aviation accident investigation report runway overrun on landing american airlines flight aa331 ...

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AVIATION ACCIDENT INVESTIGATION REPORT

RUNWAY OVERRUN ON LANDING

AMERICAN AIRLINES

FLIGHT AA331

BOEING 737-823

UNITED STATES REGISTRATION N977AN

NORMAN MANLEY INTERNATIONAL AIRPORT
KINGSTON, JAMAICA (MKJP)

22 DECEMBER 2009

REPORT NUMBER JA-2009-09

The Jamaica Civil Aviation Authority (JCAA) investigated this occurrence in accordance
with Annex 13 to the Convention on International Civil Aviation. It is not the purpose of
aircraft accident investigation to apportion blame or liability. The sole objective of the
investigation and the Final Report is the prevention of accidents and incidents.

Accredited Representative: The National Transportation Safety Board of the United States
of America.
Jamaica Civil Aviation Authority – American Airlines 331 Accident Report
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Synopsis

American Airlines Flight AA331, a Boeing 737-823 in United States registration N977AN,
carrying 148 passengers, including three infants, and a crew of six, was being operated under the
provisions of 14 Code of Federal Regulations (CFR) Part 121. The aircraft departed Miami
(KMIA) at 20:22 Eastern Standard Time (EST) on 22 December 2009 (01:22 Universal
Coordinated Time (UTC) on 23 December 2009) on an instrument flight rules (IFR) flight plan,
on a scheduled flight to Norman Manley International Airport (NMIA), ICAO identifier: MKJP,
Kingston, Jamaica.

The aircraft landed at NMIA on runway 12 in the hours of darkness at 22:22 EST (03:22 UTC)
in Instrument Meteorological Conditions (IMC) following an Instrument Landing System (ILS)
approach flown using the heads up display (HUD) and becoming visual at approximately two
miles from the runway. The aircraft touched down at approximately 4,100 feet on the 8,911 foot
long runway in heavy rain and with a 14 knot left quartering tailwind.

The crew was unable to stop the aircraft on the remaining 4,811 feet of runway and it overran the
end of the runway at 62 knots ground speed. The aircraft broke through a fence, crossed above a
road below the runway level and came to an abrupt stop on the sand dunes and rocks between the
road and the waterline of the Caribbean Sea.

There was no post-crash fire. The aircraft was destroyed, its fuselage broken into three sections,
while the left landing gear collapsed. The right engine and landing gear were torn off, the
left wingtip was badly damaged and the right wing fuel tanks were ruptured, leaking jet fuel onto
the beach sand.

One hundred and thirty four (134) passengers suffered minor or no injury, while 14 were seriously
injured, though there were no life-threatening injuries. None of the flight crew and cabin crew
was seriously injured, and they were able to assist the passengers during the evacuation.
__________________________________________________

Throughout the text, the male gender refers to both male and female.

Jamaica Civil Aviation Authority – American Airlines 331 Accident Report
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Table Of Contents

