped

with the required sensors and associated hardware, the left aileron surface position data

were invalid; therefore, the airplane did not meet the requirements of 14 CFR 121.344.

The aileron sensors installed on the accident airplane were string potentiometers.

The string is attached to the aileron linkage so that any aileron movement is registered by

the potentiometer, which produces a voltage input to the digital flight data acquisition unit

(DFDAU). The DFDAU then converts the voltage to a digital value that is recorded by the

FDR and then calibrated by Executive Airlines to determine the aileron surface position.

Executive Airlines stated that it added aileron surface position sensors to its

41 ATR-72 airplanes (2 sensors per airplane, for a total of 82 sensors) in accordance with

STC No. ST01310NY, and that, in the last 3.5 years, the company has replaced 47 of these

sensors, which is a 57 percent failure rate. The company indicated that the sensors are not

tracked and, therefore, that the times from installation to failure could not be determined.

The company also indicated that the sensors do not incorporate a warning or an indication

system. The company further indicated that aileron surface position sensor failures were

typically caused by wear or weather-related damage.

At the time of the accident, Executive Airlines performed FDR functional checks

every 3,000 flight cycles. Executive Airlines indicated that the accident airplane’s last

FDR functional check was conducted on January 3, 2003, about 1 year and 5 months after

the STC modification and about 1 year and 4 months before the accident. After the

accident, Executive Airlines started conducting FDR functional checks every 1,000 flight

cycles.

The accident flight crew made the airplane’s last landing at MAZ about 1347 on the same day of the

accident.

Most of the 56 verified parameters recorded from 1449:58.8 to 1450:01.86 (the first 3 seconds of the

third segment) were deemed invalid.

An STC is issued for major design changes to type-certificated products when the change is not

extensive enough to require a new type certificate.

Executive Airlines stated that all of its ATR-72s were modified in accordance with STC

No. ST01310NY.

Factual Information 15 Aircraft Accident Report

1.12 Wreckage and Impact Information

1.12.1 General Wreckage Description

The first evidence of ground impact (from the airplane’s third touchdown) was

located on runway 8 about 44 feet left of the runway centerline and about 3,361 feet

beyond the runway threshold. Various ground impact, gouge, scrape, and tire marks were

found near the first ground impact mark. These marks were on a magnetic heading of

about 075° and were consistent with the landing gear tires on the accident airplane. The

tire marks extended about 40 feet from the first ground impact area in the direction of the

main wreckage. No other tire marks that were consistent with the tires on the accident

airplane were found beyond the first impact area. An oily spray pattern extended outward

to the left of the gouge marks. The oily substance was consistent with the fluid contained

in the MLG shock absorbers. Most of the pieces found at the first ground impact area were

small sections of the NLG, including the NLG door, pieces of the left MLG, and the

fuselage belly fairing.

Evidence of another ground impact (from the airplane’s fourth touchdown) was

found on the grassy area about 145 feet left of the runway 8 centerline and 4,053 feet

beyond the runway threshold (about 692 feet from the initial ground impact area). This

evidence included left wing tip scrape marks, left engine propeller strike marks, and a

fuselage belly impact impression, which were all on a magnetic heading of about 070°.

The marks on the grassy area continued from the second ground impact area to the main

wreckage location. Sections of the outboard left wing and the left propeller blades were

also found in this area.

The main wreckage was located about 217 feet left of the runway 8 centerline and

about 4,317 beyond the runway threshold. The main wreckage consisted of most of the

airplane structure, except for the lower section of the left MLG tire assembly, which was

found about 302 feet left of the runway 8 centerline and 3,944 feet beyond the runway

threshold (about 373 feet from the main wreckage). Figure 3 shows ground scrape marks

and the main wreckage.

Factual Information 16 Aircraft Accident Report

Figure 3. Ground scrape marks and the main wreckage.

The landing gear handle was found in the down position. The parking brake and

gust lock levers were found positioned to off. The flap handle showed 030° of flaps. The

captain and first officer internal V

HB30 (minimum high bank at flaps 030°) airspeed

bugs were found set at 96 KIAS. The power management selector was found set at CLB

(climb). The CVR, left elevator, rudder, and first officer-side fuel pump circuit breakers

were found tripped.

1.12.2 Fuselage, Wings, and Engines

The airplane fuselage was found intact and orientated upright. The vertical and

horizontal stabilizers remained attached to the tail structure and showed no evidence of

impact damage. The left forward hatch exit was found open, and the hatch was found

The Safety Board documented the positions of the circuit breakers, switches, and movable controls

on the day after the accident. The documented positions of the circuit breakers, switches, and other movable

controls may not represent their actual positions after the accident. Emergency medical technicians entered

the cockpit during the emergency response to help the flight crew evacuate the airplane. Further, an

Executive Airlines mechanic entered the cockpit after the emergency response and reportedly turned off all

switches and disconnected the battery system.

Factual Information 17 Aircraft Accident Report

inside the airplane. The aft main entry door was found open, and the handrail was found

locked in the up position.

A section of about 13 feet of the forward, left side of the lower fuselage was

severely crushed. The left forward cargo door and surrounding structure were severely

deformed and buckled. A section of about 8 feet of the forward, right side of the lower

fuselage was crushed. The damage on both the left and right sides of the lower fuselage

extended from the belly to the floor line, and the left side exhibited some evidence of

scrape marks just below the floor line.

Most of the left belly fairing forward and aft of the left MLG was found crushed

and deformed, and a portion was missing. The aft, lower surface of both sides of the

fuselage exhibited evidence of scraping, minor crushing damage, and skin wrinkling. The

aft fuselage just forward of the tail cone was found wrinkled around its circumference.

All eight of the wing attachment fittings and the two shear web supports located on

the fuselage were fractured; however, the wing assembly remained near its installed

location in the fuselage. The left wing was found rotated counter-clockwise about 15° left

(as viewed from aft), and the wing tip and engine propeller hub contacted the ground. The

right wing section was found attached to the center wing box and exhibited minimal

damage. All control surfaces were found intact and exhibited no damage. All of the

fracture surfaces on the wing frames, struts, and shear web were consistent with overload

failure.

The left and right engine assemblies were found attached to the airframe. All four

propeller blades on the left engine were sheared off at the blade root section. A section of

about 12 inches was missing from each of the right propeller blades, which remained

attached to the engine. The fuselage near the right engine exhibited propeller strike marks.

1.12.3 Landing Gear System and Components

The right MLG was found down and locked and remained attached to the fuselage

by the trunnion attach points. All of the right MLG components, including the trunnion

leg, side brace, shock absorber, and actuator, were found intact and attached to the gear

assembly. The right MLG outboard tire was found inflated, and the inboard tire was found

deflated. The right MLG inboard tire exhibited some evidence of rubber scraping and

minor tears along several circumferential tread lines. No evidence of preexisting damage

was found on either tire. Both tires were free to rotate with slight resistance. Both brake

assemblies were found intact. Both ground proximity sensors were found attached.

The left MLG was fractured circumferentially at its vertical trunnion leg just

below the actuator attach point. The upper portion of the vertical trunnion leg, which

remained attached to the horizontal trunnion leg, was 4 inches long. The horizontal

trunnion leg remained attached to the fuselage by the trunnion attach points, and no

evidence of any damage to these components was found. The lower portion of the vertical

trunnion leg, which remained attached to the wheel assembly, was 24 inches long.

Factual Information 18 Aircraft Accident Report

Sections of the vertical trunnion that contained the fractures were removed from the

airplane and sent to the Safety Board’s Materials Laboratory for further examination. The

examination revealed that the fracture surfaces were consistent with overstress separation.

No evidence of fatigue was found.

The upper portion of the left MLG side brace remained attached to the fuselage,

and the lower portion had separated from the fractured vertical trunnion leg and showed

no evidence of scraping or scoring. The secondary side brace remained attached to the left

MLG and exhibited minimal damage. The left MLG shock absorber was found separated

from the MLG assembly. The shock absorber was found along the wreckage path in the

fully compressed condition, and no shock absorber fluid was present. The shock absorber

base was fractured about 5 inches from the bottom. The upper portion of the shock

absorber was intact.

Both left MLG tires were found inflated. The inboard tire exhibited evidence of

scoring and rubber tearing over about 22 inches of the circumference of the tire. Both tires

rotated freely with slight resistance. Both brake assemblies were found intact.

The NLG was found embedded in the belly of the forward fuselage, folded

rearward (opposite of its normal position), and rotated counter-clockwise (the right tire

was in contact with the ground). The NLG had separated from its fuselage attach points in

the wheel well, which was severely crushed. The right attach point had sheared off. The

NLG remained attached to the fuselage by the actuating cylinder.

Both NLG tires were found deflated and exhibited evidence of rubber scoring and

tearing. No evidence of tire rupture or burst was found. Both inner hubs were fractured,

and pieces of the hubs were found on runway 8 near the first ground impact area. The

wheel well structure was severely crushed.

1.12.4 Elevator and Rudder Control Systems

The elevator pitch uncoupling mechanism was found uncoupled. All of the other

tail section elevator components were found intact and attached to their respective

attachment points. Both elevator control quadrants could be rotated by hand until their

respective elevators contacted their up or down stops. No mechanical binding or resistance

was felt. The elevator components beneath the cockpit floor, including the pulleys and

brackets, were found damaged. All of the elevator cables were found intact and routed

through and contained within their respective pulleys.

The tail section rudder components were found intact and attached to their

respective attachment points. The aft rudder control quadrant showed limited travel in

both directions when rotated forward and aft using hand pressure.

Factual Information 19 Aircraft Accident Report

1.12.5 Cockpit Seats

The captain seat was found attached to the floor at all mounting points, and the

floor beneath the mounting brackets was not deformed. The inertia reel was found in the

locked position and worked normally. The forward and aft seat adjustment lever would

not move. The seat height lever moved freely, but the seat would not lock into any

position. The seat was found in the lowest height position and moved freely up and down.

The first officer seat was found attached to the floor at all mounting points, and the floor

beneath the mounting brackets was not deformed. The first officer seat operated normally.

Both seats were removed from the airplane and sent to the Safety Board’s Materials

Laboratory for examination.

1.13 Medical and Pathological Information

Required Federal drug and alcohol testing of the captain and first officer were

negative for alcohol and drugs of abuse. Company drug and alcohol testing also tested

negative for alcohol and a wider range of drugs, including alprazolam.

A review of the captain’s postaccident medical records revealed that he sustained a

compression fracture of the first lumbar vertebrae. The first officer reported that he

sustained a contusion on his forehead. The forward flight attendant reported that she had

arm, shoulder, and neck pain and bruises on her arms. The aft flight attendant reported that

she had neck and back pain. According to medical records and personal injury reports, 16

of the 22 passengers sustained minor injuries. The remaining six passengers did not report

any injuries.

1.14 Fire

No evidence of an in-flight or a postcrash fire was found.

1.15 Survival Aspects

1.15.1 General

The airplane was configured with 64 passenger seats in a single-aisle

configuration. The cockpit contained two flight crew seats and one retractable observer

seat. An aft-facing, single-occupancy, retractable flight attendant jumpseat was mounted

on the forward bulkhead, and a forward-facing, single-occupancy, retractable flight

attendant jumpseat was mounted on the aft bulkhead. Figure 4 shows the interior

configuration of the airplane.

For information about the metallurgical examinations of the cockpit seat assemblies, see

section 1.16.3.

Factual Information 20 Aircraft Accident Report

Figure 4. Interior configuration of the airplane.

As shown in figure 4, the airplane had a main entry door on the left side of the aft

fuselage, emergency hatch exits on each side of the first row of passenger seats, and a

service door on the right side of the aft fuselage. The airplane was equipped with all

required cabin emergency equipment, as specified in Executive Airlines’ In-Flight

Manual.

1.15.2 Evacuation of Passengers and Crewmembers

The cabin crew initiated the evacuation of the passengers in accordance with

standard company procedures. The forward flight attendant stated that she looked out the

Factual Information 21 Aircraft Accident Report

forward left emergency exit window and saw a lot of “crash debris” on the ground and that

she then looked out the right emergency exit window and thought that the exit looked as if

it were too far above the ground to use; therefore, she decided not to open either forward

exit. This flight attendant stated that most of the passengers were seated near the rear of

the airplane.

The aft flight attendant stated that, after she assessed conditions, she asked a

nonrevenue pilot who was sitting in the back of the airplane to open the service door. This

flight attendant stated that, while he opened the service door, she opened the main entry

door. She added that emergency response personnel were waiting outside the airplane and

that they assisted the passengers as they exited the airplane through the main entry door.

1.15.3 Emergency Response

An ARFF specialist in a fire truck was positioned between the Executive Airlines

operations area and the taxiway adjacent to runway 8 (about 1,500 feet from the approach

end of the runway). The ARFF specialist stated that, about 1455, he watched the accident

airplane make the approach to landing. The ARFF specialist stated that, after the second

touchdown, the airplane pitched up “sharply” and that he called the ARFF station because

he thought that something might be wrong. The ARFF specialist stated that he then turned

on the vehicle beacon and siren and visually tracked the airplane until it came to a

complete stop. The ARFF specialist stated that he drove to the location where the airplane

had stopped and then approached it from the left aft side. He stated that, because he saw

“black and white” smoke coming from near the left engine, he “hosed [it] down.”

By 1500, four additional ARFF vehicles and five additional ARFF personnel and

G.E.S. Ambulance Service ambulances had arrived. About 1515, the State Emergency

Medical, San Juan Municipal, Carolina Municipal, and Guaynabo City Emergency

Medical Service units arrived. Additionally, five fire trucks and crews from off-airport

mutual aid services responded to the accident. According to the airport operations

coordinator, he coordinated with the operations supervisor and ARFF and security

personnel to escort these units to the main terminal building. The captain and the injured

passengers were transported to area hospitals.

1.16 Tests and Research

1.16.1 Airplane Performance Study

The Safety Board conducted an airplane performance study, which used CVR

transcript information and FDR and radar data

that were correlated to a common time

reference. The study integrated FDR lateral, vertical, and longitudinal loads with pitch,

According to passenger information provided by Executive Airlines, the passengers were assigned to

seats 4A, 5B and 5C, 6B and 6C, 7A and 7D, 8A through 8D, 9A through 9D, 10A through 10D, 11A, 14D,

and 16A.

Factual Information 22 Aircraft Accident Report

roll, and yaw values and wreckage survey data and determined the accident airplane’s

ground track, the corresponding time history of the airplane’s motions, and the estimated

load factors on the left MLG and cockpit area. The airplane performance study also

derived windspeed and direction to determine whether the winds had affected the

airplane’s performance.

