NTSB Factual Report

HISTORY OF FLIGHT

On March 11, 2005, at 2302 central standard time, a Bombardier CL-600-2B19, N8932C, operated by Pinnacle Airlines as "Flagship 2823," received substantial damage when it veered off the left side of runway 1L (9,690 feet by 200 feet, asphalt-concrete, grooved) during landing at the Milwaukee/General Mitchell International Airport (MKE), Milwaukee, Wisconsin. The captain, first officer (FO), flight attendant, and nine passengers received no injuries. The 14 Code of Federal Regulations Part 121 scheduled domestic passenger flight departed LaGuardia International Airport (LGA), New York, New York, at 2137 eastern standard time. Night instrument meteorological conditions prevailed at the time of the accident. The flight was on an IFR flight plan.

The captain reported that the taxi and takeoff portions of the flight were normal. During climbout through Flight Level 20 (20,000 feet), the #1 Hydraulic Low Pressure caution light illuminated. The captain asked the FO to run the Quick Reference Handbook (QRH) checklist for the caution message. Once the checklist was accomplished, the captain sent Pinnacle's Maintenance Operations Center (MOC) an Aircraft Communications And Reporting System (ACARS) message informing the MOC of the caution message. Numerous ACARS messages were sent between the flight crew and the MOC. The QRH indicated that the outboard ground spoilers were not available due to the loss of the #1 hydraulic system, and that a 1.13 landing distance penalty would need to be applied to the landing runway. The captain reported that he decided to continue the flight to MKE after considering MKE's weather and runway length.

MKE Approach Control delayed the flight for about 10 minutes to allow for snow removal operations that were being conducted at the intersection of runway 1L and 25L. The flight crew had obtained Automated Terminal Information System (ATIS) Oscar prior to flying the approach to MKE. The last braking action reported to ATC was from a flight that landed at about 1026, which reported the braking action as FAIR. ATC did not inform the flight crew what the braking action was on runway 1L, and the flight crew did not request the braking action report for the runway. The flight was cleared for the approach after intercepting the localizer for the ILS 1L approach.

The flight was cleared to land on runway 1L. The reported winds were 290 degrees at 10 knots. The pilot reported that the landing approach was flown at Vref +5 and that he planned to touchdown firm due to the runway condition and the loss of the outboard ground spoilers. He reported that the landing was normal until the airplane started to veer off the left side of the runway.

The airplane departed the left side of the runway about 4,600 feet from the approach end of runway 1L. The airplane veered across the grass infield before crossing runway 07R/25L. The airplane traveled through the intersection of taxiways A, E, and T before crossing another snow-covered grass in-field where the aircraft went through a snow bank and onto taxiway B. The airplane stopped near the intersection of taxiway B and M in front of concourse D.

The captain reported that nothing appeared to be wrong with the airplane so the decision was made to taxi to gate E64. The captain reported to ATC that the braking action was "very poor." Then when queried by ATC, the captain reported the braking action was, "Extremely poor. NIL." The flight crew received progressive taxi instructions and taxied to the gate where the passengers were deplaned via the airstairs instead of the jet bridge.

An examination of the airplane revealed that the forward pressure bulkhead at Fuselage Station 202.75 was compromised. The flaps, the main landing gear doors, the nose landing gear, and various skin panels also were damaged during the accident.

PERSONNEL INFORMATION

The captain was hired by Pinnacle Airlines in July 2002 as a Bombardier CL-600-2B19 copilot and was upgraded to Pilot-in-Command (PIC) in July 2004. He held an airline transport certificate with multiengine land airplane and an airplane instrument rating. He held a first class medical certificate with no limitations. He had about 4,900 hours of total flight time, including about 3,008 hours in multiengine airplanes. He had about 1,763 hours in the Bombardier CL-600-2B19 and had flown about 265 hours in the last 90 days and 85 hours in the last 30 days.

The First Officer (FO) was hired by Pinnacle Airlines in July 2004 as a Bombardier CL-600-2B19 copilot. He held a commercial certificate with single-engine land, multiengine land, and instrument airplane ratings. He held a first class medical certificate. He had about 1,100 hours of total flight time, including about 750 hours in multiengine airplanes. He had about 450 hours in the Bombardier CL-600-2B19 and had flown about 193 hours in the last 90 days and 73 hours in the last 30 days.

AIRCRAFT INFORMATION

The airplane was a twin-engine Bombardier CL-600-2B19, serial number 7932, with a maximum takeoff weight of 53,000 pounds. The engines were General Electric CF-34-3B1 engines that delivered 8,900 pounds of thrust each. The airplane was on a Continuous Airworthiness maintenance program. The last service check was conducted on March 11, 2005.