Synopsis ..................................................................................................................................................................2
Table Of Contents ...........................................................................................................................................3
ABBREVIATIONS ..............................................................................................................................................15
SECTION 1 ...........................................................................................................................................................19
FACTUAL INFORMATION ...............................................................................................................................19
1.0 Factual Information .........................................................................................................................................20
1.1 History of the Flight ....................................................................................................................................20
1.1.1 Departure..............................................................................................................................................20
1.1.2 Enroute .................................................................................................................................................21
1.1.3 Descent and Approach .........................................................................................................................24
1.1.4 Landing ................................................................................................................................................29
1.1.5 Information given to AA331 flight crew during approach ..................................................................31
1.2 Injuries To Persons .................................................................................................................................33
1.3 Damage To Aircraft ................................................................................................................................33
1.4 Other Damage .........................................................................................................................................33
1.5 Personnel Information .............................................................................................................................34
1.5.1 ATC Operational Personnel .................................................................................................................34
1.5.2 Flight Crew – General ..........................................................................................................................34
1.5.3 Flight Crew and Cabin Crew – Flight/Duty/Rest Times ......................................................................34
1.5.4 Captain .................................................................................................................................................35
1.5.5 First Officer ..........................................................................................................................................36
1.5.6 Cabin Crew ..........................................................................................................................................38
1.5.7 Crew Pairing ........................................................................................................................................38
1.6 Aircraft Information ................................................................................................................................38
1.6.1 General .................................................................................................................................................38
1.6.2 Maintenance .........................................................................................................................................39
1.6.3 Weight and Balance .............................................................................................................................39
1.6.4 Landing Speeds ....................................................................................................................................39
1.6.5 Automatic Flight System and HUD .....................................................................................................39
1.6.6 Weather Radar .....................................................................................................................................40
1.6.7 Wind Shear Detection and Prediction ..................................................................................................40
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1.6.8 Ground Spoilers ...................................................................................................................................40
1.6.9 Brake System .......................................................................................................................................40
1.6.10 Engine Controls .................................................................................................................................41
1.6.11 Rain Removal System ........................................................................................................................41
1.6.12 GPS Navigation Equipment ...............................................................................................................41
1.6.13 Aircraft description – Cabin, Seats and Exits ....................................................................................42
1.6.14 Aircraft Seats and Restraint Systems .................................................................................................43
1.6.15 Emergency Exits – Flight Deck .........................................................................................................43
1.6.16 Emergency Exits - Cabin ...................................................................................................................43
1.6.17 Evacuation Escape Slides .................................................................................................................44
1.6.18 Emergency Lighting ...........................................................................................................................46
1.6.18.1 Emergency Lighting - General ........................................................................................................46
1.6.18.2 Interior Emergency Lighting ..........................................................................................................46
1.6.18.3 Exterior Emergency Lighting ..........................................................................................................46
1.6.19 Public Address and Communication System .....................................................................................47
1.6.20 Emergency Equipment .......................................................................................................................47
1.7 Meteorological Information ........................................................................................................................47
1.7.1 METARS on AA331 Dispatch Document ...........................................................................................47
1.7.2 Graphic Area Forecasts ........................................................................................................................47
1.7.3 Weather over Jamaica ..........................................................................................................................48
1.7.4 En route Weather .................................................................................................................................48
1.7.5 Thunderstorms and Lightning ..............................................................................................................48
1.7.6 Hourly Weather Observations ..............................................................................................................49
1.7.7 Aerodrome Forecasts ...........................................................................................................................50
1.7.7.1 Kingston/Norman Manley International Airport (NMIA) ................................................................50
1.7.7.2 Montego Bay - Sangster International Airport .................................................................................51
1.7.7.3 Grand Cayman - Owen Roberts International Airport - MWCR ......................................................51
1.7.8 Area Forecast and Flash Flood Warning ..............................................................................................51
1.7.9 Kingston/Norman Manley International Airport, Wind Information ...................................................52
1.7.10 Weather Information From Radar ......................................................................................................52
1.7.11 Recorded Rainfall Rates At MKJP Norman Manley International Airport .......................................53
1.7.11.1 Recorded Rainfall at MKJP Norman Manley International Airport ..............................................53