Before and during the time that the CVR recorded the sound of the first thump

(1449:41), the airplane encountered an 8-knot decrease followed by an 11-knot increase in

windspeed. Immediately thereafter, the CVR recorded the captain’s statement, “my

aircraft.” At this time, FDR data showed the engine torque decrease from about 30 to

10 percent, which is slightly above the flight idle position, and the elevators deflect from

5° to -2°. At 1449:45, the CVR recorded the sound of a second thump. FDR data showed

that, immediately thereafter, the airplane pitch angle decreased to -4°, and the derived

windspeed increased by 6 knots. The pitch angle then increased to about 9° while climbing

to an altitude of 37 feet, and the engine torque started to increase from 10 to 43 percent.

About 3 seconds later, the engine torque started to reduce to 20 percent, and the pitch

angle decreased to -3°. While the pitch angle continued to decrease to -10°, the derived

windspeed decreased by 8 knots, and the elevator deflection began to increase to 4°.

The airplane performance study showed that, about 1449:51, when the airplane

was about 3,300 feet beyond the runway 8 threshold, the CVR recorded a very loud bang,

and the FDR recorded vertical and lateral loads of about 5 Gs and 0.85 G, respectively.

The average vertical load for the left side of the cockpit area was calculated to be about

12 Gs. It is possible that the vertical loads experienced in the cockpit during the third

touchdown were more than 12 Gs; however, this value could not be calculated because of

the low FDR sampling rate. The airplane’s descent rate was determined to be about 19 to

32 fps.

During the last touchdown, when the most substantial damage to the airplane most

likely occurred (especially to the left side of the cockpit), the left bank angle recorded by

the FDR was 29° left wing down. The average vertical loads experienced in the cockpit

during the last touchdown could not be determined because the FDR data became

unreliable at this point and because of the airplane’s orientation.

1.16.2 Air Traffic Control Radar Data Study

The Safety Board conducted an ATC radar data study to evaluate the separation of

radar tracks associated with the accident airplane and the preceding 727 that landed on

runway 10 about 3 minutes before the accident airplane landed on runway 8. The study

began at 1444:26, when the 727 was about 5.7 miles west of SJU on final approach to

runway 10 and the accident flight was about 4.3 miles behind the 727. The study ended at

1446:42, when the last radar return associated with the 727 was received. At their closest

Radar data from the U.S. Air Force 84th Radar Evaluation Squadron, which were recorded by the

SJU Airport Surveillance Radar-8 sensor, were used in the calculations.

Factual Information 23 Aircraft Accident Report

point, the airplanes were separated about 4.3 miles laterally and 400 feet vertically, which

is greater than the minimum lateral separation specified in Federal requirements.

1.16.3 Cockpit Seat Assembly Metallurgical Examinations

1.16.3.1 Accident Airplane Cockpit Seat Assemblies

The accident airplane’s cockpit seat assemblies were sent to the Safety Board’s

Materials Laboratory for metallurgical examination. Figure 5 shows a schematic of the

cockpit seat assembly.

Figure 5. Schematic of the cockpit seat assembly.

FAA Order 7110.65, “Air Traffic Control,” paragraphs 4-5-1, 5-5-4, and 5-5-5, require that airplanes

be separated at least 3 miles laterally and/or 1,000 feet vertically.

Factual Information 24 Aircraft Accident Report

Visual examinations of the captain seat revealed that the weld that attached the end

cap to the sleeve was fractured at both welded joints, releasing the end cap from the

sleeve. Visual examinations of the fractured welded joints revealed the presence of dark,

oxidized, preexisting regions that were consistent with weld discontinuities at the inner

diameter side of both joints. On the forward sidewall fracture, intermittent weld

discontinuities extended along most of the 4.2-inch circumferential length of the joint to a

depth of about 0.03 to 0.06 inch.

On the aft sidewall fracture, the weld discontinuity was

continuous and extended along the entire circumferential length of the joint to a depth of

about 0.03 to 0.06 inch.

A Safety Board materials engineer estimated that the weld discontinuities

extended through about 25 percent of the cross-sectional area on the forward side and

about 40 percent of the cross-sectional area on the aft side. The discontinuities contained

repeating columnar patterns with curved features at an angle to the surface, which was

consistent with a lack of fusion that resulted from molten regions not bonding during the

welding process. High-magnification optical and scanning electron microscope

examinations of the aft sidewall fracture showed the presence of small fatigue cracks that

had propagated from the weld discontinuity region toward the outer diameter, which

slightly increased the total penetration of the preexisting defect region.

Visual examinations of the intact welded joints on the first officer seat revealed

that gaps existed between the mating surfaces of both welded joints, which was consistent

with incomplete weld penetration. The forward sidewall region had about a 2.9-inch-long

gap (the total joint length was 4.2 inches). The aft sidewall region had two slightly

overlapping gaps that extended about 3 inches. A section of the forward sidewall welded

joint was excised and fractured open, revealing that the gaps at the inner diameter of the

welded joint had features similar to the preexisting weld discontinuity (lack of fusion)

regions on the inner diameter of the welded joints on the captain seat. The maximum

penetration of the weld discontinuity was about 0.045 inch in the section that was

fractured open for examination.

1.16.3.2 FAA Vertical Drop Test of ATR-42 Cockpit Seats

In May 2003, the FAA Technical Center in Atlantic City, New Jersey, conducted a

vertical drop test of an ATR-42 airplane that had cockpit seats with the same design and

part number as the cockpit seats on the accident airplane. According to the test report,

vertical loads in the cockpit area were measured at 30 Gs for the left cockpit floor and

34 Gs for the right cockpit floor.

Neither of the cockpit seats broke during the test.

Because of the similarities between the accident and test airplanes’ cockpit seats and

vertical loading, the cockpit seats from the FAA drop test were sent to the Safety Board’s

Materials Laboratory for comparison to the cockpit seats from the accident airplane.

An Ipeco representative stated that the manufacturing specification for the sleeve assembly called for

100 percent weld penetration; therefore, the accident end cap and sleeve assemblies did not meet

manufacturing specifications.

Federal Aviation Administration, The Vertical Drop Test of an ATR-42-300, FAA Technical Center

(Atlantic City, New Jersey: FAA, 2004).

Factual Information 25 Aircraft Accident Report

Visual examination of the test airplane’s captain seat parts revealed that gaps

existed at the inner diameter between the end cap and sidewall portions of the sleeve on

both the forward and aft welded joints. No evidence indicated that the inner diameter

surface had become molten during the welding process. Both the forward and aft welded

joints were fractured in the laboratory by bending the sidewall portion outward relative to

the end cap, revealing that the gaps at the inner diameter of the welded joints corresponded

to weld discontinuity regions. These weld discontinuity regions extended along the entire

circumferential length of the joints and penetrated about 50 to 60 percent of the joints’

depth. Visual examination of the test airplane’s first officer seat parts revealed gaps at the

inner diameter that extended along the circumferential length of the welded joint.

1.17 Organizational and Management Information

Executive Airlines began service as Executive Air Charter in 1982 and began

scheduled passenger operations in 1985. American Eagle Holding Corporation bought

Executive Air Charter in 1989. In October 2002, the company reorganized, and Executive

Airlines began operations as a separate entity doing business as American Eagle and AMR

Leasing Corporation.

Executive Airlines is a regional airline that provides Part 121 scheduled passenger

service to 40 island locations in the Caribbean. The company operates 130 flights daily

from its major hubs at SJU and Miami International Airport, Miami, Florida. At the time

of the accident, Executive Airlines was the largest ATR-42 and -72 operator in the United

States and had a fleet of 8 ATR-42 and 41 ATR-72 airplanes.

1.17.1 Flight Crew Training

Executive Airlines’ pilots attend training at the American Eagle training center

located at Dallas/Forth Worth International Airport (DFW), Dallas/Fort Worth, Texas. All

first-time pilots at Executive Airlines attend a basic indoctrination course, where they are

taught general information on company operations. Pilots then attend initial and/or

transition ground school and simulator training. According to the Executive Airlines

ATR-42/72 Ground Training Instructor Lesson Plan, the typical initial and transition

training consists of 10 days of ground school and 20 hours of IOE. As stated previously,

new and upgrade pilots perform their IOE in the presence of a check airman. In addition,

all pilots are required to attend recurrent training (a 4-hour, line-oriented flight training

[LOFT] session)

and perform a 1.5-hour proficiency checkride every year. Recurrent

training and the proficiency checkrides are conducted by company check airmen.

1.17.1.1 Simulator Flight Training

According to the Executive Airlines ATR-42/72 Simulator Training Syllabus, all

new pilots and pilots qualifying for upgrades receive nine 4-hour simulator lessons (for a

LOFT facilitates the transition from simulator to line flying.

Factual Information 26 Aircraft Accident Report

total of 36 hours of simulator training)

and one 2-hour simulator checkride. In addition,

pilots receive 2 hours of ATR-42 training and a 1.5-hour airplane checkride. Further,

pilots receive 5 hours of ATR-72 differences training.

Simulator training is conducted by

a company check airman and a simulator instructor.

Executive Airlines uses an ATR-42 simulator located at DFW for most of its pilot

training. The company also uses an ATR-42 simulator located at FlightSafety

International, Houston, Texas, when not enough training time is available in the DFW

simulator. The ATR-42 simulators used for Executive Airlines’ training are Level C

simulators.

1.17.1.1.1 Observations of Simulator Sessions

On June 20, 2004, the Safety Board observed various flight profiles and

procedures conducted by Executive Airlines pilots in the ATR-42 simulator at DFW,

including the following:

• a visual approach to the runway with the first officer as the flying pilot,

090° winds at 10 knots, gusts at 15 knots, and ATC assigning various airspeeds

during the approach;

• an initiation of a go-around after touchdown; and

• a visual approach to the runway with the first officer as the flying pilot, the

captain taking control at 80 feet, and a pitch uncoupling during a go-around—

making the trim system inoperative.

Executive Airlines’ procedures for operation of the ATR-72 allow the flying pilot

to position the condition levers

to 100 percent for landing or to leave the levers

positioned at 86 percent. During a go-around, if the condition levers are positioned at

86 percent, the propellers automatically position to 100 percent when the throttles are

advanced and the power management selector

is in the TO position. This automatic

The hours scheduled for the nine simulator training periods are based on the pairing of two students.

A student who does not have a partner is scheduled for only 18 hours of simulator training.

The Executive Airlines FAA-Approved Training Manual states that differences training is required

for ATR-42 captains and first officers before they can serve as flight crewmembers on the ATR-72 during

revenue operations. The manual states that the required crewmember emergency training and operating

experience for either initial or recurrent training may be accomplished in either the ATR-42 or -72 and that

the crewmember will be considered trained for both airplane models.

Level C simulators may be used for specified light operational task training for Part 121 and 135

transition, upgrade, recurrent, and requalification training. These simulators may also be used for initial new

hire and initial equipment training on specified events for individuals who have previously qualified as PIC

or second-in-command with the training operator or who meet the FARs for advanced simulator training.

An emergency was declared, and the appropriate checklist was completed.

The condition levers, which are located next to the power management selector, control propeller

rpm.

The power management selector, which is located on the center instrument panel, provides maximum

torque limit indications on each torque indicator for the selected mode of operation. The selector has four

labeled operating modes: TO (takeoff), MCT (maximum continuous), CLB (climb), and CRZ (cruise).

Factual Information 27 Aircraft Accident Report

feature is not available in the ATR-42. During the simulations, investigators observed that

the flying pilot always positioned the condition levers to 100 percent before landing.

1.17.1.2 Crew Resource Management

The Executive Airlines FAA-Approved Training Manual, chapter 1, section 2,

page 24, outlined the curriculum for the 2.5-hour, stand-alone crew resource management

(CRM) training segment, which all new-hire pilots were required to attend. The manual

states the following:

Material presented in this subject area acquaints the crewmember with the

principles and importance of effective crew resource management. Emphasis shall

be placed on precise communication, crewmember interaction, crewmember

assertiveness, and delegation of cockpit duties.

The CRM curriculum contains instruction on methods of fostering crew input,

maintaining situational awareness, crew coordination during an emergency or abnormal

situation, cockpit discipline, and proper cockpit procedures.

During day 5 of basic indoctrination training, all first officers attend a 4-hour First

Officer Duties and Responsibilities Program, which is based on CRM techniques and

R.E.A.C.T procedures

and includes instruction on flight crew communications,

decision-making, and stress and fatigue management. When pilots transition from first

officer to captain, they attend a 6.5-hour Captain Leadership Duties and Responsibilities

Program, which emphasizes flight crew roles and responsibilities, leadership

development, and conflict resolution.

1.17.1.3 Bounced Landing Recovery Training

Executive Airlines’ manager of training and standards stated that the company did

not provide formalized bounced landing recovery techniques to pilots before the accident

and that none of the company manuals contained any information about bounced landing

recovery.

The manager stated that he would not want to conduct bounced landing

recovery techniques in the simulator because it is very difficult to demonstrate a bounce.

The manager stated that bounced landing recovery techniques could be addressed during

pilot briefings. The manager stated that, after the accident, Executive Airlines’ president

and vice president of operations asked him to look into the feasibility of conducting

bounced landing recovery training and incorporating bounced landing recovery techniques

in the company manuals.

One simulator instructor stated that, if the airplane landed hard enough to bounce,

the pilot should execute a go-around. He added that, if an airplane bounced 15 to 20 feet

According to company documentation, a first officer can use R.E.A.C.T. (review and reconfirm,

evaluate, advise, challenge, and take) procedures to challenge the captain if the first officer believes that the

captain’s actions might jeopardize the safety of the operation.

A Safety Board review of Executive Airlines’ operations and training manuals verified that the

company had no documentation regarding bounced landing recovery techniques.

Factual Information 28 Aircraft Accident Report

into the air after touchdown, the pilot should power up and get back to the flare position.

Another simulator instructor stated that a pilot should add power to recover from a

bounce. A third simulator instructor stated that, if sufficient runway existed, the pilot

should add power and land, and, if sufficient runway did not exist, the pilot should execute

a go-around.

A company line check airman stated that, if a first officer were to bounce the

airplane on landing, he would take control of the airplane, apply power, and go around.

Another company line check airman stated that, if a bounced landing could be corrected

safely, the pilot should proceed with the landing, and, if a bounced landing could not be

corrected safely, the pilot should execute a go-around. This line check airman added that

he would allow the first officer to execute the go-around after the bounce but that he

would take control of the airplane if he felt the need to do so.

