NTSB Factual Report

HISTORY OF FLIGHT

On February 14, 2003, at 2053 central standard time, a Canadair CL-65, N653BR, operated by Atlantic Coast Airline (ACA), flight 7675, sustained minor damage when the nose gear collapsed during landing rollout. The Title 14 CFR Part 121 domestic passenger flight departed the Chicago O'Hare Airport (ORD) at 2026 and landed on runway 20 (7,000 feet by 100 feet, concrete) at the Central Illinois Regional Airport (BMI), Bloomington, Illinois. The captain, first officer (FO), flight attendant, and 26 passengers were not injured. An emergency evacuation was not required. Instrument meteorological conditions prevailed and the flight was on an IFR flight plan.

The flight to BMI was the second, and final, flight of the day for the flight crew. On the first flight of the day they had departed from Lexington, Kentucky, at 1808, and arrived at ORD at 1911. During the flight to BMI, the captain was the pilot flying the airplane and the FO was the pilot not flying.

The cockpit voice recorder (CVR) transcript indicated that ACA flight 7675 (Blue Ridge 675) departed from ORD Runway 9L at approximately 2026, and was cleared to climb to flight level 200 (20,000 feet).

At 2033, the FO listened to Automated Terminal Information Services (ATIS) information Delta (D). ATIS information D contained the following:

"Bloomington tower information Delta, time zero one four five Zulu. Wind zero six zero at one four; visibility one, one half miles; light snow; ceiling two hundred overcast; temperature zero; dewpoint zero; altimeter two niner niner zero. Airfield advisories all runways and taxiways and ramp areas, loose wet snow less than one quarter of an inch with MU ratings above four zero. Advise on initial contact, you have information Delta."

At 2036, the captain stated, "Ehh, there you go ... ninety-two, left and center."

At 2036:26, Chicago Center cleared Blue Ridge 675 direct to BMI and to descend at pilot's discretion to 10,000 feet.

Between 2038:00-2038:39, the FO provided the captain the ATIS brief and set approach speeds. He stated, "ILS is two zero. Here's your ATIS. It's um, zero six zero at fourteen, one and a half, light snow, two hundred over, zero and zero." ... "We got the visibility for it ... ninety on the meters. ILS twenty is in use." ... "There's loose wet snow on taxiways ... but its MU is greater than four." ... "Approach is forty, REF is thirty-five, go-around N1 is off the box, V2's one forty one, VT's sixty-eight. They are set ... my flow's complete."

Between 2038:41-2039:16, the captain gave the Approach Brief. He stated, "All right. ILS two zero. It's in the box. One ninety-eight inbound, top's at twenty four forty eight, bottom's at we're gonna call it ten eighty here." ... "Bottom at uh, ten eighty, airport at eight seventy one, MSA twenty eight hundred. Looks like there's some big MALSR lights on the runway." ... "We will put in on runway twenty, take it probably down to Golf and come back. Let's make sure we don't turn on that little stub down there." ... "And Golf will take us right across the other runway to the ramp."

At 2039, the flight was cleared to descend to 6,000 feet.

At 2041, the FO contacted the company's operations personnel at BMI to inform them that the airplane was 13 minutes from BMI and was inbound for landing. The operation's personnel responded, "All right, good luck in landing. We'll hopefully see you in 15." ... "Uhh. Northwest just did a missed approach because of the snow, so good luck."

At 2042, the FO reported the information received from BMI operations to the captain by stating, "Yeah, he goes, 'I hope you make it in. Northwest just went missed.'"

At 2042:44, the captain asked, "What are they calling the weather?"

The FO responded, "Two hundred over ... but you got plenty of vis."

The captain asked, "Oh, they're calling it two hundred over?"

The FO responded, "Yeah, it's two hundred over, but a mile and a half, so we should be fine."

At 2048, Peoria Approach Control cleared Blue Ridge 675 for the BMI ILS Runway 20 approach.

At 2049, flight 7675 contacted the BMI tower.

At 2050, BMI tower reported, "Blue Ridge 675, reference runway 20, I have had my snow removal been able to plow down the centerline of the, of the field, and I did have a Saab aircraft report braking action uh ... fair to poor." The tower subsequently cleared Blue Ridge 675 to land on runway 20.

At 2051, while on the approach to runway 20 with the landing ckecklist complete, the captain said, "Forty-five knots of wind." The FO responded, "I see that. Quartering, uh."

Approximately 500 feet above ground level (agl), the FO reported seeing "lights."

At 2052:12, the airplane's Ground Proximity Warning System (GPWS) stated, "Minimums."

At 2052:13, BMI tower reported, "Windcheck. Zero eight zero at one five."

At 2052:25, the CVR transcript indicated, "Sound similar to touchdown."

At 2052:26, the CVR transcript indicated, "End of recording."

In a written statement, the captain reported, "We broke out of the overcast at approximately 300' AGL, lights and runway in sight. Touched down in the touchdown zone and approximately a few seconds later as we were rolling across the stub end of RWY 11-29 and E taxiway, I heard and felt a bang and the nosegear collapsed. We received a "nosegear disagree" aural warning as we continued the rollout. As the flying pilot I maintained directional control of the aircraft using rudder, differential braking and thrust reversers and brought the aircraft to a stop a few feet to the right of the centerline with about 1500' of runway remaining. Per company procedures we ran the QRC (Quick Reference Checklist) for a shutdown/evacuation."