1.7.11.2 Definitions of Rainfall ....................................................................................................................54
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1.7.12 Weather Conditions on the Ground at Kingston ................................................................................54
1.7.13 AA Field Condition Report for Kingston ..........................................................................................54
1.7.14 Weather Information Provided by Air Traffic Control ......................................................................55
1.7.15 Rain Reports During Approach from Flight Crew .............................................................................56
1.8 Aids To Navigation .................................................................................................................................56
1.8.1 General .................................................................................................................................................56
1.8.2 Instrument Approaches at MKJP, Norman Manley International Airport ...........................................56
1.8.2.1 Runway 12 Instrument Approaches ..................................................................................................56
1.8.2.2 Runway 30 Instrument Approaches ..................................................................................................58
1.9 Communications .....................................................................................................................................58
1.10 Airport Information ...............................................................................................................................59
1.10.1 General ...............................................................................................................................................59
1.10.2 Runway Description ...........................................................................................................................60
1.10.2.1 Runway 12 ......................................................................................................................................60
1.10.2.2 Runway 30 ......................................................................................................................................60
1.10.2.3 Runway 12/30, Transverse and Longitudinal Slopes ......................................................................61
1.10.2.4 Runway Survey ...............................................................................................................................62
1.10.2.5 Runway Drainage System ..............................................................................................................63
1.10.2.6 Runway 12 Lighting and Markings ................................................................................................63
1.10.2.7 Runway 30 Lighting and Markings ................................................................................................65
1.10.2.8 Runway End Safety Area (RESA) ..................................................................................................66
1.10.3 Runway Surface Friction Measurement .............................................................................................67
1.10.4 Runway Surface Condition Reports ...................................................................................................68
1.10.4.1. AIP Jamaica ...................................................................................................................................68
1.10.4.2 Air Traffic Control (ATC) .............................................................................................................68
1.10.4.3 AA Flight Manual Part II Jeppesen Page 10-7X .............................................................................69
1.10.4.4 American Airlines Field Condition Reports ..................................................................................69
1.10.4.5 Runway Condition Reports – ICAO Requirements ........................................................................71
1.10.4.6 Runway Condition Reports at Kingston .........................................................................................72
1.10.5 Airport Rescue and Fire Fighting (ARFF) .........................................................................................74
1.10.6 Meteorological Services and ATIS weather information ..................................................................74
1.10.7 Airport Lighting .................................................................................................................................75
1.11 Flight Recorders ....................................................................................................................................75
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1.11.1 Cockpit Voice Recorder (CVR) .........................................................................................................75
1.11.2 Flight Data Recorder (FDR) ..............................................................................................................75
1.11.2.1 Flight Data Recorder .......................................................................................................................75
1.11.2.2 Information from Flight Data Recorder ..........................................................................................76
1.12 Wreckage And Impact Information ......................................................................................................82
1.12.1 Debris Path and Other Damage ..........................................................................................................82
1.12.2 Damage to Aircraft - General .............................................................................................................83
1.12.3. Damage to Engines ...........................................................................................................................86
1.12.4 Damage to Landing Gear ...................................................................................................................86
1.12.4.1 Nose Gear ........................................................................................................................................86
1.12.4.2 Main Landing Gear .........................................................................................................................87
1.12.4.2.1 General .........................................................................................................................................87
1.12.4.2.2 Right Main Landing Gear ............................................................................................................87
1.12.4.2.3 Left Main Landing Gear ..............................................................................................................88
1.12.4.2.4 Evidence of Hydroplaning ...........................................................................................................90
1.12.5 Damage to Exits .................................................................................................................................90
1.12.5.1 Forward Left Door (L1) and Escape Slide ......................................................................................90
1.12.5.2 Forward Right Door (R1) and Escape Slide ...................................................................................91
1.12.5.3 Aft Left Door (L2) ..........................................................................................................................92
1.12.5.4 Aft Right Door (R2) ........................................................................................................................93
1.12.5.5 Automatic Over-wing Exits ............................................................................................................94
1.12.6 Damage to Flight Deck ......................................................................................................................94
1.12.6.1 General ............................................................................................................................................94
1.12.6.2 Flight Deck Seats ............................................................................................................................95
1.12.6.3 Flight Deck Floor ............................................................................................................................96
1.12.6.4 Flight Deck Sidewalls .....................................................................................................................96
1.12.6.5 Flight Deck Windows .....................................................................................................................96
1.12.6.6 Flight Deck Instrument Panel .........................................................................................................96
1.12.6.7 Flight Deck Door ............................................................................................................................97
1.12.6.8 Forward Entry, Cabin Crew Seats and Forward Galley Area .........................................................97
1.12.7 Main Cabin.........................................................................................................................................98