On September 25, 2004, Executive Airlines incorporated bounced landing

recovery techniques in its Airplane Operating Manual (AOM). The bounced landing

recovery guidance states the following:

In the event the aircraft should bounce after landing, hold or re-establish a normal

landing attitude and immediately add power as necessary to control the rate of

descent. When using this recovery technique, exercise extreme caution not to

increase the pitch attitude above normal as this will only increase the height of the

bounce and may cause entry into stall warning. DO NOT push over, as this will

only cause another bounce and damage the nose gear. If there is any doubt as to a

safe recovery, the captain will call for and conduct an immediate go-around.

Apply go-around power and fly the Missed Approach/Rejected Landing Profile.

DO NOT retract the Landing Gear until a positive rate of climb is established

because a second touchdown may occur during the recovery.

The Safety Board informally surveyed six airlines, an airplane manufacturer, and a

pilot training facility to determine if bounced landing recovery techniques were typically

contained in industry flight manuals. The survey revealed that only some of the companies

included bounced landing recovery techniques in their flight manuals and discussed these

techniques during training. Most of the companies indicated that bounces commonly

occurred during IOE checkrides and that, when a bounce did occur, the check airman

would provide verbal guidance to the pilot on how to recover the airplane.

1.17.2 Operational Guidance

1.17.2.1 Approach Airspeed Guidance

Executive Airlines’ ATR-42/72 AOM, Volume 1, Performance, “Landing Speeds”

(dated April 1, 2004), contains initial approach airspeed guidance. The manual states that

app,

which is the initial approach airspeed, is to be selected at the pilot’s discretion and

must be more than V

ref

plus V

GA15 (minimum go-around airspeed, 15° of flaps, low

bank) and less than or equal to V

LB0 (minimum low bank, 0° of flaps) or V

HB0

(minimum high bank, 0° of flaps).

The manual adds that V

app

is to be maintained until

Factual Information 29 Aircraft Accident Report

500 feet, at which point, power and attitude should be adjusted to ensure that the airplane

crosses the runway threshold within +10/-0 knots of V

ref

. According to the airspeed flip

cards and the airspeed guidance contained in Executive Airlines’ AOM, assuming an

airplane weight of 37,000 pounds, the flight crew should have selected an initial approach

airspeed more than 107 KIAS and less than or equal to 128 KIAS.

Executive Airlines’ ATR-42/72 AOM also contains wind additive to approach

airspeed guidance. The manual states that V

ref

is determined by correcting V

HB30

(minimum high bank, 30° of flaps) for wind. The manual states that the wind factor should

be the greater of one-third of the headwind component or the full gust factor

and should

not exceed 15 knots of correction. The manual also states that the pilot should set the

calculated V

ref

on the airspeed bug.

The manual states that the airspeeds are published in the AOM and in the flip

cards

for various landing weights and that the airspeeds to be used for approach and

go-around are based on actual airplane weight and are rounded to the next heaviest

increment. The AOM and the flip cards showed that the V

ref

for the accident flight,

assuming a landing weight of 37,000 pounds, would have been 95 KIAS.

As noted

previously, ATIS Juliet, which was current at the time of the accident, reported winds of

060° at 17 knots with gusts up to 23 knots. According to the wind data, one-third of the

headwind component (1/3 x 17 knots) would have been 6 knots, and the full gust factor

(23 - 17 knots) would also have been 6 knots; therefore, the correct V

ref

for the accident

flight would have been 101 KIAS.

During postaccident interviews, the captain stated that he could not recall what

airspeeds were used throughout the approach. Further, he could not remember if he made

a correction to the airspeed during the accident flight or if he used the airspeed that was

specified on the airspeed flip card (95 KIAS). He stated that airspeed corrections were

needed most of the time when he landed at SJU. The first officer stated that he set the bugs

on his airspeed indicator according to the airspeeds read to him by the captain. He stated

that the captain did not mention if he had made an airspeed correction. Neither pilot could

recall the airspeed when the airplane crossed the approach end of runway 8.

1.17.2.2 Before Landing Checklist

Executive Airlines’ ATR-42/72 AOM, Volume 1, Normals, “Before Landing

Checklist,” states that the power management selector should be set to the TO position by

the nonflying pilot before landing. The power management selector was found in the CLB

position. During postaccident interviews, the captain stated that he could not recall if the

power management selector was in the CLB or TO position before landing. The captain

thought all of the appropriate checklists were performed. The first officer stated that the

The full gust factor is the gust speed minus the headwind speed.

Flip cards are carried on board all company airplanes and list takeoff and approach airspeeds for

various landing weight and flap configurations.

During postaccident examinations, Safety Board investigators found the flip cards in the airplane

opened to the page that specifies the airspeed for a landing weight of 37,000 pounds.

Factual Information 30 Aircraft Accident Report

power management selector was in the TO position before departing MAZ. The first

officer stated that he did not notice if the power management selector was positioned to

CLB when he called for the climb checklist after departure from MAZ. He thought that the

captain had moved the power management selector to the CRZ position when he called for

the cruise checklist. Shortly after recording the captain stating that he had completed the

before landing checklist, the CVR recorded him stating that he was going to position the

power management selector to CLB. The CVR did not record the captain stating that he

was repositioning the selector to TO.

Executive Airlines’ ATR-42/72 AOM states that the condition levers should

normally remain at 86 percent for landing and that the minimum setting for landing is

86 percent. The AOM adds that the maximum rpm could be set at the captain’s discretion.

The AOM notes that, if the power management selector is set to TO before retarding the

power levers, the condition levers might automatically advance to 100 percent. During the

cruise portion of the flight, the CVR recorded the captain discussing the use of the

condition levers with the first officer. The captain stated that he always landed with the

condition levers set at 86 percent. He added that some pilots landed with the condition

levers set at 100 percent but that he did not see any reason to land with the levers set at

100 percent. During the before landing checklist, the CVR recorded the captain stating

that he was setting the condition levers to 86 percent. On September 25, 2004, Executive

Airlines standardized its procedures and required that the condition levers on all of its

ATR airplanes be set to 100 percent before landing.

1.17.2.3 Evacuation Procedures

Executive Airlines’ ATR-42/72 AOM, Volume 1, Emergency/Abnormals, states

that the alternate evacuation signal if the PA system becomes inoperative is the following:

SEATBELT SIGN ........................................................................... OFF

EMER EXIT LT [light] .....................................................................ON

ATTND [attendant] Calls pb [push button]................................Depress

Executive Airlines’ ATR-42/72 AOM, Volume 1, Emergency/Abnormals,

contains the following ground evacuation checklist:

AIRCRAFT PARKING BRAKE ..........................................STOP/SET

ATC (TIME PERMITTING) (F/O)..........................................NOTIFY

CL [Condition Levers] (BOTH) ................. FEATHER then FUEL S/O

MIN [Minimum] CAB LIGHTS........................................................ON

FLIGHT ATTENDANT (PA) ................................................. NOTIFY

SEATBELTS SIGN......................................................................... OFF

EMERGENCY EXIT LIGHTS .........................................................ON

ENGINE FIRE HANDLES (both) ................................................PULL

FIRE AGENTS ......................................................................... AS RQD

ENG [Engine] START Selector ...................................................... OFF

Factual Information 31 Aircraft Accident Report

FUEL PUMPS (both)....................................................................... OFF

BAT [Battery] (before leaving A/C [aircraft]) ................................ OFF

VOICE RECORDER CB [Circuit Breaker] 42/Row D 72/Row...PULL

After the airplane came to a complete stop, the CVR recorded a discussion

between the first officer and the captain about which checklist should be initiated. The

CVR recorded the captain instructing the first officer to perform the emergency

evacuation checklist, which was on placards on both the first officer and captain control

wheels. The first officer stated that he did not know “where to start,” and the captain then

told him to perform the fire on ground checklist, which was located on the yellow

emergency procedures checklist in the cockpit.

During postaccident interviews, the captain stated that he tried to perform the

emergency evacuation checklist but that he could not recall specifically how many steps

were accomplished or if the battery switch was turned off. He stated that he tried to shut

down the right engine and feather

the right propeller. The captain added that, after

shutting down the engines, his main concern was evacuating the passengers. The captain

stated that he could not remember who pulled the engine fire handles or whether the fire

bottles were activated.

The first officer stated that he performed the fire on ground checklist first and then

the emergency evacuation checklist. The first officer stated that he recalled that the

captain attempted to feather the propellers and that he was able to feather the left propeller

but not the right propeller because the condition lever in the cockpit had jammed. He

stated that battery power was available but that the radios and the PA system were

inoperative.

1.18 Additional Information

1.18.1 Additional Information About Ipeco Cockpit Seats

1.18.1.1 General Information

An Ipeco representative stated that, since 1983, when the cockpit seat design found

on the accident airplane went into service, the company had produced 1,420 seat

assemblies and had never received a report that a seat had broken similarly to the accident

seat. The representative stated that, since 1983, the company had manufactured 125 sleeve

assemblies as spare parts, which were provided to FAA-authorized repair stations. He

stated that he did not know how many of these assemblies had been used or were still in

parts inventories. He also stated that Ipeco did not maintain records indicating why the

parts were replaced.

Feathering means to rotate the propeller blades so that the blades are parallel to the line of flight

(streamlined to the airflow) to reduce drag in flight and prevent further damage to an engine that has been

shut down.

Factual Information 32 Aircraft Accident Report

An Ipeco representative from the company’s subsidiary in Torrance, California,

stated that sleeve assemblies are periodically replaced on seats sent to its facility for

overhaul. The representative stated that, during overhaul, the entire cockpit seat is

inspected and that sleeve assemblies are replaced when evidence of cracking in the metal

adjacent to the weld at the base of the sleeve is found. He stated that he thought that the

damage on these assemblies was caused when mechanics dropped or dragged them during

the removal process. According to the representative, during the last 5 years, the company

had overhauled 131 ATR seats and had replaced the sleeve assemblies on 45 of the

overhauled seats.

1.18.1.2 Ipeco Cockpit Seat Tensile Strength Testing

As a result of the Safety Board’s metallurgical findings and Ipeco’s U.S.

subsidiary’s reports of damaged sleeve assemblies, Ipeco conducted tests in December

2004 to determine the effects of weld discontinuity and cracking on the tensile strength of

the sleeve assemblies.

The Ipeco test report stated that, of the six sleeve assemblies that

were used during the tests, five had been removed from in-service seats by Ipeco’s U.S.

subsidiary because the assemblies had cracks, which were found during overhaul, and

exhibited a lack of weld penetration that was similar to that found on the accident sleeve

assemblies. The sixth sleeve assembly was newly manufactured and had 100-percent weld

penetration.

According to Ipeco’s report, the tests were conducted on a tensile/compression

machine. Fixtures were used to mount the sleeve assemblies as they would be when

normally installed on a cockpit seat. Tensile loads were then applied to the assemblies

until they failed or stopped reacting to the loads. The highest load value attained before the

assemblies failed or stopped reacting was recorded and was considered the ultimate load

for each assembly. All of the test assemblies exceeded the certification strength

requirements, including the 6-G vertical load requirement, contained in 14 CFR 25.561.

1.18.1.3 Ipeco’s Postaccident Actions

Since the accident, Ipeco has taken several actions to address the issues found

during the investigation. According to an Ipeco representative, Ipeco changed the type of

weld it used on the sleeve assemblies to allow easy visual inspection of the weld

penetration. In May 2005, Ipeco performed tensile strength tests (identical to the

December 2004 tensile strength tests) on a number of parts welded with the new weld

material to ensure that the parts met the seat’s strength requirements, and the weld was

found to meet the requirements. The company started using the new weld in its new

production seats beginning in July 2005.

Further, on June 5, 2005, Ipeco issued service bulletin (SB) No. 063-25-04 to

direct all operators and approved repair facilities to visually inspect under magnification

all in-service sleeves at the next aircraft “C” check (conducted every 4,000 flight hours)

for signs of cracks and replace all cracked sleeves before returning the seat to service. The

A representative of the British Civil Aviation Authority attended the tests.

Factual Information 33 Aircraft Accident Report

SB also stated that seat assemblies held as spares should be inspected within 90 days of

receipt of the bulletin and, if cracks are found, the sleeve should be destroyed.

1.18.2 Previous Bounced Landing Recovery Guidance and

Training-Related Safety Recommendation

On July 31, 1997, Federal Express flight 14, a McDonnell Douglas MD-11,

N611FE, bounced once and then crashed while landing at Newark International Airport,

Newark, New Jersey. In its final report on this accident, the Safety Board concluded that

the captain’s overcontrol of the elevator during the landing and his failure to execute a

go-around from a destabilized flare were causal to the accident.

The report stated the

following:

The risk of a future catastrophic accident could be reduced if air carrier pilot

training programs devote additional attention to safety issues related to landings.

It is particularly important to instill in pilots the orientation to perform a

go-around in the event of an unstabilized approach or destabilized landing flare.

On August 25, 2000, the Safety Board issued the following recommendation to the

FAA:

Convene a joint government-industry taskforce composed, at a minimum, of

representatives of manufacturers, operators, pilot labor organizations, and the

FAA, to develop, within 1 year, a pilot training tool to provide a syllabus for

simulator training on the execution of stabilized approaches to the landing flare,

the identification of unstabilized landing flares, and recovery from these

situations, including proper sink rate recovery techniques during flare to landing,

techniques for avoiding and recovering from overcontrol in pitch before

touchdown, and techniques for avoiding overcontrol and premature derotation

during a bounced landing. (A-00-93)

In a May 15, 2002, letter, the FAA stated that a joint taskforce had produced the

following training materials to address Safety Recommendation A-00-93:

• Advisory Circular 120-71, “Standard Operating Procedures for Flight Deck

Crewmembers,” Appendix 2, “Stabilized Approach: Concepts and Terms,” in

August 2000.

For more information about this accident, see National Transportation Safety Board, Crash During

Landing, Federal Express, Inc., McDonnell Douglas MD-11, N611FE, Newark International Airport,

Newark, New Jersey, July 31, 1997, Aircraft Accident Report NTSB/AAR-00/02 (Washington, DC: NTSB,

2000).

Factual Information 34 Aircraft Accident Report

• Flight Standards Information Bulletin for Air Transportation 00-08, “Standard

Operating Procedures for Flightdeck Crewmembers, Including Stabilized

Approach,” in August 2000.

• Approach and Landing Accident Reduction (ALAR) Training Guide,

July 2001.

The FAA stated that the ALAR training guide specifically addressed guidance on

maintaining a stabilized approach and identifying an unstable approach. The FAA further

stated that the taskforce member organizations endorsed the use of the training guide in

developing and evaluating ALAR training. On October 22, 2002, the Safety Board

classified Safety Recommendation A-00-93 “Closed—Acceptable Action.”