The captain reported that because the weather was so extremely cold, snowy, and windy on the runway, he stopped the emergency evacuation and kept the passengers on board the airplane until buses arrived to take the passengers to the terminal. The captain reported, "After the passengers were deplaned I obtained a ride with airport personnel in a pickup truck to the touchdown zone and observed snowbanks and FOD (large ice and snow chunks) in the touchdown zone. I inquired of the driver about this and he said they were just presently plowing RWY 11-29. I returned to the aircraft, completed the QRC shutdown and the crew was transported to the terminal."

During an interview, the captain reported the ridges of snow and ice on the runway were located between Echo taxiway and the intersection of runway 02/20 and runway 11/29.

PERSONNEL INFORMATION

The captain was an airline transport rated pilot with single-engine land, multi-engine land, glider, and instrument airplane ratings. He was a certified flight instructor in single engine land airplanes, multi-engine land airplanes, gliders, and an instrument airplane instructor. He held a First Class medical certificate. He had a total of 4,550 flight hours with 2,140 hours in make and model. He flew 255 hours in the last 90 days. He had been employed by ACA for approximately five years.

The FO was an airline transport rated pilot with single-engine and multi-engine land ratings. He was a certified flight instructor in single-engine land airplanes, multi-engine land airplanes, and as an airplane instrument instructor. He held a First Class medical certificate. He had a total of 3,337 flight hours with 1,269 hours in make and model. He flew 174 hours in the last 90 days. He had been employed by ACA for approximately two years.

AIRCRAFT INFORMATION

The airplane was a twin-engine Canadair CL-65, serial number 7438, with a maximum takeoff weight of 53,000 pounds. The engines were General Electric CF-34-3B1 engines that delivered 8,729 pounds of thrust. The airplane was on a Continuous Airworthiness maintenance program. The last service check was conducted on February 11, 2003. The airplane had a total time of 5,962 hours.

The airplane is equipped with an electronic flight instrument system (EFIS). Two primary flight displays (PFD) and two multifunction displays (MFD) receive altitude, heading, airspeed and attitude data from the respective on-side sensors.

According to the aircraft manufacturer, the MFD wind speed and wind direction data is updated at 2 Hz. The wind data is recorded on the Flight Data Recorder (FDR) once every 4 seconds. The wind data is calculated in the aircraft's Flight Management System (FMS). The accuracy is a function of the errors associated with the mode of navigation, heading and airspeed. At 200 kts true airspeed (TAS), the windspeed accuracy would not be better than + / - 10 kts.

METEOROLOGICAL CONDITIONS

Surface weather observations at BMI are made by personnel from the Midwest Air Traffic Control (ATC) and by personnel of the Mobile Weather Team. The Midwest ATC weather observations are taken in the BMI tower, and the Mobile Weather Team weather observation location is in the BMI main terminal building. Midwest ATC makes the weather observations whenever the tower is in operation. The BMI Mobile Weather Team makes the weather observations between the hours of 2230 to 0530 local time, when the BMI tower is not in operation.

The wind sensor used by the BMI tower is located about 2,000 feet west-northwest of runway 29 at a height of about 22 feet agl. The wind sensor used by the BMI Mobile Weather Team is located on top of the BMI main terminal building at a height of about 25 feet above the terminal roof. It is located about 3,600 feet west-northwest of the wind sensor used by the BMI tower.

At 1945, the recorded wind information obtained from the BMI Mobile Weather Team indicated average winds of 030 degrees at 24 knots. The wind information reported on the Surface Weather Observations form for the BMI tower indicated a wind of 060 degrees at 14 knots.

At 2045, the BMI Mobile Weather Team wind information indicated an average wind of 040 degrees at 25 knots. At 2045, the BMI tower reported wind from the Surface Weather Observations form of 060 degrees at 12 knots. A peak wind from the BMI Mobile Weather Team wind data of 36 knots was noted at 2048.

A review of wind information from Peoria and Springfield, Illinois, indicated winds consistent with the BMI Mobile Weather Team wind data. In addition, the wind report from the Flight Data Recorder (FDR) of N653BR indicated a wind near the approach end of runway 20 of about 075 degrees at 40 knots. (The National Transportation Safety Board's [NTSB] Meteorology Report is in the docket material associated with this case.)

The surface weather observations for BMI between the times of 1945 on February 14 to 0053 on February 15 are listed below:

METAR KBMI 141945 06014KT 1 1/2SM -SN OVC002 00/00 A2990

METAR KBMI 142145 06014KT 1SM -SN OVC002 00/00 A2991

METAR KBMI 142353 05028G32KT 1 1/2SM -SN BR BKN002 OVC010 M01/M01 A2994 RMK PKW ND 05034/30

METAR KBMI 150053 06028G33KT 21/4SM -SN BR BKN006 OVC010 M01/M01 A2994 RMK PK WND 0540/19

The flight crew for Blue Ridge 675 received their ACA dispatch release and weather briefing for the flight from ORD to BMI at 1856 on February 14, 2004. The surface weather observations provided to the pilots in the weather briefing were the following:

At 1645, the surface observation at BMI was: Winds 080 degrees at 12 knots, 3 statute miles (sm) visibility, light rain and mist, overcast 1,000 feet above ground level (agl), temperature 1 degree C, dew point zero degree C, altimeter 29.85 inches of mercury.

