Miami B738 at Jacksonville on May 3rd 2019, runway overrun on landing, aircraft ends up in river

Last Update: August 4, 2021 / 20:57:38 GMT/Zulu time

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Incident Facts

Date of incident
May 3, 2019

Classification
Accident

Flight number
LL-293

Aircraft Registration
N732MA

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
KNIP

A Miami Air International Boeing 737-800, registration N732MA performing flight LL-293 from Guantanamo Bay Naval Air Station (Cuba) to Jacksonville Naval Air Station,FL (USA) with 136 passengers and 7 crew, landed on Jacksonville NAS's runway 10 at 21:42L (01:42Z May 4th) but overran the end of the runway and came to a stop in the shallow waters of St. John's River about 380 meters/1250 feet past the end of the runway and was partially submerged. All occupants were able to evacuate the aircraft, 22 occupants received minor injuries, one of them was taken to a hospital and released the following day.

Jacksonville's Sheriff Office reported Marine Units were called in to assist rescue. All persons on board are alive and accounted for. There were minor injuries, a number of people were transported to a hospital. The office later added 21 people were taken to hospitals with non-critical injuries.

The airport reported the aircraft crashed into the river past the end of the runway, about 100 feet off the paved surface.

Jacksonville's Mayor reported the aircraft landed during a rainstorm with low visibility, which may be a factor into the accident.

The NTSB have opened an investigation and dispatched an investigation team on site. The flight data recorder has been recovered.

On May 4th 2019 the NTSB reported in their press conference that 16 investigators have been dispatched to join this major investigation. The aircraft went off the right edge of the runway near the end of the runway and impacted a seawall before coming to a stop in the river. The runway is not grooved. The bottom half of the aircraft is covered with water. A number of pets carried in the cargo bays have perished. The flight data recorder is undamaged and is currently being read out. The CVR is currently under water and the NTSB can not get to it until the aircraft has been moved. The Naval commander stated that they do not know about the status of the pets, the cargo bay was checked and no pet noises could be heard and no pet carriers could be seen above the water line. The NTSB reported there may be surveillance videos around, however, they do not yet have those data. The runway had been renovated in 2016 and has a "crown", higher elevation around the center line, so that the water runs off the side of the runway. 22 people looked for medical attention, only one was hospitalized and released the following day. The airfield features a RNAV approach (no ILS available) or a SAR approach.

On May 5th 2019 the NTSB reported in their press conference, weather has complicated their efforts. The FDR was read out, preliminary information indicated the IAS at touchdown was 163 knots, 178 knots over ground (about 15 knots tail wind) at 30 degrees of flaps, ground spoilers deployed 3 seconds after touch down. The left hand thrust reverser was inoperative and the aircraft was dispatched under MEL. The CVR is still in the tail of the aircraft and under water. About 1200 gallons of fuel were remaining (some fuel spilled into the river). Divers are currently trying to remove the pets from the forward cargo bay. The crew initially planned to land to the west (runway 28), however, as the aircraft got closer to the airport they requested runway 10. Due to a deployed wire barrier the runway threshold was displaced by about 1200 feet leaving 7800 feet of landing distance available.

On May 7th 2019 the NTSB reported the aircraft was recovered onto a barge, as result the NTSB was able to access and recover the cockpit voice recorder.

In late May the NTSB released an investigative update stating that approach had advised the crew that both runway looked pretty bad and were "socked in". Winds favoured runway 28, however, as the aircraft came closer, tower queried whether the crew wanted runway 10 as it was looking better. The crew accepted runway 10. Tower reported the winds from 240 degrees at 10 knots when he cleared the flight to land. The aircraft touched down about 1600 feet past the displaced threshold of runway 10 about 20 feet to the right of the runway centerline, returned onto the center line about 1000 feet further down the runway, then veered right again and was 75 feet right of the runway, already off the runway about 6200 feet past the threshold and struck a rock embankment. The captain (ATPL, 7,500 hours total, 3,000 hours on type, therefore 1,000 hours in command) was assisted by a first officer (ATPL, 7,500 hours total, 18 hours on type). The NTSB wrote: "The accident flight was part of an operating experience trip for the first officer that began the day before the accident. On the day of the accident, the crew operated a flight from KNIP to MUGM, then operated the return flight to KNIP (accident flight)."

On Apr 21st 2021 the NTSB released their very brief factual report and opened their investigation docket.

The NTSB stated the captain (55, ATPL, 7500 hours total, 2204 hours on type) was assisted by a first officer (47, ATPL, 7500 hours total, 18 hours on type). The accident resulted in one minor injury, the aircraft received substantial damage.