1.18.3 Previous Flight Data Recorder Potentiometer

Sensor-Related Safety Recommendations

On August 21, 1995, Atlantic Southeast Airlines flight 529, an Embraer

EMB-120RT, crashed on approach to West Georgia Regional Airport, Carrollton,

Georgia. The flight crew was attempting to make an emergency landing after the in-flight

failure of a propeller blade. Examination of the FDR data for this accident revealed that

two flight control position sensors had malfunctioned, preventing the required data from

being accurately recorded. The Safety Board determined that the absence of the data

hindered its investigation.

The EMB-120 was equipped with potentiometer sensors that were similar to those

installed on the ATR-72; however, the potentiometers installed on the EMB-120 used an

input shaft instead of a string. Examination of the EMB-120 revealed that the coupler

connecting the input shaft of the potentiometer to the rudder pedals had become loose,

causing incorrect data to be recorded. Further, the control wheel and column

potentiometers were not calibrated correctly, rendering the recorded data inaccurate.

In a June 27, 1996, recommendation letter to the FAA regarding the flight 529

accident, the Safety Board noted that it had investigated seven other EMB-120 accidents

and incidents. For six of these seven airplanes, malfunctions of the potentiometers

prevented accurate data from being recorded. The letter noted, “these malfunctions are

indicative of a design deficiency and/or inadequate FDR system maintenance practices.”

The letter also noted that tests, such as FDR parameter readouts and potentiometer

calibrations, could be conducted to ensure timely identification and repair of

potentiometer malfunctions. The letter further stated the following:

For more information about this accident, see National Transportation Safety Board, In-Flight Loss

of Propeller Blade, Forced Landing, and Collision with Terrain, Atlantic Southeast Airlines, Inc., Flight

529, Embraer EMB-120RT, N256AS, Carrollton, Georgia, August 21, 1995, Aircraft Accident Report

NTSB/AAR-96/06

(Washington, DC: NTSB, 1996).

Factual Information 35 Aircraft Accident Report

The Maintenance Program Manual for the EMB-120 requires operators to

perform a readout of the FDR each year. Potentiometer malfunctions are often

identified and repaired during these checks, but malfunctions that occur between

readouts are undetected….the Maintenance Manual contains the procedure to test

the potentiometers for proper operation and calibration; however, operators are

not required to perform this test at regular intervals.

As a result of its investigation, the Safety Board issued the following two

recommendations to the FAA:

Conduct a design review of the Embraer-120 flight data recorder system, with

emphasis on potentiometer failures, and mandate design, installation, and/or

maintenance changes, as necessary, to ensure that reliable flight control data are

available for accident/incident investigation. (A-96-33)

Require Embraer-120 operators to perform a flight data recorder (FDR) readout or

a potentiometer calibration test per section 31-31-00 of the Embraer-120

Maintenance Manual every 6 months until FDR sensor design, installation, and/or

maintenance improvements are incorporated. (A-96-34)

Because of high maintenance costs and the need for frequent inspections and

replacement of the sensors, the primary operator of EMB-120s in the United States

identified an alternative sensor design that would be more reliable. In December 2002, the

FAA issued an STC for the EMB-120 FDR system that authorized the replacement of the

potentiometer rudder and control column position sensors with the improved sensor. In an

August 3, 2004, e-mail, the FAA stated that a survey of EMB-120 commercial operators

indicated that 74 of the 88 EMB-120s in operation had or would have the upgraded

sensors installed. On October 21, 2004, the Safety Board responded that upgraded sensors

eliminated the need to revise the FDR system inspection procedures and, therefore,

classified Safety Recommendation A-96-33 “Closed—Acceptable Action.”

On September 19, 1997, the FAA issued Flight Standards Handbook Bulletin for

Airworthiness (HBAW) 97-14B, “Embraer EMB-120 Flight Data Recorder Test,” which

directed principal avionics inspectors to require affected EMB-120 operators to perform

an initial and recurring potentiometer calibration test every 6 months until the FDR design

and installation were enhanced. On May 5, 1998, the Safety Board classified Safety

Recommendation A-96-34 “Closed—Acceptable Action.”

In an August 11, 2003, letter, the Safety Board noted that the FAA had reversed its

position on these inspections by issuing a supplemental notice of proposed rulemaking

(SNPRM), which proposed to adopt an airworthiness directive to require the replacement

of noisy potentiometers with sensors of the same make and model that are less than

On November 30, 1998, the Safety Board issued Safety Recommendation A-98-104, which asked the

FAA to revise its current EMB-120 FDR system inspection procedure to include an FDR readout and

evaluation of parameter values from normal operations to ensure a more accurate assessment of the

operating status of the flight control position sensors on board the airplane. As a result of the FAA’s actions

taken in response to Safety Recommendation A-96-33, the Safety Board classified Safety

Recommendation A-98-104 “Closed—Acceptable Alternate Action.”

Factual Information 36 Aircraft Accident Report

12 months old and conduct annual inspections of the potentiometers. The Board stated

that the FAA’s proposed corrective action did not address the sensor reliability problem

addressed in Safety Recommendation A-96-34. The Board reiterated its position on

inspection intervals, stating that the only way to properly evaluate the effectiveness of the

proposed corrective action was to require an FDR readout and evaluation every 6 months

for 2 years and submission of the results to the FAA for evaluation.

37 Aircraft Accident Report

2. Analysis

2.1 General

The captain was properly certificated and qualified under Federal regulations. No

evidence indicated any preexisting medical or physical conditions that might have

adversely affected his performance during the accident flight. The first officer held a

current FAA airman medical certificate at the time of the accident; however, he failed to

provide information about his medical condition (anxiety) or his use of the prescription

drug alprazolam when he applied for the certificate. When the FAA was informed about

the first officer’s medical condition and prescription drug use, his medical certificate was

revoked. For a discussion of this issue, see section 2.5.

The airplane was properly certificated, equipped, and maintained in accordance

with Federal regulations and approved company procedures. The airplane was loaded in

accordance with approved company weight and balance procedures. The weight and

balance of the airplane were within limits during all phases of the flight.

Meteorological data indicated that, before and after the time of the accident,

surface winds were about 17 to 22 knots and winds aloft were about 15 to 24 knots below

4,000 feet. Although the pilot in the 727 that preceded the accident airplane reported a

10-knot loss of airspeed during the approach to SJU about 3 minutes before the accident,

he landed the airplane safely. Further, the Safety Board’s airplane performance study and

FDR data showed that, although the accident airplane was encountering windspeed shifts

during the approach and landing phases of the flight, the airplane’s pitch motion

corresponded with the flight control inputs. Therefore, the Safety Board concludes that

winds were within the airplane’s performance capabilities and did not adversely affect the

flight crew’s ability to maneuver the airplane during the approach and landing as

significant aircraft control authority remained.

The emergency response was timely and appropriate. The passengers and

crewmembers were safely evacuated from the airplane.

Postaccident examination of the captain seat revealed that the weld that attached

the end cap to the sleeve fractured at both welded joints during the accident sequence.

Although examinations revealed that both the captain and first officer seats exhibited weld

discontinuities, the Safety Board could not determine whether the captain seat would have

failed if these defects had not existed. On the basis of the airplane performance study, the

Safety Board concludes that, at some point during the accident sequence, the captain

cockpit seat failed when it was subjected to vertical loads that exceeded those required for

certification.

This analysis discusses the accident sequence, including the role of the flight

crew’s performance. The analysis also discusses the lack of company bounced landing

Analysis 38 Aircraft Accident Report

recovery guidance and training, the failure of the airplane’s left aileron surface position

sensors, the first officer’s medical condition and prescription drug use, the uncoupling of

the pitch control uncoupling mechanism, and the failure of the left MLG.

2.2 Accident Sequence

Postaccident interviews with the flight crew and examination of CVR and FDR

data indicated that the en route and cruise portions of the flight were uneventful.

About 1437, the captain told the first officer that the V

ref

was 95 KIAS and instructed him

to “stand by for winds.” The first officer then set 95 KIAS on his airspeed bug.

Using the guidance contained in Executive Airlines’ airspeed flip cards and AOM,

the Safety Board calculated that, at the airplane’s calculated landing weight, the flight

crew should have selected an initial approach airspeed more than 107 KIAS and less than

or equal to 128 KIAS. Also, the flight crew should have maintained the selected initial

approach airspeed until the airplane reached an altitude of 500 feet and then slowed,

crossing the runway threshold within +10/-0 knots of V

ref

. In addition, the AOM stated

that, to compensate for strong wind gradients and/or gust effects during approach and

landing, V

ref

must be corrected for wind. According to the wind data reported about the

time of the accident,

the correct V

ref

for the accident flight would have been 101 KIAS.

Although the CVR recorded the captain telling the first officer to “stand by for

winds” after confirming 95 KIAS as the V

ref

, the CVR did not record him providing the

first officer with a wind-corrected V

ref

. Postaccident examinations of the cockpit revealed

that the airspeed bugs on both pilots’ airspeed indicators were set to 96 KIAS, and the

airspeed flip cards were found opened to the page that showed the airspeed for a landing

weight of 37,000 pounds (95 KIAS). Further, during postaccident interviews, neither the

first officer nor the captain could remember making any airspeed changes to compensate

for the winds. Therefore, the Safety Board concludes that the flight crewmembers did not

account for winds when calculating the V

ref,

and, as a result, they were not in compliance

with Executive Airlines’ approach airspeed procedures.

About 1443, an SJU approach controller contacted the flight crewmembers,

cautioned them of possible wake turbulence from a preceding 727, and told them to reduce

the airspeed to 160 KIAS. The captain told the first officer to reduce the airspeed even

further.

The Safety Board’s ATC radar study determined that the separation between the

accident airplane and the 727, at their closest point, was greater than the minimum lateral

separation required by Federal regulations (FAA Order 7110.65). Further, the 727 landed

on runway 10, and the first officer was performing an approach to runway 8. In addition,

the existing winds would have blown any wake turbulence from the 727 away from the

accident airplane’s approach path. Therefore, the Safety Board concludes that, given the

Winds were reported to be 060° at 17 knots and gusting at 23 knots.

The CVR recorded the captain state that they were behind a “seven five.” Therefore, the captain most

likely asked the first officer to reduce the airspeed further because the 757 is a bigger airplane than the 727

and would create greater wake turbulence.

Analysis 39 Aircraft Accident Report

relative positions of the accident airplane and the preceding 727, the runway

configuration, and the existing winds, wake turbulence was not a factor in this accident.

At 1444:57, the captain stated that he was setting the condition levers to

86 percent.

At 1445:02, the first officer called for the before landing checklist. About

1 minute later, the captain stated that he was going to move the power management

selector from TO to CLB “just for now” to prevent the condition levers from

automatically advancing to 100 percent. However, the CVR did not record the captain

repositioning the power management selector back to TO.

Postaccident documentation

of the cockpit switch positions by the Safety Board’s Operations Group confirmed that the

power management selector was set to CLB. Therefore, the Safety Board concludes that

the captain did not properly follow Executive Airlines’ before landing procedures.

At 1446:39, the SJU local controller cleared flight 5401 to land, and the first

officer turned the airplane left toward the runway and monitored the VASI for glideslope

guidance for the rest of the approach. At 1449:07, the captain told the first officer to keep

the airplane’s nose down or to increase power (to maintain airspeed) because he was

concerned that the airplane was going to balloon. About 2 seconds later, he instructed the

first officer to get the airplane’s nose up, and, at 1449:28, he told the first officer to “power

in a little bit.”

About 2 seconds later, the airplane crossed the runway threshold at an

airspeed of about 110 KIAS, which was almost 15 knots more than the V

ref

set on both

pilots’ airspeed indicators (96 KIAS) and 9 knots more than what should have been set.

After crossing the runway threshold, the captain again told the first officer to

“power in a little bit” and not to pull the airplane’s nose up. CVR and FDR data indicated

that the airplane touched down on the runway the first time about 1449:41 and then

skipped and became airborne, reaching an altitude of about 4 feet. Only minor flight

control inputs and/or slight power adjustments would most likely have been necessary to

regain the proper landing attitude and settle the airplane back on the runway. Therefore,

the Safety Board concludes that the flight crew could have completed a successful landing

after the initial touchdown.

After the initial touchdown, the captain took control of the airplane, most likely

because of the first officer’s inexperience. FDR data indicated that he then made several

abrupt changes in pitch and power. Wreckage and impact information and CVR and FDR

data indicated that the captain’s actions after the initial touchdown resulted in the airplane

bouncing on the runway twice. The captain’s inputs made it less likely that he could

Executive Airlines’ AOM states that the condition levers can remain at 86 percent for landing the

ATR-72 and that maximum rpm could be set at the pilot’s discretion. After the accident, the company

standardized its procedures, requiring that the condition levers on all of its ATR airplanes be set to

100 percent before landing.

Executive Airlines’ AOM states that the nonflying pilot should set the power management selector to

TO before landing.

As noted previously, this flight was the first officer’s first since he completed IOE; therefore, it was

appropriate for the captain to instruct the first officer during the flight.

Analysis 40 Aircraft Accident Report

recover from the two bounces and safely land the airplane; as a result, he should have

executed a go-around.

The Safety Board concludes that, after each bounce of the airplane on the runway,

the captain did not make appropriate pitch and power corrections or execute a go-around,

both of which were causal to the accident. On the basis of the evidence presented in this

section, the Safety Board concludes that the captain demonstrated poor cockpit oversight

and piloting techniques before and during the accident sequence.

2.3 Bounced Landing Recovery Guidance and Training

Postaccident interviews with the first officer, two company check airmen, and

three company simulator instructors revealed that Executive Airlines did not have

standardized guidance regarding bounced landing recovery. For example, one of the check

airmen and one of the simulator instructors stated that, if the airplane bounced, they would

execute a go-around. The other three company personnel indicated that, if possible, they

would try to correct the bounce and land and that, if not possible, they would execute a

go-around.

Further, Executive Airlines’ manager of training and standards stated that, before

the accident, the company did not teach its pilots bounced landing recovery techniques.

The manager also stated that he would not want to conduct bounced landing recovery

training in the simulator because it was very difficult to demonstrate. However, he stated

that, after the accident, the president and the vice president of operations asked him to

look into the feasibility of conducting bounced landing recovery flight training and

incorporating bounced landing recovery techniques in company manuals. The Safety

Board concludes that written company guidance on bounced landing recovery techniques

would have increased the possibility that the captain could have recovered from the

bounced landings or handled the airplane more appropriately by executing a go-around.

As noted previously, on September 25, 2004, Executive Airlines incorporated bounced

landing recovery techniques in its AOM.

