DCA17IA020

The first officer's failure to attain the proper touchdown point and the flight crew's failure to call for a go-around, which resulted in the airplane landing more than halfway down the runway. Contributing to the incident were, the first officer's initiation of the landing flare at a relatively high altitude and his delay in reducing the throttles to idle, the captain's delay in manually deploying the speed brakes after touchdown, the captain's lack of command authority, and a lack of robust training provided by the operator to support the flight crew's decision-making concerning when to call for a go-around.

Automatic terminal information service (ATIS) "Bravo" was current when the first officer, who was the pilot flying, began to brief the instrument landing system approach for runway 22. The ATIS indicated visibility 3 miles in rain, ceiling 1,500 ft broken, overcast at 2,200 ft, wind from 130º at 9 knots, and that braking action advisories were in effect. The approach briefing included the decision altitude and visibility for the approach and manual deployment of the speed brakes by the captain, with the captain stating "you're gonna do these. I'm gonna do this" to which the first officer replied "[that] is correct." (The airplane's automatic speed brake module had been deactivated 2 days before the incident and deferred in accordance with the operator's minimum equipment list, which was appropriate). The flight crew completed the approach briefing after descending through 18,000 ft mean sea level and completed the landing checklist when the airplane was near the final approach fix. The airplane was configured for landing with the autobrake set to 3 and the flaps set to 30º. ATIS information "Charlie" was current at that time and indicated visibility 3 miles in rain, ceiling 900 ft broken, overcast at 1,500 ft, and wind from 120º at 9 knots. Flight data recorder (FDR) data and postincident flight crew statements indicate that the airplane was stabilized on the approach in accordance with the operator's procedures until the flare. The airplane crossed the runway threshold at 66 ft radio altitude at a descent rate of 750 ft per minute. When the airplane had traveled about 2,500 ft beyond the runway threshold, its descent rate decreased to near zero, and it floated during the flare. Its pitch attitude started to increase in the flare from 2.8° at a radio altitude of about 38 ft, which is high compared to the 20 ft recommended by the Boeing 737 Flight Crew Training Manual. Further, the first officer didn't fully reduce the throttles to idle until about 16 seconds after the flare was initiated and after the airplane had touched down. The initiation of the flare at a relatively high altitude above the runway and the significant delay in the reduction of thrust resulted in the airplane floating down the runway, prompting the captain to tell the first officer to get the airplane on the ground, stating "down down down down you're three thousand feet remaining." The airplane eventually touched down 4,242 ft beyond the runway threshold. According to the operator's procedures, the touchdown zone for runway 22 was the first third of the 7,001-ft-long runway beginning at the threshold, or 2,334 ft. Touchdown zone markers and lights (the latter of which extended to 3,000 ft beyond the threshold) should have provided the flight crew a visual indication of the airplane's distance beyond the threshold and prompted either pilot to call for a go-around but neither did. The point at which the airplane touched down left only about 2,759 ft remaining runway to stop. The airplane's groundspeed at touchdown was 130 knots. The captain manually deployed the speed brakes about 4.5 seconds after touchdown and after the airplane had traveled about 1,250 ft down the runway. Maximum reverse thrust was commanded about 3.5 seconds after the speed brakes were deployed, and, with fully extended speed brakes and maximum wheel brakes (which were applied at main gear touchdown) the airplane achieved increasingly effective deceleration. Its groundspeed was about 35 knots when it entered the EMAS. With the effective deceleration provided by the fully extended speed brakes, maximum wheel brakes, and reverse thrust, the flight crew would have been able to safely stop the airplane if it had touched down within the touchdown zone. The captain later stated that he had considered calling for a go-around before touchdown but the "moment had slipped past and it was too late." He said that "there was little time to verbalize it" and that he instructed the first officer to get the airplane on the ground rather than call for a go-around. He reported that, in hindsight, he should have called for a go-around the moment that he recognized the airplane was floating in the flare. The first officer said that he did not consider a go-around because he did not think that the situation was abnormal at that time. Training and practice improve human performance and response time when completing complex tasks. In this case, the operator's go-around training did not include any scenarios that addressed performing go-arounds in which pilots must decide to perform the maneuver rather than being instructed or prompted to do so. Thus, the incident flight crew lacked the training and practice making go-around decisions, which contributed to the captain's