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Cases › DCA23LA005 · Part 121 airline · Class 3

BOMBARDIER INC CL-600-2B19AIR WISCONSIN AIRLINES LLC

Dayton, OH, USA · 2022-10-05·N447AW

0
fatal
0
serious
No injury
highest injury
Minor
damage

What happened

NTSB summary, verbatim

Following a normal touchdown, spoilers, reverse thrust, and wheel braking was used for the initial deceleration (about 5 knots/second), and the airplane tracked the centerline of the runway for about 9 seconds. About 1-2 seconds before the thrust reversers were stowed, the lateral acceleration began to increase (consistent with a right turning tendency). Subsequently, the magnetic heading began to increase as the airplane began a continuous right turn. The flight crew made two brief 4° to 5° left rudder inputs (each lasting 1 second or less) followed by increased wheel braking that provided more brake pressure on the left main landing gear wheels than on the right main landing gear wheels. The airplane continued to turn right, departed the runway surface into the grass alongside the runway, and came to rest on an adjacent taxiway. The airplane sustained minor impact damage to the left wingtip and a puncture in the left wing leading edge. The investigation was unable to determine what caused the airplane’s continuous right turn. The thrust reverser use was asymmetric with the peak right engine power about 12% higher than the peak left engine power, which would have produced a right-turn tendency. However, the amount of asymmetry was brief, not unusual, and unlikely to cause a continuous right turn. Once the reversers were stowed, any right-turn tendency due to asymmetrical reverse thrust would no longer be present. Three previous landings that involved the incident airplane revealed thrust asymmetries of 5% to 15% (favoring the right engine) during reverser use, and no loss of directional control ensued. For the incident landing, the right turn persisted well after the stowage of the thrust reversers. The flight crew’s two brief left rudder inputs and increased wheel braking on the left main wheels would have provided some left-turn tendency to counter the right turn; however, the right turn continued. The reported weather conditions included a crosswind from the right, which could produce a right-turning tendency. However, the crosswind component was about 3 knots, which would have had a negligible effect on the airplane. The rudder pedals also control the nosewheel steering angle. A full rudder pedal input (25°) will move the nosewheel to a maximum of 5.3° left or right. Using the rudder pedals to sufficiently turn the nosewheel is particularly important as the airplane slows and the rudder becomes less effective for directional control. Had the flight crew made a larger and sustained left rudder pedal input, the rudder surface would have deflected to generate an opposing aerodynamic yawing moment and the nosewheel would have turned to the left (or turned farther so) for a longer period, both of which would likely have been more effective in countering the airplane’s turn to the right. The investigation found no indications of a nosewheel steering system failure or malfunction in the recorded data or the operator’s post-incident examination of the airplane. However, because neither the nosewheel steering angle nor tiller control were required/recorded parameters on the flight data recorder, a determination regarding the operation of the nosewheel steering system could not be made. The flight crew’s left differential braking (until the airplane departed the runway) would have provided some left-turning tendency to counter the right turn. Although differential braking is a technique that can be used to help steer the airplane, the operator’s flight crew manual did not reference the use of differential braking for a normal landing. The manual advised that rudder steering (via the pedals) should be used at all speeds. Thus, the flight crew should have used the rudder pedals which would have provided aerodynamic yaw via the rudder surface as well turning the nosewheel steering, to prevent the airplane from departing the runway.

Photographs

27the aircraft, and what the investigators found
The aircraft before the accident
EM N447AW (3557825341)
Eddie Maloney from North Las Vegas, USA · CC BY-SA 2.0 · Wikimedia Commons
Wreckage and site documentation · 26 photographs from the docket

Photographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.

Probable cause

the Board's determination
The airplane’s right turn, which developed during the landing rollout and persisted until the airplane came to rest, for reasons that could not be determined based on the available evidence. Contributing to the incident was the pilot’s reliance primarily on differential braking, rather than sufficient and sustained opposing rudder pedal, when attempting to arrest the turn.