In its final report on the July 31, 1997, Federal Express flight 14 landing

accident,

the Safety Board concluded that the captain’s overcontrol of the elevator

during the landing and his failure to execute a go-around from a destabilized flare were

causal to the accident. As a result, the Board issued Safety Recommendation A-00-93 to

the FAA, which required, in part, that a syllabus for simulator training be developed that

addressed how to recover from unstabilized landing flares, including techniques for

avoiding and recovering from overcontrol in pitch before touchdown and techniques for

avoiding overcontrol and premature derotation during a bounced landing. In a May 15,

2002, letter, the FAA stated that an industry taskforce had been convened and that the

taskforce had produced several significant training materials, including an ALAR

NTSB/AAR-00/02.

Analysis 41 Aircraft Accident Report

Training Guide, to address the safety recommendation. On October 22, 2002, the Board

classified Safety Recommendation A-00-93 “Closed—Acceptable Action.”

The training materials produced in response to Safety Recommendation A-00-93

do not specifically address bounced landing recovery techniques. Further, an informal

Safety Board survey of six airlines, an airplane manufacturer, and a pilot training facility

revealed that only some of the companies included bounced landing recovery techniques

in their flight manuals and discussed these techniques during training. The Board is

concerned that the lack of guidance on bounced landing recovery techniques could

contribute to similar landing accidents.

The Safety Board concludes that the performance of air carrier pilots would be

improved if additional guidance and training in bounced landing recovery techniques were

available. Therefore, the Safety Board believes that the FAA should require all

14 CFR Part 121 and 135 air carriers to incorporate bounced landing recovery techniques

in their flight manuals and to teach these techniques during initial and recurrent training.

2.4 Quality of Data Provided by Flight Data Recorder

Potentiometer Sensors

The Safety Board determined that the left aileron surface position data recorded by

the accident airplane’s FDR were invalid even though the accident airplane had been

modified on August 7, 2001, with the position sensors and associated hardware required

by STC No. ST01310NY. Executive Airlines stated that the first and last FDR parameter

readout since the installation of the sensors occurred on January 3, 2003, about 1 year and

5 months after the installation and 1 year and 4 months before the accident. Executive

Airlines stated that it had replaced 47 aileron surface position sensors in the last 3.5 years.

However, the company indicated that, because the sensors are not tracked, the times from

installation to failure could not be determined.

During its investigation of the Atlantic Southeast Airlines flight 529 accident,

the

Safety Board determined that the EMB-120’s two flight control position sensors had

malfunctioned, preventing the required data from being accurately recorded, and that the

lack of data hindered the investigation. The Board’s report on the accident noted that tests

could be conducted to ensure timely identification and repair of potentiometer

malfunctions, including FDR parameter readouts. The report also noted that malfunctions

that occur between readouts are typically not detected.

As a result of the flight 529 investigation and six other investigations involving

EMB-120s in which potentiometer malfunctions prevented accurate data from being

recorded on the EMB-120, the Safety Board issued Safety Recommendations A-96-33 and

-34. Safety Recommendation A-96-33 asked the FAA, in part, to conduct a design review

of the EMB-120 FDR system, emphasizing potentiometer failures, and mandate design,

NTSB/AAR-96/06.

Analysis 42 Aircraft Accident Report

installation, and/or maintenance changes, as necessary. In December 2002, the FAA

issued an STC that authorized the replacement of the potentiometer sensors for the

EMB-120 FDR system with more reliable sensors. The Safety Board classified Safety

Recommendation A-96-33 “Closed—Acceptable Action” in October 2004.

Safety Recommendation A-96-34 asked the FAA, in part, to require EMB-120

operators to perform an FDR readout or a potentiometer calibration test every 6 months

until FDR sensor design, installation, and/or maintenance improvements are incorporated.

In September 1997, the FAA issued an HBAW, which directed operators to conduct FDR

potentiometer calibration testing every 6 months. As a result, the Safety Board classified

Safety Recommendation A-96-34 “Closed—Acceptable Action” in May 1998. However,

in an August 2003 letter commenting on an SNPRM in which the FAA proposed a

12-month FDR potentiometer inspection interval, the Board reiterated its position on the

inspection interval recommended in Safety Recommendation A-96-34.

The potentiometer sensors installed on Executive Airlines ATRs were similar to

the potentiometer sensors used on the EMB-120; therefore, they were susceptible to the

same problems that previously prevented accurate data from being recorded on the

EMB-120. However, at the time of the accident, Executive Airlines only performed

functional checks of the FDR system every 3,000 flight cycles. As evidenced by company

maintenance data, it is possible that FDR functional checks performed every 3,000 flight

cycles will only occur once every 1.5 years. As noted previously, after the accident,

Executive Airlines began conducting FDR functional checks every 1,000 flight cycles.

The Safety Board concludes that the aileron flight control surface position sensors

installed on airplanes in accordance with STC No. ST01310NY are unreliable and that

FDR functional checks every 6 months could ensure the timely identification and

correction of potentiometer malfunctions and ensure that accurate flight control data are

available for accident and incident investigations. Therefore, the Safety Board believes

that the FAA should require the replacement of aileron surface position sensors installed

in accordance with STC No. ST01310NY with more reliable aileron surface position

sensors within 1 year or at the next heavy maintenance check, whichever comes first, after

the issuance of an approved STC. Until reliable aileron surface position sensors have been

installed, require FDR functional checks every 6 months and replacement of faulty

sensors, as necessary. Additionally, the Safety Board believes that the FAA should

conduct a review of all FDR systems that have been modified by an STC to determine the

reliability of all sensors used as flight control surface position sensors. If the review

determines that a sensor does not provide reliable flight control surface position data,

require that the sensor be replaced with a more reliable sensor.

2.5 The First Officer’s Medical Condition and

Prescription Drug Use

The first officer’s medical records from his personal psychiatrist indicated that he

had a history of treatment for various anxiety-related symptoms, which are generally

Analysis 43 Aircraft Accident Report

considered incompatible with aviation duties, at least during the time that the disorders

require treatment.

Further, the first officer was prescribed alprazolam, which can cause

drowsiness and light-headedness and, in doses of 0.5 mg or higher, can impair the

performance of cognitive and psychomotor tasks.

The first officer should not have

omitted information regarding his medical condition on his three most recent FAA airman

medical certificate applications (dated August 14, 2001; August 7, 2003; and February 10,

2004), especially given that item Nos. 18 and 19 on the application specifically and clearly

asked for this information.

Therefore, the Safety Board concludes that, because the first

officer started getting treatment for anxiety in July 2001, he should have reported this

information on his last three FAA airman medical certificate applications. The Safety

Board is aware that, after the accident, the FAA revoked the first officer’s airman medical

certificate because he allegedly falsified his application.

The first officer stated that he typically took only 1/2 of a 0.25-mg alprazolam

tablet every 2 to 3 days; however, an examination of his recent pharmacy refill records

suggested that he likely took more than one 0.25-mg tablet per day. Although it is possible

for the drug to cause impairment if it is taken as frequently as was prescribed (one to two

0.25-mg tablets every 2 to 3 hours, as needed, not to exceed 8 mg per day), postaccident

company drug testing of the first officer, which included screening for alprazolam, tested

negative. Therefore, the Safety Board concludes that not enough evidence was available to

determine whether or to what extent the first officer’s medical condition and prescription

drug use contributed to the accident.

2.6 Uncoupling of the Pitch Control Uncoupling

Mechanism

Postaccident testing and examination revealed that the pitch control uncoupling

mechanism had uncoupled, thereby mechanically disconnecting the left and right

elevators from each other. As a result, either elevator could be independently deflected up

and down by hand to its maximum control limits without the corresponding movement of

the other elevator. During the testing, no binding or mechanical resistance was detected

when either elevator was moved.

A review of FDR data indicated that, just before the airplane’s third touchdown,

the pitch uncoupling mechanism was configured in the normal coupled position. The data

indicated that the left and right elevators deflected together throughout the entire flight

and that the elevator deflections were consistent with both control column movements.

D.R. Jones, “Aerospace Psychiatry,” Fundamentals of Aerospace Medicine (Philadelphia, PA:

Lippincott Williams & Wilkins, 2002).

R.C. Baselt, Drug Effects on Psychomotor Performance (Foster City, CA: Biomedical Publications,

2001).

The Safety Board has previously noted that pilots do not necessarily have sufficient information to

determine which medications are contraindicated for flight. As a result, the Board issued Safety

Recommendations A-00-04 through -06. For more information, see the Board’s Web site at

<www.ntsb.gov>.

Analysis 44 Aircraft Accident Report

After the airplane’s third touchdown, the data showed three simultaneous events

indicating that the pitch uncoupling mechanism had uncoupled. First, the control column

positions deviated from their normally recorded deviations. Second, the left and right

elevators began to move independently of each other. Last, the FDR pitch uncoupling

parameter showed “warn.” None of these events were present before the third touchdown.

Therefore, the Safety Board concludes that the pitch control uncoupling mechanism

uncoupled when the airplane touched down for the third time; as a result, the pitch

uncoupling would not have prevented the flight crew from controlling or safely landing

the airplane.

2.7 Failure of the Left Main Landing Gear

CVR, FDR, and wreckage and impact information indicated that the airplane’s

third touchdown severely damaged the left MLG, which caused it to fracture

circumferentially at its vertical trunnion leg just below the actuator attach point.

Examination of the fracture surfaces revealed evidence of overload failure. No evidence of

preexisting defects was found.

The ATR-72 landing gear and associated structure were designed to absorb energy

equivalent to a maximum airplane descent rate of 10 fps when landing at the airplane’s

maximum design landing weight (consistent with the landing design limits imposed by

14 CFR 25.473 to 25.487). However, the Safety Board’s airplane performance study

determined that, when the airplane touched down for the third time, the left MLG touched

down at a descent rate of about 19 to 32 fps. Therefore, the Safety Board concludes that,

when the airplane touched down for the third time, the vertical forces on the left MLG

exceeded those that the gear was designed to withstand, and these excessive forces

resulted in overload failure.

45 Aircraft Accident Report

3. Conclusions

3.1 Findings

1. The captain was properly certificated and qualified under Federal regulations. No

evidence indicated any preexisting medical or physical conditions that might have

adversely affected his performance during the accident flight. The first officer held a

current Federal Aviation Administration airman medical certificate at the time of the

accident; however, he failed to provide information about his medical condition

(anxiety) or his use of the prescription drug alprazolam when he applied for the

certificate.

2. The airplane was properly certificated, equipped, and maintained in accordance with

Federal regulations and approved company procedures. The airplane was loaded in

accordance with approved company weight and balance procedures. The weight and

balance of the airplane were within limits during all phases of the flight.

3. Winds were within the airplane’s performance capabilities and did not adversely

affect the flight crew’s ability to maneuver the airplane during the approach and

landing as significant aircraft control authority remained.

4. The emergency response was timely and appropriate. The passengers and

crewmembers were safely evacuated from the airplane.

5. At some point during the accident sequence, the captain cockpit seat failed when it

was subjected to vertical loads that exceeded those required for certification.

6. The flight crewmembers did not account for winds when calculating the minimum

approach airspeed, and, as a result, they were not in compliance with Executive

Airlines’ approach airspeed procedures.

7. Given the relative positions of the accident airplane and the preceding Boeing 727,

the runway configuration, and the existing winds, wake turbulence was not a factor in

this accident.

8. The captain did not properly follow Executive Airlines’ before landing procedures.

9. The flight crew could have completed a successful landing after the initial

touchdown.

10. After each bounce of the airplane on the runway, the captain did not make appropriate

pitch and power corrections or execute a go-around, both of which were causal to the

accident.

Conclusions 46 Aircraft Accident Report

11. The captain demonstrated poor cockpit oversight and piloting techniques before and

during the accident sequence.

12. Written company guidance on bounced landing recovery techniques would have

increased the possibility that the captain could have recovered from the bounced

landings or handled the airplane more appropriately by executing a go-around.

13. The performance of air carrier pilots would be improved if additional guidance and

training in bounced landing recovery techniques were available.

14. The aileron flight control surface position sensors installed on airplanes in accordance

with Supplemental Type Certificate No. ST01310NY are unreliable, and flight data

recorder functional checks every 6 months could ensure the timely identification and

correction of potentiometer malfunctions and ensure that accurate flight control data

are available for accident and incident investigations.

15. Because the first officer started getting treatment for anxiety in July 2001, he should

have reported this information on his last three Federal Aviation Administration

airman medical certificate applications.

16. Not enough evidence was available to determine whether or to what extent the first

officer’s medical condition and prescription drug use contributed to the accident.

17. The pitch control uncoupling mechanism uncoupled when the airplane touched down

for the third time; as a result, the pitch uncoupling would not have prevented the flight

crew from controlling or safely landing the airplane.

18. When the airplane touched down for the third time, the vertical forces on the left main

landing gear exceeded those that the gear was designed to withstand, and these

excessive forces resulted in overload failure.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was the captain’s failure to execute proper techniques to recover from the

bounced landings and his subsequent failure to execute a go-around.

47 Aircraft Accident Report

4. Recommendations

As a result of its investigation of the May 9, 2004, Executive Airlines (doing

business as American Eagle) flight 5401 accident, the National Transportation Safety

Board makes the following recommendations to the Federal Aviation Administration:

Require all 14 Code of Federal Regulations Part 121 and 135 air carriers to

incorporate bounced landing recovery techniques in their flight manuals

and to teach these techniques during initial and recurrent training.

(A-05-30)

Require the replacement of aileron surface position sensors installed in

accordance with Supplemental Type Certificate (STC) No. ST01310NY

with more reliable aileron surface position sensors within 1 year or at the

next heavy maintenance check, whichever comes first, after the issuance of

an approved STC. Until reliable aileron surface position sensors have been

installed, require flight data recorder functional checks every 6 months and

replacement of faulty sensors, as necessary. (A-05-31)

Conduct a review of all flight data recorder systems that have been

modified by a supplemental type certificate to determine the reliability of

all sensors used as flight control surface position sensors. If the review

determines that a sensor does not provide reliable flight control surface

position data, require that the sensor be replaced with a more reliable

sensor. (A-05-32)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER

Acting Chairman

ELLEN ENGLEMAN CONNERS

Member

DEBORAH A. P. HERSMAN

Member

Adopted: September 7, 2005

this page intentionally left blank

49 Aircraft Accident Report

5. Appendixes

Appendix A

Investigation and Public Hearing

Investigation

The National Transportation Safety Board was notified of the accident about 1400

eastern daylight time on May 9, 2004. A partial go-team was assembled, which departed

that evening and arrived on scene about 0230 on May 10.

The following investigative groups were formed: Operations, Meteorology, Air

Traffic Control, Aircraft Structures, Aircraft Systems, Survival Factors, Metallurgy, and

Aircraft Performance. Specialists were also assigned to conduct the readout of the flight

data recorder and transcribe the cockpit voice recorder in the Safety Board’s laboratory in

Washington, DC. A medical officer was assigned to review and analyze information on

the first officer’s medical condition and prescription drug use.