and first officer's failure to call for a go-around. Following the incident, the operator incorporated go-around training scenarios in which flight crews must decide to go around rather than being instructed to do so. The company's director of operations also stated that the company has incorporated scenarios in which go-arounds are initiated from idle power and rejected landings are performed after touchdown with the automatic speed brake inoperative. It also added a training module emphasizing that "if touchdown is predicted to be outside of the [touchdown zone], go around" and intended to require a go-around if landing outside of the touchdown zone were predicted. The operator also intended to incorporate go-around planning into the approach briefing. Flight crews would determine the cues for the touchdown zone using the airport diagram and decide at which point they would initiate a go-around if the airplane had not touched down. Given the known wet runway conditions and airplane manufacturer and operator guidance concerning "immediate" manual deployment of the speed brakes upon landing, the captain's manual deployment of the speed brakes was not timely. NTSB analysis of FDR data for previous landings in the incident airplane determined an average of 0.5 second for manual deployment of the speed brakes. Using the same touchdown point as in the incident, postincident simulations suggest that, if the speed brakes had been deployed 1 second after touchdown followed by maximum reverse thrust commanded within 2 seconds, the airplane would have remained on the runway surface. Therefore, the captain's delay in manually deploying the speed brake contributed to the airplane's runway departure into the EMAS. During the landing roll, the captain did not announce that he was assuming airplane control, contrary to the operator's procedures, and commanded directional control inputs that countered those commanded by the first officer. The captain later reported that he had forgotten that an EMAS was installed at the end of runway 22 and attempted to avoid the road beyond the runway's end by applying right rudder because he thought it would be better to veer to the right. However, the first officer applied left rudder to maintain alignment with the runway centerline and to counter the airplane pulling "really hard" to the right because of the captain's inputs. The breakdown of crew resource management during the landing roll and the captain's failure to call for a go-around demonstrated his lack of command authority, which contributed to the incident. At the time of the incident, EMAS training was not part of the operator's pilot training program, but such training was added after the incident. The circumstances of this event suggest that the safety benefit of EMASs could be undermined if flight crews are not aware of their presence or purpose.

At 1851 EDT, (ASOS) at KLGA reported the wind from 090° true at 9 knots, visibility of 3 statute miles (sm), moderate rain, ceiling broken at 900 ft agl, overcast clouds at 1,500 ft agl, temperature of 13°C and a dew point temperature of 11°C, and altimeter setting of 30.14 inches of mercury. Remarks included: surface visibility of 4 sm, precipitation accumulation of 0.14 inch since 1751 EDT. At 1951 EDT, KLGA ASOS reported the wind from 100° true at 10 knots with gusts to 15 knots, visibility of 3 sm, moderate rain, mist, ceiling overcast at 1,000 ft agl, temperature of 13°C and a dew point temperature of 12°C, and an altimeter setting of 30.10 inches of mercury. Remarks included: surface visibility of 4 sm, precipitation accumulation of 0.32 inch since 1851 EDT, precipitation accumulation of 0.61 inch during previous 3 hours. The Captain The captain, age 58, held an airline transport pilot (ATP) certificate with a rating for airplane single- and multiengine land with commercial privileges, with type ratings on the Boeing 737, DC-10, DC-8, and MD-11, Bombardier CL-65, BAE Systems HS-114, and Lockheed Martin L-188. He also held a Federal Aviation Administration (FAA) first-class medical certificate dated July 20, 2016, with a limitation for glasses or corrective lenses for near and intermediate vision. He was hired by Eastern Air Lines in June 2015 as a first officer and upgraded to captain in February 2016, when he received captain leadership training. At the time of the incident, he was based in Miami, Florida. Before joining Eastern Air Lines, the captain was a pilot at Centurion Cargo, where he was hired as a first officer on the DC-10 in 2005 and subsequently upgraded to captain on the MD-11 in 2010. According to Eastern Airlines personnel records, the captain had 20,638 hours of flight experience, 14,767 hours pilot-in-command (PIC) time, with 3,000 hours on 737s and 202 hours as PIC on 737s. He flew 75 hours, 28 hours, and 11 hours during the 90-, 30-, and 7-day periods, respectively, preceding the incident. He also reported flying 1.5 hours during the 24-hour period before the incident. His most recent 737 proficiency check occurred March 16, 2016. A review of FAA records found no prior accident, incident, or enforcement actions. 