1.12.7.1 Forward Section - First Class Cabin – Row 3 through Row 6 ........................................................98
1.12.7.2 Centre Section – Economy Class Cabin – Row 7 through Row 22 ................................................99
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1.12.7.3 Aft Section - Economy Class Cabin – Row 23 through Row 28 ....................................................99
1.12.7.4 Aft Entry, Cabin Crew Seats and Aft Galley Area .......................................................................101
1.13 Medical And Pathological Information ...............................................................................................102
1.13.1 Captain .............................................................................................................................................102
1.13.2 First Officer ......................................................................................................................................102
1.14 Fire ......................................................................................................................................................102
1.15 Survival Aspects .................................................................................................................................103
1.15.1 Notification of Accident...................................................................................................................103
1.15.2 Emergency Lighting in aircraft ........................................................................................................103
1.15.3 Communications ..............................................................................................................................103
1.15.4 Evacuation ........................................................................................................................................103
1.15.5 Emergency Exits ..............................................................................................................................105
1.16 Tests And Research .............................................................................................................................105
1.16.1 Escape Slide Tests ...........................................................................................................................105
1.16.2 Emergency Lighting in aircraft ........................................................................................................106
1.16.3 Simulator Trials ...............................................................................................................................107
1.16.4 Display Guidance Computer ............................................................................................................107
1.16.5 Tests on Braking System..................................................................................................................108
1.16.5.1 Antiskid/Autobrake Control Unit ..................................................................................................108
1.16.5.2 Antiskid Valves .............................................................................................................................109
1.16.5.3 Wheel Speed Transducers .............................................................................................................109
1.16.5.4 Autobrake Valve Module ..............................................................................................................109
1.17 Organization and Management Information .......................................................................................110
1.17.1 AA Manuals, Policies and Procedures .............................................................................................110
1.17.1.1 AA Procedures for Approach and Landing, and go-around .........................................................110
1.17.1.1.1 Stabilized Approach Requirement .............................................................................................110
1.17.1.1.2 CAT I ILS Approach Procedures ..............................................................................................111
1.17.1.1.3 Landing on a Slippery Runway/Hydroplaning ..........................................................................112
1.17.1.1.4 Factors Affecting Landing Distance ..........................................................................................114
1.17.1.1.5 AA Approach Preparation/Calculation of Landing Distance ....................................................114
1.17.1.1.6 AA Policy on the use of reverse thrust on landing ....................................................................115
1.17.1.1.7 AA Procedures for Landing with Tailwinds ..............................................................................116
1.17.1.1.8 AA Normal Procedures for Landing from ILS ..........................................................................117
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1.17.1.1.9 AA Information on Baulked Landings (Go Around) .................................................................118
1.17.1.1.10 AA No Fault Go-Around Policy and Missed Approach decision ............................................119
1.17.1.1.11 AA Bulletin 737-07 .................................................................................................................120
1.17.1.1.12 AA HUD Usage Policy and Briefing Guide ............................................................................120
1.17.1.1.13 AA B737 RRLL Tables, Wind Component and Landing Data Card .....................................121
1.17.1.2 AA– Other Information .................................................................................................................121
1.17.1.2.1. AA Crew Resource Management (CRM) Training ..................................................................121
1.17.1.2.2 AA Flight Manual Page 10-7X. .................................................................................................121
1.17.1.2.3 AA Boeing 737 Training ...........................................................................................................121
1.17.1.2.4 AA Dispatch Information .........................................................................................................122
1.17.1.2.5 AA Required Runway Landing Length (RRLL) table, and Landing Data Card. .....................125
1.17.1.2.6 AA Landing Distance Calculations............................................................................................127
1.17.1.2.6.1 Landing Data Card ..................................................................................................................127
1.17.1.2.6.2 AA Performance – Landing Table ..........................................................................................129
1.17.1.2.7 Advisory Circular No: 91-79 .....................................................................................................129
1.17.1.2.8 Crew Flight/Duty/Rest System .................................................................................................129
1.17.1.2.9 AA– Interviews with Staff .........................................................................................................129
1.17.1.2.10 AA– information regarding Bulletin 737-07 and AC 91-79 ...................................................130
1.17.1.2.11 AA Safety Initiatives Re: AA331 Landing Accident ...............................................................132
1.17.2 Boeing Information ..........................................................................................................................133
1.17.2.1 Glide path, slippery runway, friction measurement .....................................................................133
1.17.2.2 Boeing Flight Crew Operations and Training Manuals, B737, Landing .....................................134
1.17.2.3 Boeing Information on Rejected/Baulked Landings ....................................................................136
1.17.2.4 Autopilot/Autothrottle Use During Approach ..............................................................................137
1.17.3 Air Traffic Control Procedures ........................................................................................................138
1.17.3.1 Assignment of Active Runway .....................................................................................................138
1.17.3.2 Weather Standby ...........................................................................................................................138
1.17.3.3 Information for arriving aircraft ....................................................................................................138
1.17.4 FAA Information .............................................................................................................................139
1.17.4.1 FAA Regulatory Requirements Regarding Landing Distance Calculation ..................................139
1.17.4.2 History of SAFO 06012, OpSpec/MSpec C082 and AA Bulletin 737-07 ....................................139
1.17.4.3 FAA Recommendations Regarding Landing Distance Calculation .............................................140
1.17.4.4 FAA Advisory Circular AC 91-79 ................................................................................................141