Parties to the investigation were the Federal Aviation Administration, Executive

Airlines, the Air Line Pilots Association, and the Association of Flight Attendants.

Accredited representatives from the Bureau d’Enquêtes et d’Analyses pour la Sécurité de

l’Aviation Civile and the Transportation Safety Board of Canada and technical advisors

from Avions de Transport Regional and Pratt & Whitney Canada also assisted in the

investigation.

Public Hearing

No public hearing was held for this accident.

50 Aircraft Accident Report

Appendix B

Cockpit Voice Recorder Transcript

The following is the transcript of the Fairchild model A-100A cockpit voice

recorder, serial number 55031, installed on Executive Airlines flight 5401, an Avions de

Transport Regional 72-212, which skipped once, bounced twice, and then crashed while

landing in San Juan, Puerto Rico, on May 9, 2004.

2004.

LEGEND

RDO Radio transmission from accident aircraft, American Eagle 5401

CAM Cockpit area microphone voice or sound source

PA Voice or sound heard on the public address system channel

HOT Hot microphone voice or sound source

INT Voice or sound heard from the airplane’s intercom system or

“Audio Control Panel”

For RDO, CAM, HOT, INT and PA comments:

-1 Voice identified as the Captain

-2 Voice identified as the First Officer

-3 Voice identified as a flight attendant

-4 unidentified female voice

-? Voice unidentified

OPS1 Radio transmission from American Eagle Operations at Mayaguez

OPS2 Radio transmission from American Eagle Operations at San Jaun

TWR Radio transmission from the Air Traffic Control Tower at San Juan

CTR Radio transmission from San Juan Air Route Traffic Control Center

APP Radio transmission from the Approach Control at San Juan

EGPWS Electronic-automated voice callout from the Enhanced Ground

Proximity Warning System

This recording contained audio from Hot microphones used by the flightcrew. The voices or sounds on

these channels were also, at times, heard by the CVR group on the CAM channel and vice versa. In these

cases, comments are generally annotated as coming from the source (either HOT or CAM) from which

the comment was easiest to hear and discern.

Appendix B 51 Aircraft Accident Report

CLI Radio transmission from another airplane communicating with San

Juan Air Traffic Control Tower

A863 Radio transmission from another airplane communicating with San

Juan Air Traffic Control Tower

UNK unknown source

* Unintelligible word

@ Non-Pertinent word (see note 4 below)

& Third party personal name (see note 5 below)

# Expletive

-, - - - Break in continuity or interruption in comment

( ) Questionable insertion

[ ] Editorial insertion

... Pause

ch.1 heard on CVR channel 1 (First Officer’s channel)

ch.4 heard on CVR channel 4 (Captain’s channel)

Note 1: Times are expressed in Coordinated Universal Time (UTC).

Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed.

Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words

as spoken.

Note 4: A non-pertinent word, where noted, refers to a word not directly related to the operation, control or condition

of the aircraft.

Note 5: Personal names of 3

parties not involved in the conversation are generally not transcribed.

Appendix B 52 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1822:02.6

CAM [start of recording]

1822:07

HOT-1 *.

1822:10

HOT-1 seventy one Np.

1822:12

HOT-2 there it goes.

1822:12

HOT-1 goes off, (right)... AC wild.

1822:14

HOT-2 takeoff data speeds are set and checked.

1822:16

HOT-1 set check.

1822:16

HOT-2 trims?

1822:17

CTR eagle flight four zero one San Juan, go ahead.

1822:18.4

RDO-1 eh yes sir we're five minutes.

1822:23

CTR * lookin for a release?

Appendix B 53 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1822:25.0

RDO-1 uh we already got the clearance, we're five minutes prior to

departure.

1822:28

CTR Eagle zero one I know you have the clearance do you want

your release?

1822:30

RDO-1 yes sir.

1822:35

CTR Eagle flight four zero one's released for departure, clear-

ance void if not off by one... eight three five, if not off by one

eight three five advise center, center of intentions no later

than one eight three seven, time now one eight two three.

1822:50

RDO-1 clearance void three five, advise intentions no later than

three seven, Eagle flight four zero one.

1822:59

HOT-2 takeoff (set) data speeds are set and checked.

1823:01

HOT-1 set checked.

1823:02

HOT-2 trims are checked, or set.

1823:03

HOT-1 set.

1823:04

HOT-2 radar's standby.

Appendix B 54 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1823:05

HOT-1 standby.

1823:06

HOT-2 condition lever... max R- sorry.

1823:07

HOT-1 max RPM.

1823:08

HOT-2 'n nosewheel steering?

1823:11

HOT-1 its on.

1823:11

HOT-2 'n tailstand.

1823:12

HOT-1 removed.

1823:13

HOT-2 after start checklist complete.

1823:15

INT [sound similar to frequency change alert tone]

1823:16

HOT-1 just let 'em know you're taxiing fer- uh, runway nine.

1823:18

HOT-2 (yup).

1823:19

RDO-2 Mayaguez traf-

Appendix B 55 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1823:21

RDO-2 Mayaguez traffic Eagle flight four oh one's taxiing for run-

way nine, Mayaguez.

1823:31

HOT-1 try to get in the habit - that's kinda bad habit you don't need

it- it may help you now but just try to do a visual scan.

1823:37

HOT-2 ok.

1823:38

HOT-1 you don't need to touch anything, just... it may-it kind-the

way it perceived is if someone's looking you doin this to you,

it looks like you don't know what you're doin.

1823:47

HOT-2 ok.

1823:47

HOT-1 which is probably true.

1823:48

HOT-2 yeah its eh I'm not gonna lie yuh its true I mean-

1823:49

HOT-1 well, well I'm just telling ya that-

1823:51

HOT-2 no, ok.

1823:52

HOT-1 -but try to look like ya kn- ya know try to blend in, peop-

most people that know what they're doin, just look up at in a

glance an just just get uh * you'll get a flow, it just takes time

but * you see what I'm sayin there?

Appendix B 56 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1824:02

HOT-2 no, yeah (totally totally).

1824:03

HOT-1 it just makes you look more professional if you're not like-

1824:06

HOT-2 duhh.

1824:06

HOT-1 -touch duhhh... yeah exactly.

1824:10

HOT-1 taxi check.

1824:11

HOT-2 taxi check, brakes?

1824:15

HOT-2 checked.

1824:16

HOT-1 check.

1824:16

HOT-2 flight director and autopilots... set and off.

1824:19

HOT-1 set, off.

1824:20

HOT-2 flaps are fifteen?

1824:21

HOT-1 fifteen degrees.

Appendix B 57 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1824:22

HOT-2 takeoff config test is ok... takeoff briefing is complete...

cabin PA?

1824:28

HOT-1 complete.

1824:29

HOT-2 she already called?

1824:30

HOT-1 no.

1824:31

HOT-2 oh, I see what you're sayin.

1824:33

PA-2 flight attendants please prepare for takeoff.

1824:52

HOT-1 put the uh use the FMS. [flight management system]

1824:56

HOT-1 map... there you go.

1824:59

CAM [sound similar to flight attendant call tone]

1825:01

HOT-2 go ahead.

1825:02

INT-3 * we're ready for takeoff.

Appendix B 58 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1825:03

HOT-2 ok thanks.

1825:03

INT-3 bye.

1825:05

HOT-2 taxi checklist complete.

1825:07

HOT-2 * one? okay.

1825:09

HOT-1 yeah.

1825:09

HOT-2 * * * if we're flyin the departure procedure.

1825:13

HOT-1 yeah you've just got an RMI right there, right?

1825:14

HOT-2 oh... good call.

1825:17

HOT-1 * put ten six-

1825:18

HOT-2 yeah.

1825:18

HOT-1 -just do that, intercept the zero eight four on the RMI.

1825:23

HOT-1 twenty five hundred feet, join your course.

Appendix B 59 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1825:26

HOT-1 before takeoff.

1825:29

PA [sound similar to chime that accompanies the "no smoking"

sign]

1825:35

RDO-1 Mayaguez Eagle four zero one is departing on runway nine

at Mayaguez.

1825:46

HOT-2 * flight attendant's chimed flight controls are checked.

1825:48

HOT-1 check.

1825:49

HOT-2 rudder cam?

1825:49

HOT-1 centered.

1825:50

HOT-2 transponder's A-L-T and start selector continuous re-light,

de-ice anti-ice is level ones...and-

1825:56

HOT-1 level ones.

1825:57

HOT-2 ya want me to wait on the high-flow, or go?

1825:58

HOT-1 eh go ahead and turn it off.

Appendix B 60 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1825:59

HOT-2 ok.

1826:00

HOT-2 hi-flow's....bleed is off.

1826:02

HOT-2 lights?

1826:03

HOT-1 on.

1826:04

HOT-2 takeoff inhibit... is on.

1826:06

CAM [sound similar to increase in propeller/engine speed/noise]

1826:07

HOT-1 before takeoff checklist complete.

1826:07

HOT-2 before takeoff checklist complete.

1826:08

HOT-1 there you go.

1826:09

HOT-2 set power.

1826:11

HOT-1 that's my call.

1826:11

HOT-2 sorry.

Appendix B 61 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1826:12

HOT-1 set power.

1826:16

HOT-1 power's set, right?

1826:17

HOT-2 power's set, yup.

1826:17

HOT-1 your aircraft, seventy knots.

1826:22

HOT-1 centerline, V1 rotate.

1826:28

CAM [sound of click]

1826:28

HOT-2 positive rate, gear up.

1826:29

HOT-1 in transit.

1826:31

HOT-1 be careful of drifting like that's a bad habit.

1826:32

HOT-2 yup.

1826:37

INT [sound similar to frequency change alert tone]

1826:42

HOT-1 (yaw damps on).

Appendix B 62 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1826:43

HOT-2 (yuh).

1826:50

INT [sound similar to frequency change alert tone]

1826:51

HOT-1 acceleration altitude.

1826:52

HOT-2 climb power, climb sequence.

1826:55

HOT-2 flaps up, climb checks.

1826:58

CAM [sound similar to decrease in propeller/engine speed/noise]

1827:04

HOT-2 and, high-bank.

1827:05

HOT-1 you're goin to NAV, right?

1827:07

HOT-2 yup.

1827:07

HOT-1 let's do that.

1827:19

HOT-? *.

1827:22

HOT-1 you know how to use the maneuver?

Appendix B 63 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1827:25

HOT-2 ehhh. Its been a while.

1827:26

CAM [sound similar to pitch trim in motion whooler]

1827:26

HOT-1 go ahead and turn the autopilot on.

1827:28

HOT-2 autopilot on.

1827:31

PA [sound similar to chime that accompanies the "no smoking"

sign - or "fasten seatbelt sign"]

1827:32

HOT-1 climb checklist complete.

1827:33

HOT-2 allright.

Appendix B 64 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1827:35

PA-3 ladies and gentlemen all American Eagle flight are no

smoking we appreciate your cooperation. it is now to safe to

use portable electronic device, the passenger information

section of the in-flight magazine, these devices may not be

used on board the aircraft at anytime. as a reminder also

cell phones and two-way pagers may only be used on the

ground when the aircraft is park and must always be turned

off in flight. for your safety please remain seated until the

fasten seatbelt sign has been turned off. we strongly rec-

ommend unless you (may) have to leave your seat, to keep

your seatbelt securely fastened at all times. * * fasten seat-

belt sign is illuminated. please take care * you open over-

head bins as items may have shifted during takeoff, and

could possibly fall out. we extend a very special welcome to

our One World Alliance and Advantage customers. in the

seat pocket in front of you you will find complimentary copy

like American Way or Latitudes. feel free to take this publi-

cation with you at the ends. as a reminder ladies and gen-

tlemen this is a non-service flight, but if there is something

that we can make your flight more comfortable, don't hesi-

tate to ask us. once and again, thank you for choosing

American Eagle.

1827:37

HOT-1 ok check the uh... (press) heading.

1827:39

HOT-1 I put you in NAV already, so.

1827:41

HOT-2 oh, ok.

Appendix B 65 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1827:41

HOT-1 yeah, you should pass the course, now you gotta turn back

right, to zero nine five.... put zero nine five... that's gonna in-

tercept the course... enter... enter... and, there you go.

1827:55

HOT-2 that's good.

1827:55

HOT-1 no, that's not intercept... (for some reason). try a little more,

about one zero zero.

1828:04

HOT-1 there you go, enter... enter... what the #... should intercept

on that heading... ummmmm. that's weird.... heading one,

one zero five... enter.

1828:26

HOT-1 two point seven to the right.... * its showin it to the

left...allright, lets try the other way.....try heading uh... zero

eight five.

1828:37

RDO-1 San Juan Center, Eagle flight...four zero one.

1828:41

HOT-1 enter.

1828:47

HOT-1 there you go.

1828:48

CTR Eagle flight four zero one, is radar contact about five east

northeast of Mayaguez.

Appendix B 66 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1828:53

PA-3 [announcement in Spanish - duration 87 seconds]

1828:54

RDO-1 that checks. Eagle four zero one out of four for seven.

1828:58

HOT-1 ok now, enter.

1828:59

CTR Eagle flight four zero one confirm you were assigned seven

thousand? I'm showing five.

1829:02

RDO-1 ok five thousand, Eagle flight four zero one that's what we

had in our flight plan.

1829:06

CTR you wanna go up to seven that's fine, climb and maintain

seven thousand for Eagle four zero one.

1829:09

RDO-1 yeah that works better for us.

1829:12

CTR four zero one say again?

1829:13

RDO-1 that works better for us at seven.

1829:16

CTR allright climb and maintain seven thousand for Eagle flight

four zero one.

1829:18

RDO-1 ok seven thousand Eagle four zero one.

Appendix B 67 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1829:20

HOT-1 ok.

1829:20

HOT-2 I got seven thousand in there.

1829:22

HOT-1 what the # this doesn't * ... oh # it just fly it manually...

sometimes the computer, it showin you right of course, so...

try a bigger intercept. lets try a heading zero seven zero.

1829:35

HOT-1 I'm off one for a sec.

1829:37

RDO-1 Mayaguez, four oh one.

1829:41

HOT-1 allright, enter.

1829:42

OPS1 * * *.

1829:43

RDO-1 yeah, times are one five two six.

1829:47

OPS1 ok one five and two six. Have a nice flight * * happy connec-

tion.

1829:50

RDO-1 ok seeya.

Appendix B 68 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1829:53

HOT-1 I don't have a # clue what’s what’s doin (that), * that's weird.

it should intercept on that heading.

1830:00

HOT-1 we're (four) point eight miles to the right... four point nine... *

the #.

1830:08

HOT-1 see its showin you right on course.