The procedures outlined in the QRH for a #1 Hydraulic Low Pressure caution light states that if the #1 hydraulic quantity readout is less that 5 percent, or if pressure is less than 1,800 psi, or if the hydraulic pressure is rapidly decreasing, the following procedures apply:

1. Hydraulic Pump 1B ON

2. Hydraulic Pressure and Fluid Quantity MONITOR

If Hydraulic Pressure and Fluid Quantity Not Normal:

3. Hydraulic Pump Switch 1B SELECT TO OFF

4. Inoperative System REVIEW

* Left and right outboard ground spoilers inoperative.

5. Land at the nearest suitable airport.

6. ANTI SKID Switch LEAVE ARMED

7. FLAPS Selector SET TO 45 DEGREES FOR LANDING

8. Actual Landing Distance INCREASE

Increase as applicable by the following factors:

a. Without thrust reversers 1.15 percent

b. With thrust reversers: 1.13 percent

METEOROLOGICAL INFORMATION

At 2252, the surface weather observation at MKE was: Winds 270 at 8; visibility 1 1/4; light snow; 900 scattered; ceiling 1,800 broken; 9,000 overcast; temperature -1; dew point -3; altimeter 29.25

At 2259, the special surface weather observation at MKE was: Winds 290 at 10, gusts 16; visibility 3/4; light snow; ceiling 500 broken; 2,000 broken; 4,700 overcast; temperature -1; dew point -2; altimeter 29.25

At 2309, the special surface weather observation at MKE was: Winds 290 at 12, gusts 17; visibility 2 1/2; runway 1L RVR 2,800 variable 6,000; light snow; few clouds at 400; ceiling 1,000 broken; 7,000 overcast; temperature -1; dew point -2; altimeter 29.25

ATIS Information Oscar provided the following information:

Milwaukee-Mitchell Airport Information Oscar 0352 (2152) Zulu: Winds 260 at 5; visibility 10; 2,400 scattered; ceiling one zero thousand broken; temperature -1; dew point -4; altimeter 29.27; ILS runway 1L approach in use; landing runway 1L; departing runway 1L; transponders required shall be on while operating on runways and taxiways; braking action advisories in effect; all taxiing and departing aircraft remain on ground control frequency until advised; pre-departure clearance available; all other departures contact clearance delivery on 120.8 Advise on initial contact you have information Oscar.

ATIS Information Quebec was current at the time of the accident. It provided the following information:

Milwaukee-Mitchell Airport Information Quebec 0459 (2259) Zulu Special: Winds 290 at 10, gusts 16; visibility 3/4; light snow; ceiling 500 broken; 2,000 broken; 4,700 overcast; temperature -1; dew point -2; altimeter 29.25; ILS runway 1L approach in use; landing runway 1L; departing runway 1L; transponders required shall be on while operating on runways and taxiways; braking action advisories in effect; all taxiing and departing aircraft remain on ground control frequency until advised; pre-departure clearance available; all other departures contact clearance delivery on 120.8 Advise on initial contact you have information Quebec.

MKE airport surveillance videos indicated that a snow squall had passed through the airport area about 10 - 15 minutes prior to the time of the accident. The surveillance cameras indicated that the visibility was limited and the runway environment was not visible on the surveillance video during the snow squall. About 2250, the ATC transcript stated, "The braking action has been all over the board on 1L. Most of the reports have been fair and a lot also were fair, uh good and fair after 25L, landing runway 1L. Of course, that was all before this little last snow squall we're in right now."

AIRPORT INFORMATION

According to the MKE Airport Certification Manual (ACM), the Operations Section (i.e., Airport Operations Manager, Assistant Airport Operations Manager, and Airport Operations Coordinator) is responsible for the self-inspection program. Airport self-inspections are performed three times daily at MKE, once per shift. In addition to the three typical daily inspections, the ACM states, "Its inspection program includes additional inspections of and subsequent handling of any unusual conditions which might exist on the airport during periods of snow removal, construction, and immediately after any incident or accident." The Airport Operations Coordinator is responsible for taking whatever action deemed necessary to correct the condition, including closing runways.

Airports certificated under 14 CFR Part 139 that are located in areas where snow and icing conditions occur, are required to prepare, maintain, and carry out a Snow and Ice Control Plan. This plan is written by the airport certificate holder and describes how the airport will minimize the effects of winter conditions on operational safety.