Occurrence sequence

1 stepsNTSB coding · CICTT taxonomy
  1. 1 · Landing-landing roll
    Runway excursion
    defining event

Findings

2 causal · 0 contributing
  • CAUSE
    Aircraft › Aircraft oper/perf/capability › (general) — Unknown/Not determined
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Aircraft control — Pilot

Sequence of events

24 timed eventsfrom the FDR factual report · claude-sonnet-5
  1. 18:55:33 EDTapproachp.6
    Radio altitude left was 2,460 ft, computed airspeed left was 196 kts, magnetic heading left was 238 deg. Flap surface position was 8 deg. Lateral and vertical deviations were 0.00 dots and -1.34 dots, respectively.
  2. 18:55:45 EDTapproachp.6
    Radio altitude left was 2,381 ft, computed airspeed left was 190 kts, and flap surface position was 20 deg. Lateral and vertical deviations were 0.02 dots and -1.02 dots, respectively.
  3. 18:56:18 EDTapproachp.6
    Radio altitude right was 2,252 ft, computed airspeed left was 172 kts, magnetic heading left was 238 deg. Landing gear down parameter was Not Down and Locked, landing gear up parameter was Not Up and Locked, consistent with gear in transition. Lateral and vertical deviations were -0.04 dots and -0.05 dots, respectively.
  4. 18:56:24 EDTapproachp.6
    Radio altitude right was 2,233 ft, computed airspeed right was 170 kts, magnetic heading left was 238 deg. Lateral and vertical deviations were -0.04 dots and 0.09 dots, respectively.
  5. 18:56:30 EDTapproachp.6
    The nose and main landing gear down parameters were Down and Locked.
  6. 18:56:57 EDTapproachp.6
    Radio altitude left was 1,571 ft, computed airspeed left was 157 kts, magnetic heading left was 239 deg. Flap surface position was 44 deg. Lateral and vertical deviations were 0.08 dots and 0.04 dots, respectively.
  7. 18:57:39 EDTapproachp.6
    The aircraft autopilot status (left and right) transitioned from engaged to not engaged. Radio altitude left was 1,127 ft, computed airspeed left was 145 kts, magnetic heading left was 239 deg. Lateral and vertical deviations were 0.10 dots and 0.02 dots, respectively.
  8. 18:58:54 EDTlandingp.6
    The left and right main landing gear weight on wheel (WOW) sensors changed from air to ground. The ground spoilers were deployed and remained deployed.
  9. 18:58:55 EDTlandingp.6
    Ground speed was 127 kts and magnetic heading left was 240 deg.
  10. 18:58:56 EDTlandingp.7
    The nose gear status was ground. Computed airspeed right was 121 kts and magnetic heading right was 240 deg.
  11. 18:58:57 EDTlandingp.7
    The engine thrust reversers were unlocked. Ground speed was 123 kts and magnetic heading left was 239 deg.
  12. 18:58:58 EDTlandingp.7
    Computed airspeed right was 116 kts and magnetic heading right was 239 deg.
  13. 18:58:59 EDTlandingp.7
    The engine thrust reversers were deployed. Ground speed was 118 kts and magnetic heading left was 239 deg.
  14. 18:59:00 EDTlanding rolloutp.7
    Computed airspeed right was 110 kts and magnetic heading right was 240 deg. The captain applied right brake pedal.
  15. 18:59:01 EDTlanding rolloutp.7
    Ground speed was 108 kts and magnetic heading left was 239 deg. The captain applied left brake pedal.
  16. 18:59:02 EDTlanding rolloutp.7
    Computed airspeed right was 101 kts and magnetic heading right was 240 deg. The captain right brake pedal was not applied.
  17. 18:59:03 EDTlanding rolloutp.7
    Engine 2 thrust reverser transitioned to not deployed. Ground speed was 97 kts and magnetic heading left was 240 deg. The captain reapplied right brake pedal.
  18. 18:59:04 EDTlanding rolloutp.7
    Computed airspeed right was 87 kts and magnetic heading right was 244 deg.
  19. 18:59:05 EDTlanding rolloutp.7
    Engine 1 thrust reverser transitioned to not deployed. Ground speed was 82 kts and the magnetic heading left was 248 deg.
  20. 18:59:06 EDTlanding rolloutp.7
    Computed airspeed right was 73 kts and magnetic heading right was 252 deg. The first officer applied left brake pedal.
  21. 18:59:07 EDTlanding rolloutp.7
    Ground speed was 66 kts and magnetic heading left was 254 deg. The first officer applied right brake pedal.
  22. 18:59:08 EDTlanding rolloutp.7
    Computed airspeed right was 57 kts and magnetic heading right was 260 deg.
  23. 18:59:21 EDTlanding rolloutp.7
    The ground speed was 0 kts and magnetic heading left was 336 deg.
  24. 20:10:11 EDTpost-landingp.7
    The last recorded time sample.