1830:10

CAM [sound similar to altitude alerter]

1830:13

HOT-1 beats the # outta me.

1830:21

HOT-1 you know what, I think this thing is... do this... direct.... to

Dorado... three, enter... now go NAV... there you go. I don't

know, its some- something got messed up on the ground

there for some reason.

1830:42

HOT-1 you see what it was showin you, it was showing you to the

right, and its like goin in the course.

1830:43

HOT-2 yeah it is.

1830:47

HOT-1 hundred feet.

1830:47

HOT-2 hundred to go.

Appendix B 69 Aircraft Accident Report

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1830:48

PA [sound similar to chime that accompanies the "no smoking"

sign - or "fasten seatbelt sign" being cycled]

1830:57

HOT-1 the seventy two, it stays in the notch.

1830:58

HOT-2 oh that's right, sorry.

1830:59

HOT-1 yeah.

1830:59

HOT-1 you're familiar with the notch, right.

1831:01

HOT-2 yeah, no yeah, I'm just-

1831:02

HOT-1 yeah.

1831:02

HOT-2 used to having- my last Captain....

1831:06

HOT-1 what? he want you to have-

1831:08

HOT-2 nuh. whu- he's like - I'm more used to it when we were

hand flying it, I was having you know like kinda doin a lot of

this with the * with the power, when I was when I was flying

on final and approaches, so I just naturally just had my hand

here, cause (when) we're comin back in and we're getting

ready to s- slow down so I just had, I always just had it rest-

ing here... just so... to remind me. its its fine.

Appendix B 70 Aircraft Accident Report

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1831:28

HOT-1 ok... works for you.

1831:37

HOT-1 that's what they're teaching you at the academy, I guess.

1831:43

HOT-2 aand... prolly*... well... I guess we're still acceleratin.

1831:52

HOT-1 this plane, the seventy two, if you're below about seven -

you need trim by the way - * *... below seven, you probably

go above... you may have to pull the power back a little bit.

1832:03

HOT-2 ok.

1832:04

HOT-1 cause it goes above uhhh.... not yet, till you get (some).

1832:07

CTR Clipper one and Eagle flight four zero one San Juan altime-

ter three zero zero one.

1832:11

RDO-1 uh zero zero one, Eagle three zero...

1832:13

RDO-1 four zero one.

1832:15

CTR Eagle flight four zero one uh, turn twenty degrees to the left

for sequencing, and should take you around some weather.

Appendix B 71 Aircraft Accident Report

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1832:21

RDO-1 ok twenty left, Eagle four zero one.

1832:30

HOT-1 zero five five.

1832:41

HOT-2 now we can probably run the cruise checklist.

1832:44

HOT-1 ok.

1832:45

HOT-1 (altimeter's) three zero zero one, set cross check, cruise

power.

1832:49

HOT-2 seventy seven, err you want eighty... six?

1832:51

HOT-1 whatever you want, you're pilot flying.

1832:53

HOT-2 oh... kay.

1832:55

HOT-1 check.

1832:56

HOT-2 bring er back to seventy seven.

1832:57

HOT-1 allright.

1832:58

HOT-2 why you gotta make a connecting flight?

Appendix B 72 Aircraft Accident Report

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1833:00

HOT-1 uh. no I got plenty of time.

1833:02

HOT-2 ok.

1833:11

HOT-1 most people put it at seventy seven, we're not in icing condi-

tions, so.

1833:15

HOT-2 allright.

1833:24

HOT-1 but I do always land at eighty six, though.

1833:28

HOT-2 what?

1833:28

HOT-1 the condition levers... eighty six... on the Np. for landing.

1833:35

HOT-2 oh, right right right.

1833:36

HOT-1 yeah. some people want it (one) hundred, I see no reason

to do that.

1833:40

HOT-2 oh yeah we were *-

1833:40

HOT-1 its another change in the book they made.

Appendix B 73 Aircraft Accident Report

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1833:44

HOT-1 used to be pilot-pilot's flying discretion, now its Captains's

discretion.

1833:51

CTR Eagle flight four zero one, San Juan approach on one uh,

correction right turn direct Dorado when you're around the

weather and uh San Juan approach on one one niner point

four.

1833:58

RDO-1 right direct Dorado and nineteen four, Eagle four oh one.

1834:05

HOT-1 (its in there).

1834:06

HOT-2 I was makin sure.

1834:07

HOT-1 yeah that's it.

1834:16

INT [sound similar to frequency change alert tone]

1834:21

RDO-1 (San Juan) approach Eagle four zero one seven thousand

direct Dorado.

1834:24

APP Eagle flight four zero one San Juan Approach expect the

ILS runway one zero, descend and maintain six thousand.

1834:29

RDO-1 seven for six, Eagle four zero one.

Appendix B 74 Aircraft Accident Report

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1834:31

APP Eagle (flight) four zero one you said that you have Juliet?

1834:33

RDO-1 affirm.

1834:34

APP four zero one *.

1834:36

HOT-2 so I normally... you're supposed to do this, but I started do-

ing it.

1834:41

HOT-1 six... well what they teach you in the academy and what

people do on the line is-

1834:44

CAM [sound similar to altitude alerter]

1834:46

HOT-2 often times different, I uh-

1834:47

HOT-1 yeah.

1834:48

HOT-2 -realize that .

1834:49

HOT-1 yeah.

1834:50

HOT-1 and one other thing you gotta do... is keep your heading

bug.

Appendix B 75 Aircraft Accident Report

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1834:56

HOT-1 *.

1834:59

PA [sound similar to chime that accompanies the "no smoking"

or "fasten Seatbelt" sign being cycled, followed by a single

chime(same tone). ]

1835:05

APP Eagle flight four zero one descend and maintain five thou-

sand.

1835:07

INT [sound similar to Morse code navaid identifier]

1835:08

RDO-1 down to five thousand, four zero one.

1835:10

INT-3 yeah?

1835:11

INT-1 hey, we're in range.

1835:12

INT-3 uhhh, I don't need anything.

1835:14

INT-1 ok.

1835:14

INT-3 ok bye bye.

1835:18

HOT-1 (five).

Appendix B 76 Aircraft Accident Report

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CONTENT SOURCE CONTENT

1835:19

HOT-2 (five).

1835:20

HOT-1 I'm off of one.

1835:20

APP Eagle flight four zero one turn left heading zero eight zero,

vector for the sequence.

1835:24.0

RDO-1 heading zero eight zero, four zero one.

1835:28.5

RDO-1 operations, four zero one.

1835:36

CAM [sound similar to altitude alerter]

1835:38.4

RDO-1 San Juan Eagle, four zero one.

1835:42

HOT-2 thousand to go.

1835:50

HOT-1 lights on, cabin sign's on, CAP recall, pressurization's

checked, seatbelt (shoulder harness) on.

1835:55

HOT-1 descent checklist.

1835:55

CAM [sound similar to flight attendant call tone]

Appendix B 77 Aircraft Accident Report

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CONTENT SOURCE CONTENT

1835:55

HOT-1 hey what’s up?

1835:59

HOT-1 hello?

1836:04.2

RDO-1 San Juan Eagle four zero one, third call.

1836:09

OPS2 (four zero one).

1836:10.2

RDO-1 in range, alpha 1.

1836:13

OPS2 copy, gate one.

1836:13.7

RDO-1 roger.

1836:17

HOT-1 you know what I was gonna do, I brought my cell phone with

my charger and I didn't bring it.

1836:21

HOT-1 (think I) *.

1836:28

HOT-1 yah you know you can charge your cell phone on this,

right?... right behind you?

1836:31

INT [sound similar to Morse code navaid identifier]

Appendix B 78 Aircraft Accident Report

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1836:32

HOT-2 I didn't know that.

1836:33

HOT-1 plug in.

1836:36

HOT-1 one of those things that's not in-

1836:37

HOT-2 other way.

1836:37

HOT-1 -the book... yeah.

1836:38

HOT-2 there you go.

1836:40

HOT-1 comes in handy in a pinch... those long flights.

1836:49

HOT-1 or... what I've seen some people do, they bring uh... a DVD

player with a movie.

1836:55

HOT-2 ohh *.

1836:56

HOT-1 * right in the middle.

1836:59

HOT-1 you got your power outlet.

1837:01

INT [sound similar to Morse code from navaid identifier – ch.4]

Appendix B 79 Aircraft Accident Report

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1837:05

HOT-2 (allright so they're sayin we could prolly run err uh)... we got

the ATIS, I believe, you said?

1837:10

HOT-2 Juliet?

1837:10

HOT-1 uhh yeah you wanna pull it up there?

1837:16

HOT-1 preflight?... I can do that.

1837:27

HOT-1 landing speeds.

1837:30

HOT-1 thirty seven. ninety five, one oh seven, twenty one, twenty

eight.

1837:34

HOT-1 standby on the winds.

1837:36

HOT-2 ninety five internal?

1837:37

HOT-1 yeah.

1837:42

HOT-1 AOA speeds reviewed and checked.

1837:44

HOT-1 flight instrument (and radios) set checked.

Appendix B 80 Aircraft Accident Report

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1837:45

HOT-2 set checked.

1837:45

HOT-1 approach briefing.

1837:46

HOT-2 uhhh, we're doin the ILS ten.

1837:48

HOT-1 yup.

1837:51

APP Eagle flight four zero one descend and maintain four thou-

sand.

1837:53.1

RDO-1 four thousand, (Eagle) four zero one.

1837:55

HOT-1 (you'll) probably circle to eight.

1837:56

HOT-2 ok.

1837:57

HOT-1 probably be (a) lagoon.

1838:01

HOT-1 complete, landing PA's comin up.

1838:03

CAM [sound similar to altitude alerter]

1838:06

PA-1 flight attendants please prepare the cabin for landing.

Appendix B 81 Aircraft Accident Report

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1838:08

HOT-1 approach checklist complete.

1838:09

HOT-2 allright.

1838:15

PA-3 ladies and gentlemen as we prepare for landing return your

seatback to the upright position... stow your tray tables and

secure your seatbelt... please turn out all electronic devices

and... carry on items should be placed under the seat in

front of you... or in the overhead bins. we'll be landing soon.

[followed by Spanish PA announcement, duration 22 sec-

onds]

1838:20

HOT-2 one oh nine seven's the inbound... one oh one's across

CONDO.

1838:24

APP Eagle flight four zero one, turn right heading one zero zero.

1838:26.4

RDO-1 right turn one zero zero, Eagle four zero one.

1838:42

HOT-1 ahh this is nice, he's bringin us around all that crud... I came

in this morning and just got hammered, * * (bam), all the

way from Mayaguez, like-

1838:52

HOT-2 oh really?

Appendix B 82 Aircraft Accident Report

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1839:31

HOT-1 briefing is complete.

1839:35

HOT-1 check your trim... rudder trim.

1839:40

APP Eagle flight four zero one turn * right heading one five zero

1839:42.3

RDO-1 right turn one five zero, Eagle flight four zero one.

1839:48

HOT-1 you have to trim this plane all the time.

1839:53

HOT-1 don't (go) crazy on it.

1839:57

HOT-1 small (changes), see you went too far.

1839:59

HOT-1 small changes.

1840:00

HOT-2 yeah but * (its still) one thousand one, one thousand two in

my head.

1840:03

HOT-1 yeah just (go) like two (or) three knots...'n see what hap-

pens.

1840:06

HOT-2 I'll wait till we're straight and level here.

Appendix B 83 Aircraft Accident Report

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1840:08

HOT-1 yeah, there you go.

1840:09

APP Eagle flight four zero one descend and maintain three thou-

sand.

1840:10.9

RDO-1 three thousand Eagle flight four zero one.

1840:13

HOT-1 * * * .

1840:15

HOT-1 before I land I always put it back in the center that way I

don't have all this out of trim when I'm landing.

1840:22

CAM [sound similar to altitude alerter]

1840:30

CAM [sound of clicks]

1840:45

HOT-2 allright (sorry/so I) * ... again we... brief whatever approach

they gave us, and then expect the visual?... so... so you're

sayin-

1840:53

HOT-1 ninety nine percent of the time approaches you do in San

Juan are visual approaches-

1840:57

HOT-2 ok so you-

Appendix B 84 Aircraft Accident Report

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1840:57

HOT-1 they give you an ILS-

1841:00

APP Eagle flight four zero one, reduce speed to two one zero.

1841:01.4

RDO-1 two one zero, Eagle four zero one.

1841:06

HOT-1 they givin you an ILS to get you inbound, an then they prolly

gonna ask you, 'you got the airport runway eight in sight?',

'roger', 'clear lagoon visual eight', you're gonna circle to

eight.

1841:15

HOT-1 that's the most common approach they do here.

1841:17

HOT-2 ok.

1841:20

HOT-1 the only time you do approaches here, to minimums, is

when its raining.

1841:24

APP Eagle flight four zero one, traffic, ten o'clock and two miles,

moving to the east. (Cessna) one seventy two at one thou-

sand five hundred.

1841:31.5

RDO-1 Eagle four zero one we have him on TCAS. [traffic collision

avoidance system]

1841:52

HOT-1 the autopilot's on.

Appendix B 85 Aircraft Accident Report

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1841:53

APP Eagle flight four zero one turn uh left one three zero inter-

cept runway one zero localizer, reduce speed to one eight

zero.

1841:58.5

RDO-1 one eight zero and uh one three zero intercept the one zero

localizer, Eagle flight four zero one.

1842:11

HOT-1 most people, what they do... if the autopilot's on.

1842:13

HOT-2 uh huh.

1842:14

HOT-1 set your power, take your hands, put 'em back on your lap.

1842:17

HOT-2 ok.

1842:23

APP Eagle flight four zero one, one one mile from CONDO pre-

sent heading, maintain uh two thousand till established on

the localizer, clear ILS runway one zero approach, one eight

zero knots until CONDO.

1842:32.7

RDO-1 two thousand one eight zero to CONDO Eagle flight four

zero one, cleared ILS one zero approach.

1842:39

HOT-2 allright.

Appendix B 86 Aircraft Accident Report

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1842:40

HOT-2 cross check no flags, so heading bug runway heading.

1842:43

HOT-1 well get the altitude in there first * *.

1842:44

HOT-2 ok.

1842:46

HOT-1 two thousand set.

1842:46

HOT-2 two thousand.

1842:48

CAM [sound similar to altitude alerter]

1842:50

HOT-1 the autopilot's on, right?

1842:52

CAM [sound similar to altitude alerter]

1842:51

HOT-2 yup.

1842:52

HOT-1 so you do that.

1842:54

HOT-2 oh ok, they- they were having the non flying pilot do it then

we set it.

1842:58

HOT-1 allright.

Appendix B 87 Aircraft Accident Report

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1842:58

HOT-2 ok, that's fine.