Jacksonville Naval Air Station features a runway 10/28 of 9003 feet/2740 meters length, landing distance available on runway 10 is 8006 feet/2440 meters. The airport features RNAV and TACAN approaches (as well as SAR approaches) to both runways 10 and 28.

On Aug 4th 2021 the NTSB released their final report concluding the probable causes of the accident were:

An extreme loss of braking friction due to heavy rain and the water depth on the ungrooved runway, which resulted in viscous hydroplaning.

Contributing to the accident was the operator’s inadequate guidance for evaluating runway braking conditions and conducting en route landing distance assessments.

Contributing to the continuation of an unstabilized approach were
1) the captain’s plan continuation bias and increased workload due to the weather and performing check airman duties and
2) the first officer’s lack of experience.

The NTSB analysed:

According to both pilots, the takeoff, climb, and cruise portions of the flight were uneventful.

The No. 1 (left) thrust reverser was not operational and deferred for the flight in accordance with the airplane’s minimum equipment list. The captain was the pilot flying for the accident flight, and the first officer was the pilot monitoring. The captain was also performing check airman duties for the first officer who was in the process of completing operating experience training.

During the approach to Jacksonville Naval Air Station (NIP), the flight crew had two runway change discussions with air traffic controllers due to reported weather conditions (moderate to heavy precipitation) near the field; the pilots ultimately executed the area navigation GPS approach to runway 10, which was ungrooved and had a displaced threshold 997 ft from the threshold, leaving an available landing distance of 8,006 ft.

As the airplane descended through 1,390 ft mean sea level (msl), the pilots configured it for landing with the flaps set at 30º and the landing gear extended; however, the speedbrake handle was not placed in the armed position as specified in the Landing checklist. At an altitude of about 1,100 ft msl and 2.8 nm from the runway, the airplane was slightly above the glidepath, and its airspeed was on target. Over the next minute, the indicated airspeed increased to 170 knots (17 knots above the target approach speed), and groundspeed reached 180 knots, including an estimated 7-knot tailwind.

At an altitude of about 680 ft msl and 1.6 nm from the threshold, the airplane deviated further above the 3° glidepath such that the precision approach path indicator (PAPI) lights would have appeared to the flight crew as four white lights and would retain that appearance throughout the rest of the approach. Eight seconds before touchdown, multiple enhanced ground proximity warning system alerts announced “sink rate” as the airplane’s descent rate peaked at 1,580 fpm. The airplane crossed the displaced threshold 120 ft above the runway (the PAPI glidepath crosses the displaced threshold about 54 ft above the runway) and 17 knots above the target approach speed, with a groundspeed of 180 knots and a rate of descent about 1,450 ft per minute (fpm). The airplane touched down about 1,580 ft beyond the displaced threshold, which was 80 ft beyond the designated touchdown zone as specified in the operator’s standard operating procedures (SOP).

After touchdown, the captain deployed the No. 2 engine thrust reverser and began braking; he later reported, however, that he did not feel the aircraft decelerate and increased the brake pressure. The speedbrakes deployed about 4 seconds after touchdown, most likely triggered by the movement of the right throttle into the idle reverse thrust detent after main gear tire spinup. The automatic deployment of the speedbrakes was likely delayed by about 3 seconds compared to the automatic deployment that could have been obtained by arming the speedbrakes before landing. The airplane crossed the end of the runway about 55 ft right of the centerline and impacted a seawall 90 ft to the right of the centerline, 9,170 ft beyond the displaced threshold, and 1,164 ft beyond the departure end of runway 10. After the airplane came to rest in St. Johns River, the flight crew began an emergency evacuation.

The tailwind, the airplane’s excessive approach speed, and delayed speedbrake deployment increased the energy with which the airplane departed the runway and impacted the seawall, which contributed to the severity of the accident. However, postaccident landing performance calculations revealed that even if the airplane had landed on target speed within the operator’s specified touchdown zone, it would not have been able to stop before reaching the end of the paved runway surface due to the presence of standing water (with depths close to that defined as a flooded condition) on portions of the runway and the resulting viscous hydroplaning.

Viscous hydroplaning is associated with the buildup of water pressure under the tire due to viscosity in a thin film of water between a portion of the tire footprint and the runway surface.

The maximum wheel braking friction coefficient developed by the airplane during the landing ground roll was significantly less than the maximum wheel braking friction coefficient underlying the wet runway landing distances published in the airplane manufacturer’s flight crew operating manual (FCOM), computed by the operator’s onboard performance tool (OPT) application, and described in standards and models concerning landing performance in wet runway conditions. Conversely, had the airplane achieved the good braking action associated with a wet (but not flooded) runway published in the FCOM, it would have stopped on the runway even with the approach speed recorded before the accident landing, a 10-knot tailwind, and delayed speedbrake deployment.