At 1745, the surface observation at BMI was: Winds 070 degrees at 10 knots, 3 sm visibility, light rain and mist, overcast 1,000 feet agl, temperature 1 degree C, dew point 0 degree C, altimeter 29.85 inches of mercury.

The ACA weather briefing RAMTAF (terminal area forecast weather) provided to the pilots the following forecast weather information:

Forecast weather for BMI for 1600 was: Winds 130 degrees at 10 knots, 4 sm visibility, light freezing rain and mist, overcast 1,500 feet agl; temporarily from 1600 to 2200 feet agl, 2 sm visibility, light freezing rain, light ice pellets, mist, overcast 600 feet agl.

Forecast weather for BMI for 2200 was: Winds 130 degrees at 10 knots, 3 sm visibility, light freezing rain, light ice pellets, mist, overcast 600 feet agl; temporarily from 2200 to 0400 feet agl, 1 sm visibility, light freezing rain, light ice pellets, light snow, mist, overcast 300 feet agl.

COMMUNICATIONS

The BMI ATC tower reported that a power failure occurred at approximately 2034:30, prior to the arrival of Blue Ridge 675. The control tower facility temporarily lost electrical power that deactivated the control tower tape recorder, and the ATC tower controller was unable to reset the tape recorder prior to Blue Ridge 675's arrival. Therefore, no ATC transcript exists of the communications between BMI tower and Blue Ridge 675.

The communications between BMI tower/ground control and snow removal equipment were recorded between 2017 - 2029. (The BMI ATCT transcript is in the docket material associated with this case.)

AIRPORT INFORMATION

Commercial air carrier service is provided to BMI, and as such, BMI is governed by 14 CFR Part 139. As a result of the incident that occurred to Blue Ridge 675, an Airport/Safety Inspector from the Certification Office of the Federal Aviation Administration's (FAA) Central Region conducted a separate investigation into the circumstances on the incident. When the FAA had completed its investigation, it issued BMI a Warning Letter, EIR #2003GL800031. It stated, "The Federal Aviation Administration is unable to conclude definitively whether or not unsafe conditions were present on Runway 2/20 at the time of landing for Blue Ridge #675 on February 14, 2003. During the investigation, we did however discover that the Central Illinois Regional Airport had violated 14 CFR Part 139 under numerous subparts of the regulation the evening of February 14, 2003." The findings of the investigation included:

1. The BMI certification manual "did not identify the maintenance personnel who were responsible for issuing Notice to Airmen Reports (NOTAMS) and airport condition reports on the evening of February 14, 2003."

2. BMI failed to comply with the provisions concerning "Snow and Ice Control" measures as outlined in the certification manual. The report stated, "BMI did not conduct or provide friction measurement reports between the hours of 7:00 p.m. and 10:00 p.m. when airport conditions were rapidly changing with significant snowfall accumulations and snow removal equipment was actively operating on Runway 2/20."

3. BMI had only one individual on the airport that was available and authorized to conduct airfield condition reports, issue NOTAMS and conduct friction measurement reports. However, that person (snow crew leader) was also tasked with other collateral duties that prevented him from providing a runway condition report on Runway 2/20 after snow removal operations.

The FAA made the following recommendations to BMI:

1. BMI close all runways during snow removal activities to ensure that "safe conditions are present for air carrier operations."

2. Discontinue the practice of "allowing air carrier aircraft to operate on air carrier runways that are not plowed full length and width. While the regulation does not prohibit the practice of opening runways that have been partially plowed (providing a NOTAM is in place), the airport operator must ensure that snow is positioned off movement area surfaces."

3. Opening runway 11/29 following the Blue Ridge #675 incident resulted in the potential contamination of evidence at the intersection of Runway 11/29 and Runway 2/20. The report stated, "At a very minimum, a thorough inspection of Runway 2/20 should have been conducted and properly documented prior to initiating snow removal activities into the intersection of Runway 2/20."

4. On the evening of February 14, 2003, the personnel inside the snow removal vehicles were making runway condition assessments by looking out their side view mirrors. Instead, personnel need to "follow up behind all snow removal equipment to accurately and carefull

NTSB Probable Cause

The pilot's improper in-flight decision to land on a runway with a tailwind component that exceeded the airplane's tailwind limitation and his failure to perform a go-around which resulted in the proper touchdown point not being attained and the airplane landing long. Also causal was the inadequate snow removal procedures used by the airport personnel and the airport personnel failed to issue NOTAMS in accordance with existing regulations, resulting in the landing gear to fail in overload as a result of hitting a ridge of snow and/or ice on the runway during landing roll. Additional factors included the contaminated runway; the tailwind; the snow; and the dark night.