1843:00

HOT-1 the only thing the non flying pilot does, that I've always seen

is-

1843:03

APP Eagle flight four zero one, you're four miles behind a Boeing

seven twenty seven, caution wake turbulence.

1843:07.3

RDO-1 uh Eagle flight four zero one.

1843:09

HOT-1 slow your s-...

1843:10

HOT-2 ok.

1843:12

HOT-1 get your speed back.

1843:14

HOT-1 you do not want to take wake turbulence from a seven five.

1843:16

HOT-2 yeah.

1843:19

HOT-1 you're going crazy with the power setting * jus-jus-

1843:21

HOT-2 (sorry).

Appendix B 88 Aircraft Accident Report

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1843:23

HOT-1 -go flaps fifteen.

1843:24

HOT-2 flaps fifteen.

1843:25

HOT-1 now put it about thirty.

1843:29

HOT-1 now leave it there.

1843:30

CAM [sound similar to pitch trim in motion whooler]

1843:31

HOT-1 see what it does.

1843:36

HOT-2 (runway) bug * .

1843:37

HOT-1 (there you go).

1843:44

APP Eagle flight four zero one reduce speed to one six zero,

tower one three two point zero five. good day.

1843:47.8

RDO-1 good day, four zero one.

1843:50

INT [sound similar to frequency change alert tone]

1843:51

INT [sound similar to frequency change alert tone]

Appendix B 89 Aircraft Accident Report

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1843:53

HOT-1 gear down, right?

1843:54

HOT-2 yeeaah.

1843:55

CAM [sound of click]

1843:56

HOT-2 ok.

1843:57

CAM [sound similar to landing gear operation]

1843:59

HOT-1 that was a little * *.

1844:01

INT [sound similar to frequency change alert tone]

1844:08

CAM [sound similar to pitch trim in motion whooler]

1844:11

HOT-1 bulb's burned out.

1844:13

HOT-2 three green.

1844:14

HOT-1 allright.

1844:15

HOT-2 *.

Appendix B 90 Aircraft Accident Report

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1844:18

CAM [sound similar to altitude alerter]

1844:24

HOT-1 get slowed down I don't wanna get too close (to this thing).

1844:26

HOT-2 they said one sixty though I thought.

1844:27

HOT-1 yeah, slow it down even more though, because you're al-

ready-

1844:33

HOT-1 you ever been rolled by a seven five seven?

1844:35

HOT-2 no, no I yeah no I agree I'm-

1844:37

HOT-1 yeah.

1844:37

CAM [sound similar to pitch trim in motion whooler]

1844:38

HOT-2 you're gonna do a flaps thirty then?

1844:39

CAM [sound of click similar to flap handle operation]

1844:40

HOT-1 there you go.

Appendix B 91 Aircraft Accident Report

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CONTENT SOURCE CONTENT

1844:41

HOT-1 I've had the # thing roll it like fifty five degrees in an ATR.

1844:45

HOT-? *.

1844:45

HOT-1 scares the # out of the passengers.

1844:47

HOT-2 oh I'm sure it does.

1844:48

HOT-1 yeah.

1844:49

HOT-1 allright just go about one forty.

1844:50

HOT-2 ok.

1844:57

HOT-1 * (the) condition levers (going) eighty six.

1845:00

HOT-2 and before landing checklist.

1845:02

HOT-1 allrighengstsel kinyusrelay [Before landing checklist starts

with 'Engine Start Selector, continuous re-light']* landing

gear is-

1845:04

HOT-2 three green.

Appendix B 92 Aircraft Accident Report

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1845:05

HOT-1 three green.

1845:05

HOT-1 flaps set thirty degrees.

1845:07

HOT-2 thirty.

1845:08

HOT-1 there you go.

1845:09

HOT-1 power management to... takeoff, condition levers are... *

crazy cause now its gonna go a hundred percent. (keep

your) there you go.

1845:16

HOT-1 see that ARM light?

1845:16

HOT-2 yeah.

1845:17

HOT-1 you go, you know what happens when you come back too

fast? * its gonna go to a hundred percent Np.

1845:23

HOT-2 ok.

1845:25

HOT-2 oh, I see EEC's [electronic engine control] kickin in.

1845:28

HOT-1 yuh... see that seven five?

Appendix B 93 Aircraft Accident Report

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1845:31

HOT-2 uhhh... lookin.

1845:34

HOT-1 you're ok now.

1845:35

HOT-2 allright.

1845:37

HOT-1 keep it up about one forty, now.

1845:39

HOT-1 uhh... and before landing checklist complete.

1845:42

HOT-2 allright.

1845:44

HOT-1 I'm gonna put you in climb just for now so it doesn't do that.

1846:04

HOT-2 aaay, set the altimeter or the altitude to uh missed approach

altitude two thousand.

1846:08

HOT-1 set.

1846:08

HOT-2 thanks.

1846:12

CLI San Juan Clipper one advise uh, out of seven hundred feet,

loss of ten knots.

Appendix B 94 Aircraft Accident Report

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1846:16

TWR Clipper one, thank you.

1846:17.6

RDO-1 San Juan tower Eagle four zero one ILS runway one zero,

with eight in sight.

1846:24

TWR Eagle flight four zero one San Juan tower, cleared to land

runway one zero, one departure prior to your arrival, then uh

seven twenty seven, mile final just reported loss of ten mu-

uh ten knots on final.

1846:32.4

RDO-1 kay, one zero and eight is not available?

1846:35

TWR Eagle flight four zero one uh, confirm you have eight in

sight?

1846:37.9

RDO-1 (affirm).

1846:39

TWR Eagle flight four zero one uh, change runways, cleared la-

goon visual runway eight approach, runway eight cleared to

land.

1846:43.8

RDO-1 cleared to land runway eight, Eagle flight four zero one.

1846:45

CAM [sound similar to altitude alerter]

1846:47

HOT-1 you got cleared to land, eight.

Appendix B 95 Aircraft Accident Report

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1846:48

HOT-2 allright cleared to land eight... and runway in sight, good.

1846:55

HOT-2 you still want me to keep it up * slow down to one twenty?

1846:57

HOT-1 nah... just do whatever you need. just ya ya got traffic on a

five mile final behind you anyway * you get too slow be-

cause it screws their sequence up.

1847:03

HOT-2 ok.

1847:04

HOT-1 cause I'se I slowed you up more than he wanted, so.

1847:10

HOT-1 (cause) you were you were about four miles behind 'em

and there's not very much wind.

1847:14

HOT-2 ok.

1847:14

HOT-1 and below his glideslope, which is a bad combination.

1847:17

HOT-2 I am now.

1847:18

HOT-1 you're ok now.

1847:19

HOT-2 ok.

Appendix B 96 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1847:19

HOT-1 yeah... no, cause you're on the glideslope now.

1847:21

HOT-2 right.

1847:22

HOT-1 but you were below the glideslope before.

1847:23

HOT-2 I gotcha.

1847:26

HOT-1 winds light, you're below the glideslope-

1847:28

HOT-2 oh yeah.. (that's)

1847:29

HOT-1 itsa itsa bad-

1847:30

HOT-2 bad.

1847:30

HOT-1 -combination.

1847:35

HOT-1 just fly a normal approach now * eight.

1847:52

HOT-1 so (I always) do before I land, I always center these, that

help's me out when I'm in ground.

Appendix B 97 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1847:57

HOT-2 ok.

1847:57

HOT-1 you don't have all this control force.

1848:01

HOT-1 that's just ah * somethin I do, its not somethin you have to

do.

1848:03

HOT-2 ok.

1848:04

HOT-1 just makes it easier for me.

1848:06

HOT-1 thousand feet.

1848:06

HOT-2 allright.

1848:08

HOT-2 I'll wait till five hundred and I'll bring the autopilot off and

ADU [advisory display unit] standby.

1848:17

HOT-2 little fast, correcting.

1848:18

HOT-2 if I talk to-

1848:19

HOT-1 allright, you're fine.

Appendix B 98 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1848:19

HOT-2 -myself. If I talk to myself, its just so I... know what I'm do-

ing.

1848:24

HOT-1 ok (that) works for yuh.

1848:27

CAM [sound of brief interruption in recording]

1848:33

HOT-1 actually its better you keep the speed up on this long run-

way, and you got traffic behind ya doin about a hundred and

fifty knots.

1848:40

HOT-2 ok.

1848:43

HOT-2 allright autopilot's coming off.

1848:44

CAM [sound similar to autopilot disconnect alert ]

1848:45

HOT-2 ADU to standby.

1848:49

HOT-2 and you probably turn yaw damp off.

1848:52

HOT-1 you want it off, you said?

1848:53

HOT-2 yeah... its (ok).

Appendix B 99 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1848:57

HOT-2 allright, red over white, lookin ok.

1849:00

HOT-2 I'm just gonna kinda square it off here.

1849:02

HOT-2 winds were... what?

1849:04

HOT-1 out of the east.

1849:04

HOT-2 ok.

1849:07

HOT-2 *.

1849:07

HOT-1 but you better keep that nose down or get some power up

because you're gonna balloon like #.

1849:14

HOT-2 yeah help me *.

1849:15

HOT-2 *.

1849:15

HOT-1 bring the power back to seventeen.

1849:17

EGPWS minimums minimums.

1849:17

HOT-1 get your nose up.

Appendix B 100 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1849:19

EGPWS glideslope.

1849:19

HOT-1 below the glideslope.

1849:20

HOT-2 correcting.

1849:21

HOT-1 right there.

1849:21

HOT-? *.

1849:22

HOT-1 power.

1849:22

HOT-1 your're gonna balloon.

1849:28

HOT-1 * power in a little bit.

1849:32

HOT-1 * your power in a little bit.

1849:33

HOT-1 don't pull the nose up, don't pull the nose up.

1849:34

TWR American eight sixty three traffic on final landing runway

one zero, runway eight, position and hold.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1849:36

HOT-1 now start (walking) it back *.

1849:39

HOT-1 * you're ballooning.

1849:40

A863 position and hold on eight, eight six three.

1849:40

HOT-2 allright.

1849:40.4

CAM [sound of thump]

1849:40.6

UNK [sound of 2 squeaks or beeps in succession heard only on

ch.1]

1849:41

HOT-1 get the power *.

1849:42

HOT-2 sorry.

1849:42.0

HOT-1 my aircraft.

1849:42.4

CAM [sound of click]

1849:43

HOT-2 your aircraft.

1849:43.4

CAM [sound of rustling]

Appendix B 100.1 Aircraft Accident Report

Appendix B 101 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1849:45

CAM [sound of thump on ch.1, ch.4. and CAM]

1849:46

HOT-? God. [said in a whisper]

1849:46.2

CAM [sound of brief squeak or beep]

1849:47.2

CAM [sound of click]

1849:49

HOT-1 # # *.

1849:51

HOT-? [sound similar to breath]

1849:51

HOT-? [sound similar to grunt]

1849:51.4

CAM [sound of very loud bang]

1849:52.5

CAM [sound of single chime similar to master caution / master

warning]

1849:53.6

CAM [sound of continuous repetitive chime similar to master

warning starts]

1849:56

CAM-1 awe #.

Appendix B 102 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1849:56

CAM [sound of loud crunch]

1849:58

PA [sound similar to chime that accompanies the "no smoking"

sign - or "fasten seatbelt sign"]

1850:00.3

PA [sound of unidentifed tone]

1850:00

CAM-1 #.

1850:20

CAM-? #.

1850:35

CAM-2 should I pull the fire (handles)?

1850:36

CAM-? *.

1850:38

CAM [sound similar to decrease in engine/propeller speed or

noise]

1850:40

CAM-? *.

1850:44

CAM-1 emergency checklist.

1850:48

CAM-1 #.

Appendix B 103 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1850:59

CAM-1 go ahead and run the uh, checklist *.

1851:06

CAM-2 allright *.

1851:09

CAM-2 I don't even know where to start.

1851:11

CAM-1 evacuate.

1851:12

CAM-1 awe #. * *.

1851:16

CAM-1 go ahead and... run the fire checklist.

1851:19

CAM-2 allright fire checklist, circuit breakers.

1851:25

CAM-2 you allright?

1851:26

CAM-1 yeah.

1851:29

CAM-1 #.

1851:32

CAM-1 emergency checklist for a fire please.

1851:34

CAM-2 emergency checklist, fire.

Appendix B 104 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1851:37

CAM-2 fire on the ground, power levers both. ground idle/reverse.

1851:40

CAM-2 (aircraft stopped) feathered fuel shutoff.

1851:44

CAM-2 engine fire * * discharge.

1851:50

CAM-1 awe # #.

1851:53

CAM-2 * cabin PA.

1852:00

CAM-1 cancel the warning.

1852:05

CAM [sound of continious repetive chime similar to master warn-

ing ends]

1852:09

CAM-1 awe #.

1852:12

CAM-1 go ahead and continue with the checklist please.

1852:15

CAM-2 ok.

1852:16

CAM-1 the uh.

1852:16

CAM-2 (min) cabin light.

Appendix B 105 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1852:18

CAM-2 ATC.

1852:18

CAM [sound similar to flight attendant call tone]

1852:21

CAM [sound similar to flight attendant call tone]

1852:22

CAM [sound similar to cockpit door operating]

1852:23

CAM-1 we're ok.

1852:24

CAM-4 you guys ok?

1852:25

CAM-1 we're ok.

1852:25

CAM-2 yeah.

1852:26

CAM-4 ok.

1852:27

CAM-1 can you get the door open?

1852:28

CAM-1 pull the circuit breaker for the CVR please.

1852:30

CAM [sound similar to interruption in recording]

Appendix B 106 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1852:32

CAM-2 ATC F/O notify.

1852:34

CAM-2 what should I tell em just we're here?

1852:36

CAM-1 yeah, evacuate.

1852:37

CAM-1 awe # my back.

1852:39

CAM [sound similar to knocking]

1852:40

CAM-1 we're ok.

1852:40

CAM-? *.

1852:41

CAM-1 yeah, we need to evacuate.

1852:42

CAM-? *.... Captain-

1852:42

CAM-1 yeah we're-

1852:43

CAM-? -ok yeah yeah I got it no problem.... take it easy, ok?

1852:44

CAM-1 ok.

Appendix B 107 Aircraft Accident Report

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and TIME and

SOURCE

CONTENT SOURCE CONTENT

1852:45

CAM-? (give me a few) *.

1852:46

CAM-1 ok.

1852:48

CAM [sound similar to emergency vehicle siren(s)]

1852:49

CAM-2 that's all static I don't think they're comin in.

1852:51

CAM-1 oh God... ok.

1852:54

CAM-1 cvr's pull-

1852:54.5

CAM [end of recording]