The operator’s guidance did not require flight crews to conduct en route landing performance calculations (landing distance assessment) under certain conditions, including reported braking action that is good or better, the use of maximum manual braking, and a tailwind of 5 knots or less. However, none of these criteria applied to the accident flight’s approach to NIP.

No braking action reports were provided to or requested by the accident flight crew, the flight crew briefed using autobrakes rather than maximum manual braking, and the last wind report provided to the flight crew (240° heading at 10 knots) suggested that an estimated 7-knot tailwind component existed during the landing on runway 10.

These considerations should have prompted the flight crew to perform updated landing performance calculations. However, had they done so, they still would have likely determined that the landing distance available on runway 10 was sufficient, under the conditions at the time, if they assumed good braking action (in the absence of reports indicating otherwise) and
a merely wet (rather than flooded) runway condition.
To address braking friction shortfalls observed during landings on wet runways, Safety Alert
for Operators (SAFO) 15009 (current at the time of the accident) suggested that operators take
appropriate action to address landing performance on wet runways such as “assuming a braking action of medium or fair when computing time-of-arrival landing performance or increasing the factor applied to the wet runway time-of-arrival landing performance data.”

However, similar guidance was not included in the operator’s SOPs at the time of the accident.

Had such guidance been included, the flight crew would have been obligated to assign a surface condition value indicating a condition worse than “good” because the runway was wet, which would have prohibited them from attempting the landing with the tailwind.

To further clarify that advisory data for wet runway landings may not provide a safe stopping margin, especially in conditions of moderate or heavy rain on smooth runways, the Federal Aviation Administration issued SAFO 19003, which replaced SAFO 15009, 2 months after the accident. The new SAFO recommends that pilots verify, before initiating an approach, that the aircraft can stop within the landing distance available using a runway condition of medium-topoor whenever there is the likelihood of moderate or greater rain on a smooth runway or heavy rain on a grooved/porous friction course runway.

The operator’s SOPs would have prohibited landing if runway 10’s surface condition were assigned a value less than “good,” given the existing tailwind at the time of the accident; according to the operator’s SOPs, a “wet” runway is considered to have good braking action.

Consequently, the flight crew’s ability to determine whether they could safely land on the runway was critically dependent on their ability to determine that the actual condition of the runway was worse than “good.”

Notably, although not directly causal to the accident (because the worse-than-expected runway friction prevented the airplane from stopping on the runway), the airplane’s approach to NIP did not meet the operator’s stabilized approach criteria by the time the airplane descended to 1,000 ft agl, and several cues should have led the flight crew to call for a missed approach as required by SOPs. The airplane’s airspeed exceeded the target approach speed, it was above the glidepath, and its descent rate was greater than 1,000 fpm, which prompted multiple sink rate alerts that should have induced the flight crew to call for a missed approach. Additionally, the Miami Air Flight Operations Manual (FOM) required a flight crew to initiate a missed approach if the aircraft was not stabilized by 1,000 ft.

At the time of the accident, the first officer had only 18 hours in the Boeing 737 and most of his previous experience was operating light aircraft. Thus, his lack of experience flying jet aircraft likely played a role in his inadequate monitoring of the approach (his lack of experience was also exemplified by his failure to note, as part of his monitoring duties, that the speedbrake handle had not been armed after calling the item as part of the Landing checklist).

The captain’s continuation of the approach, contrary to the operator’s stabilized approach criteria, was likely due to a combination of factors. The first was plan continuation bias (an unconscious cognitive bias to continue with the original plan despite changing conditions). The captain’s bias may have been reinforced by a self-induced pressure to land because the flight was late due to an earlier maintenance delay and, the captain and the first officer were approaching the end of their legal duty day. A go-around or diversion to an alternate airport would have caused additional delays.

Another factor was the captain’s increased workload during the approach. Flying and monitoring duties are typically divided to reduce workload for each crewmember. However, cockpit voice recorder data indicate that, rather than relay queries or responses to ATC through the first officer, the captain made multiple radio communications to the approach controller regarding the weather, despite the first officer being responsible for performing this task as part of his monitoring duties.

In addition to performing some of the first officer’s radio duties, the captain was also performing check airman duties in a bad weather situation. Further, the captain’s failure to check that the speedbrake handle was armed, as part of the Landing checklist, was an oversight that was likely another result of his increased workload. Combined with plan continuation bias, the captain’s increased workload from performing additional tasks narrowed his attention and limited his ability to recognize and correctly respond to the cues of an unstabilized approach.