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1.17.4.5 SAFO 10005 .................................................................................................................................142
1.17.5 NTSB Recommendations to FAA ....................................................................................................143
1.17.5.1 NTSB Recommendations, General ...............................................................................................143
1.17.5.2 NTSB Safety Recommendation, in reply to A-07-58 through -64 ...............................................143
1.18 Additional Information ......................................................................................................................144
1.18.1 Air Traffic Control ...........................................................................................................................144
1.18.1.1 Enroute Radar Service ..................................................................................................................144
1.18.1.2 Approach Radar Control Service .................................................................................................144
1.18.1.3 Aerodrome Control Service ..........................................................................................................144
1.18.2 JCAA ATS QA Audits, and Controller Training and Checking ....................................................145
1.18.3 JCAA Automatic Terminal Information Service (ATIS) ................................................................145
1.18.4 JCAA Notices To Airmen (NOTAMS) ..........................................................................................145
1.18.5 JCAA Air Traffic Control Radar ...................................................................................................147
1.18.6 Estimated Water Depth and Braking Action ..................................................................................147
1.18.7 NTSB Review of Fatigue in Major U.S. Accidents .........................................................................149
1.18.8 AA use of FAA Safety Recommendations in AC No: 91-79 .........................................................149
1.18.9 GPS Approach Requirements and Information ...............................................................................149
1.18.10 Stopping Performance Information ...............................................................................................150
1.18.11 Runway Water Depth Measurement .............................................................................................150
1.18.12 Hazards associated with tailwind landings. ..................................................................................151
1.18.13 The Hazards Associated With Go-Around After Touchdown .....................................................151
1.18.14 Flight Safety International Approach and Landing Accident Reduction Report ...........................152
1.18.15 Boeing 737-800 Tailwind Certification Process ...........................................................................152
1.18.16 Definition of Black Hole Approach ...............................................................................................152
APPENDICES TO FACTUAL INFORMATION .............................................................................................153
ANALYSIS .........................................................................................................................................................233
2.0 Analysis ........................................................................................................................................................234
2.1 Aircraft ..................................................................................................................................................234
2.2 Flight Crew Qualifications ....................................................................................................................234
2.2.a NOTAMS ...........................................................................................................................................234
2.3 Airport ...................................................................................................................................................235
2.4 Runway .................................................................................................................................................236
2.4.1 Runway Surface .................................................................................................................................236
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2.4.2 Runway Slope ....................................................................................................................................236
2.5 Air Traffic Services (ATS) ..................................................................................................................237
2.6 Meteorological Information .................................................................................................................240
2.7 Operations ............................................................................................................................................240
2.8 RNAV (GPS) Runway 30 Approach at Kingston ................................................................................241
2.9 Crew Resource Management (CRM) ...................................................................................................242
2.10 Go-Around .........................................................................................................................................245
2.11 Flight Crew Fatigue ...........................................................................................................................246
2.12 Pitch-Up Inputs and Visual Illusions .................................................................................................246
2.13 Simulator Trials .................................................................................................................................247
2.14 Runway Condition Report “Wet” ......................................................................................................247
2.15 Inconsistency between AC91-79 and SAFO 06012...........................................................................249
2.16 Kingston Field Report ........................................................................................................................249
2.17 Determination of Depth of Water on Runway, and Runway Braking Action ...................................251
2.18 Survival Aspects and Injuries ............................................................................................................251
2.19 AA Bulletin 737-07 and Landing Data Card .....................................................................................252
2.20 Bulletin 737-07 and “Advance Analysis” .........................................................................................252
2.21 AA Flight Crew Landing Distance Assessment..................................................................................253
2.22 Calculation of landing distances .......................................................................................................254
2.23 Flight crew compliance with Bulletin 737-07 ....................................................................................258
2.24 Discussion of “advance analysis” ......................................................................................................258
2.25 Placement of Bulletin 737-07 in AA Manuals ....................................................................................259
2.26 Issue of Autothrottle/Autopilot use ....................................................................................................260
2.27 FAA Safety Information SAFO 06012 and AC 91-79, and AA Bulletin 737-07 ...............................261
2.28 Landing Conditions and Landing Performance Assessment .............................................................262
2.29 Tailwind Landing Hazards and Tailwind Landing Training ...............................................................266
2.30 AA Management And Operational Control .......................................................................................267
2.31 FAA Advisory Circular (AC) 91-79 ..................................................................................................267
2.32 Situational Awareness .........................................................................................................................268
2.32.1 Situational Awareness – Definition .................................................................................................268
2.32.2 Situational Awareness before Departure ..........................................................................................268
2.32.3 Situational Awareness during Approach and Landing .....................................................................269
2.33 System Safety .....................................................................................................................................272
Jamaica Civil Aviation Authority – American Airlines 331 Accident Report