72-Hour History On Monday, October 24, the captain flew from Indianapolis, Indiana, to Charlotte, North Carolina; Charlotte to Greensboro, North Carolina; and Greensboro to Indianapolis, arriving at 2119 EDT. He went to bed about 0030 EDT and slept until 1100 EDT. On Tuesday, October 25, he and the first officer flew commercially to Salt Lake City, Utah, via Minneapolis, Minnesota. After arriving about 1700 mountain daylight time (MDT), he went to dinner with his son. He watched television for about an hour and went to sleep about 2230 MDT. On Wednesday, October 26, he slept until 0800 MDT and went to breakfast about 1000 MDT. He met his son briefly in the morning and flew from Salt Lake City to Colorado Springs, Colorado, then Colorado Springs to Omaha, Nebraska. He was off duty at 2356 CDT and went to bed about 0130 CDT on October 27. On Thursday, October 27, he awoke about 0830 CDT. He reported having no difficulties sleeping that night and stated that, when he awoke, he felt as rested as could be expected with "normal flying" 14 days into a trip (the first leg of the captain's trip began on October 14). He took a shuttle to the airport about 1000 CDT. He flew to KFOD from which he departed for the incident flight to KLGA. The First Officer The first officer, age 49, held an ATP certificate with a rating for airplane single- and multiengine land with commercial privileges and with type ratings on the Boeing 737, Cessna Citation CE-500, and Embraer ERJ-170 and ERJ-190. He also had an FAA first-class medical certificate dated October 11, 2016, with a limitation for glasses for near vision. His date of hire with Eastern Air Lines was December 1, 2015. At the time of the incident, he was based in Miami, Florida. Prior to Eastern Air Lines, he was employed by Republic Airlines as a pilot flying the ERJ-170. In 2007, he began working as a flight instructor, which he did for about 5 years. He began flight training in 2002. According to Eastern Airlines personnel and FAA records, the first officer had 6,200 hours of flight experience, 3,137 hours PIC time, and 225 hours on 737s. He flew 57 hours, 35 hours, and 11 hours during the 90-, 30-, and 7-day periods, respectively, preceding the incident. He also reported flying 1.5 hours during the 24-hour period before the incident. The first officer's most recent 737 proficiency check occurred February 2, 2016. A review of FAA records found no prior accident, incident, or enforcement actions. 72-Hour History On Monday, October 24, the first officer had a 31-hour rest period in Indianapolis that ended at 1530 EDT. He flew from Indianapolis to Charlotte, Charlotte to Greensboro, and Greensboro to Indianapolis. He reported sleeping well that night but did not indicate when he went to bed. He awoke between 0815 to 0830 EDT on Tuesday, October 25. He flew from Indianapolis to Salt Lake City arriving about 1641 MDT. He estimated he went to bed between 0130 and 0200 MDT on October 26. On Wednesday, October 26, he had a report time of 1540 MDT and flew from Salt Lake City to Colorado Springs then to Omaha. He went to bed around 0100 CDT on October 27. He estimated that he awoke between 0815 to 0830 CDT on Thursday, October 27, and ate breakfast. He could not recall the quality of his rest the night before the incident. He remained in the hotel after breakfast and went to the gym, worked out, and did laundry. He then showered and departed for the airport. He operated the flight to KFOD then departed on the incident flight to KLGA. The Boeing 737-700 airplane, serial number 28006, was manufactured May 15, 1998, and equipped with two CFM International CFM56-7B22 engines. At the time of the incident, the airplane had accumulated 48,179 hours of operation, the No. 1 (left) engine had 34, 671 hours, and the No 2. (right) engine had 20,456 hours. The airplane was equipped with an auto speed brake system that, when armed, automatically deployed the spoilers after touchdown to reduce the airplane's lift and increase the effectiveness of the wheel brakes. Alternatively, the flight crew could use the speed brake lever to deploy the spoilers manually. As previously mentioned, the system's automatic mode was inoperative; maintenance records indicate that a ground spoiler did not automatically deploy during a previous landing. The status of the automatic mode was indicated by a paper sticker wrapped around the base of the speed brake handle. In addition, the amber SPEED BRAKE DO NOT ARM light above the captain's right display unit illuminated when the automatic mode was unavailable. The flight crew's paperwork for the flight contained the procedures for the MEL item (see Organization and Management Information for more information). Each engine was equipped with a hydraulically operated thrust reverser, which consisted of left and right translating sleeves. Reverse thrust was produced by aft movement of the reverser sleeves, which caused blocker doors to deflect fan discharge air forward through fixed cascade vanes. According to manufacturer guidance, thrust reversers are manually deployed after touchdown to slow the airplane, reducing stopping distance and brake wear. The autobrake system, which is part of the airplane's hydraulic brake system, monitored the airplane's deceleration after landing and metered hydraulic pressure (via the antiskid/autobrake control unit) to the brakes to achieve the level of deceleration selected by the autobrake select switch. The switch on the incident airplane was found positioned at "3." A manual brake application by either flight crewmember would override and disarm the autobrake system. The