NTSB analysis

from the final report

Following a normal touchdown, spoilers, reverse thrust, and wheel braking was used for the initial deceleration (about 5 knots/second), and the airplane tracked the centerline of the runway for about 9 seconds. About 1-2 seconds before the thrust reversers were stowed, the lateral acceleration began to increase (consistent with a right turning tendency). Subsequently, the magnetic heading began to increase as the airplane began a continuous right turn. The flight crew made two brief 4° to 5° left rudder inputs (each lasting 1 second or less) followed by increased wheel braking that provided more brake pressure on the left main landing gear wheels than on the right main landing gear wheels. The airplane continued to turn right, departed the runway surface into the grass alongside the runway, and came to rest on an adjacent taxiway. The airplane sustained minor impact damage to the left wingtip and a puncture in the left wing leading edge. The investigation was unable to determine what caused the airplane’s continuous right turn. The thrust reverser use was asymmetric with the peak right engine power about 12% higher than the peak left engine power, which would have produced a right-turn tendency. However, the amount of asymmetry was brief, not unusual, and unlikely to cause a continuous right turn. Once the reversers were stowed, any right-turn tendency due to asymmetrical reverse thrust would no longer be present. Three previous landings that involved the incident airplane revealed thrust asymmetries of 5% to 15% (favoring the right engine) during reverser use, and no loss of directional control ensued. For the incident landing, the right turn persisted well after the stowage of the thrust reversers. The flight crew’s two brief left rudder inputs and increased wheel braking on the left main wheels would have provided some left-turn tendency to counter the right turn; however, the right turn continued. The reported weather conditions included a crosswind from the right, which could produce a right-turning tendency. However, the crosswind component was about 3 knots, which would have had a negligible effect on the airplane. The rudder pedals also control the nosewheel steering angle. A full rudder pedal input (25°) will move the nosewheel to a maximum of 5.3° left or right. Using the rudder pedals to sufficiently turn the nosewheel is particularly important as the airplane slows and the rudder becomes less effective for directional control. Had the flight crew made a larger and sustained left rudder pedal input, the rudder surface would have deflected to generate an opposing aerodynamic yawing moment and the nosewheel would have turned to the left (or turned farther so) for a longer period, both of which would likely have been more effective in countering the airplane’s turn to the right. The investigation found no indications of a nosewheel steering system failure or malfunction in the recorded data or the operator’s post-incident examination of the airplane. However, because neither the nosewheel steering angle nor tiller control were required/recorded parameters on the flight data recorder, a determination regarding the operation of the nosewheel steering system could not be made. The flight crew’s left differential braking (until the airplane departed the runway) would have provided some left-turning tendency to counter the right turn. Although differential braking is a technique that can be used to help steer the airplane, the operator’s flight crew manual did not reference the use of differential braking for a normal landing. The manual advised that rudder steering (via the pedals) should be used at all speeds. Thus, the flight crew should have used the rudder pedals which would have provided aerodynamic yaw via the rudder surface as well turning the nosewheel steering, to prevent the airplane from departing the runway.