Metars:
KNIP 040253Z 24005KT 10SM FEW010 SCT040 BKN120 BKN250 24/22 A2998 RMK AO2 RAE23 TSE39 SLP147 T1 SET P0000 60074 T02440222 50014 $=
KNIP 040240Z 13004KT 10SM FEW015 SCT080 BKN250 24/22 A2997 RMK AO2 RAE23 TSE39 T1 SET P0000 T02390217 $=
KNIP 040217Z 00000KT 10SM -TSRA SCT025CB BKN080 BKN120 BKN250 24/21 A2997 RMK AO2 OCNL LTGIC VC E TS E MOV E T1 SET P0000 T02390211 $=
KNIP 040153Z 13003KT 2SM +TSRA BR SCT010 BKN021CB OVC035 23/21 A2998 RMK AO2 TSB04 SLP149 FRQ LTGIC OHD TS OHD MOV E T1 SET P0074 T02280206 $=
KNIP 040145Z 29008G16KT 3SM +TSRA BR SCT008 BKN015CB OVC032 24/22 A2999 RMK AO2 TSB04 FRQ LTGIC OHD TS OHD MOV E T1 SET P0063 T02440222 $=
KNIP 040122Z 35004KT 5SM +TSRA BR SCT008 BKN018CB OVC030 24/22 A2998 RMK AO2 TSB04 FRQ LTGIC OHD TS OHD MOV E T1 SET P0010 T02440222 $=
KNIP 040105Z 08003KT 10SM -TSRA SCT008 BKN030CB BKN045 BKN250 25/23 A2997 RMK AO2 TSB04 OCNL LTGIC VC W TS W MOV E T2 SET P0000 T02500228 $=
KNIP 040103Z 06003KT 10SM -RA SCT008 BKN030CB BKN250 25/23 A2997 RMK AO2 OCNL LTGIC DSNT SW CB DSNT SW T2 SET P0000 T02500228 $=
KNIP 040053Z 00000KT 10SM -RA SCT010 BKN030 BKN045 BKN250 25/22 A2997 RMK AO2 RAB52 SLP143 OCNL LTGIC DSNT SW CB DSNT SW T2 SET P0000 T02500222 $=
KNIP 032353Z 12004KT 10SM FEW015 SCT030 BKN120 BKN250 26/21 A2994 RMK AO2 SLP133 CB DSNT SW-W T2 SET 60001 T02560206 10289 20256 53001 $=
KNIP 032253Z 19004KT 10SM FEW020 SCT035 BKN065 BKN250 26/22 A2993 RMK AO2 RAB2154E37 TSE53 SLP130 CB DSNT W-NW T1 SET P0001 T02560222 $=
KNIP 032153Z 13007KT 10SM TS SCT020 BKN035CB BKN065 BKN250 27/21 A2993 RMK AO2 RAB27E41 TSB29 SLP131 FRQ LTGICCG OHD TS OHD MOV E T1 SET P0000 T02720211 $=
KNIP 032130Z 14005KT 9SM -TSRA SCT025 BKN035CB BKN070 BKN250 27/22 A2993 RMK AO2 RAB27 TSB29 OCNL LTGICCG VC W TS W MOV E T1 SET P0000 T02720222 $=
KNIP 032053Z 13004KT 10SM FEW020 SCT035 BKN080 BKN250 27/21 A2993 RMK AO2 TSE1959 SLP131 CB DSNT N-NE AND S T1 SET T02720211 57013 $=
KNIP 032000Z 20006KT 10SM FEW015 SCT035 BKN180 BKN250 26/22 A2994 RMK AO2 TSE1959 FRQ LTGIC DSNT NE CB DSNT NE T1 SET T02610217 $=
Incident Facts

Date of incident
May 3, 2019

Classification
Accident

Flight number
LL-293

Aircraft Registration
N732MA

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
KNIP

Photos

Photo from NTSBgov
JACKSONVILLE, Florida (May 4, 2019) – The NTSB is investigating the runway overrun of a Miami Air International Boeing 737-800 that overran the runway at Naval Air Station Jacksonville and came to rest in the St. Johns River in Jacksonville, Florida, on M (Photo credit: NTSBgov / Flickr / License: Public Domain)
Photo from NTSBgov
JACKSONVILLE, Florida (May 4, 2019) – The NTSB is investigating the runway overrun of a Miami Air International Boeing 737-800 that overran the runway at Naval Air Station Jacksonville and came to rest in the St. Johns River in Jacksonville, Florida, on M (Photo credit: NTSBgov / Flickr / License: Public Domain)
Photo from NTSBgov
JACKSONVILLE, Florida (May 6, 2019) -- NTSB investigator Clint Crookshanks Monday examining the main landing gear trunnions through the main landing gear access panel of the Miami Air International Boeing 737-800 that overran the runway in Jacksonville, F (Photo credit: NTSBgov / Flickr / License: Public Domain)

This article is published under license from Avherald.com. © of text by Avherald.com.
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