The MKE snow removal plan stated the "Airport Operation Coordinator on duty is responsible for conducting all field inspections and will investigate the extent and nature of any condition reported by airlines/FAA that presents a safety hazard."

A Letter of Agreement between the MKE Air Traffic Control Tower (ATCT) and Milwaukee County stated that MKE Airport Operations shall provide MU-value readings, and MKE ATCT "should provide the MU-value measuring vehicle an opportunity to make an uninterrupted runway check to ensure that accurate MU-value reading are obtained." Also, MKE ATCT, "upon receipt of a runway braking action report of "NIL," landings and takeoffs on the respective runway shall be terminated and MKE Airport operations notified."

MKE has five runways. The two runways that were operational on the night of the accident were runways 1L-19R and 7R-25L. Runway 1L-19R (9,690 feet by 200 feet, asphalt-concrete, grooved) has an ILS precision instrument approach. Runway 7R-25L (8,012 feet by 150 feet, concrete) has a non-precision localizer instrument approach. Due to weather conditions, the smaller three runways were closed. Although the prevailing winds on March 11, 2005, were from the west, the runway in use throughout the day and night periods was Runway 1L-19R due to the length of runway and the lower approach minimums provided by the ILS precision instrument approach.

Runway 1L-19R was de-iced the day prior to the accident at approximately 1930. A NOTAM was issued that stated the runway was "deiced 80 feet, and friction was reported at 40+." According to the decelorometer recordings, MU values averaged above 70.

No MU readings were taken on Runway 1L-19R the day of, nor immediately following, the accident. MU readings were taken at about 0130 the day following the accident, after the runway was cleared. No NOTAM was published for Runway 1L-19R until 0139 on the day after the accident. This NOTAM reported patchy 1/2 inch loose snow on runway over patchy thin ice on runway with MU readings of 26, 39, and 46. No deice treatment was reported on this NOTAM.

Airport Operations had completed three self-inspections on March 11, 2005, prior to the accident, but the runway conditions listed for Runway 1L-19R remained the same, although the weather conditions were changing throughout the day.

FAA AC 150/5200-30A, Airport Winter Safety and Operations, states friction tests should be conducted " ... (2) whenever visual runway inspections and/or pilot braking action reports indicate that a runway friction is changing; and (4) at least once during each 8-hour shift while contaminants are present; and (5) immediately following any aircraft incident or accident on the runway."

The ATCT was landing aircraft on runway 19R prior to 2015. According to ATC communication tapes, at approximately 2018 a Beechjet reported NIL breaking action on Runway 1L-19R. Prior to this report, breaking action reports ranged from good to poor with many pilots reporting fair.

The MKE Snow Removal Plan stated "a runway will be closed to aircraft landings and departures when a major portion of the runway is covered with ... (4) any amount of ice or snow creating NIL breaking action."

According to ATCT communication tapes and the Airport Operations Coordinator, after the Beechjet reported NIL braking action on Runway 19R, the Airport Operations Coordinator requested to change snow removal plans from clearing Runway 7R-25L to clear Runway 1L-19R.

Instead of changing the active runway to Runway 25L after the Beechjet reported NIL braking action on Runway 19R, ATCT switched the active runway to Runway 1L. ATCT requested that Airport Operations continue to clear Runway 7R-25L before clearing Runway 1L-19R. According to the Airport Operations Coordinator, Runway 1L-19R was not closed after the Beechjet report of NIL braking action. According to airport flight logs, there were 59 airplanes that had landed on Runway 1L after the Beechjet report NIL braking action. The pilots of the accident airplane reported braking action as NIL after the airplane veered off the runway.

FLIGHT RECORDERS

Cockpit Voice Recorder (CVR)

The CVR transcript of the communications from 2258:58 to 2302:40, March 11, 2005, is provided below. The following abbreviations were used throughout the transcript:

a. APR: Transmission from approach control.

b. CAM: Cockpit area microphone voice or sound source.

c. HOT: Crewmember hot microphone voice or sound source.

d. RDO: Radio transmission from N8932C

e. -1: Voice identified as the captain.

f. -2: Voice identified as the first officer.

The CVR transcript follows:

2258:58 HOT-2: twenty five on the right.

2258:59 HOT-1: two niner two five. left and center.

2259:08 HOT-1: we're two from the marker.

2259:11 HOT-2: yea. he hasn't cleared us for the approach or anything yet.

2259:16 HOT-1: ask him if he wants to clear us (for the) approach or turn it.

2259:19 RDO-2: and tower approach for Flagship twenty eight twenty three

are we cleared for the approach?

2259:24 APR: okay yes you are Flagship twenty eight twenty three you're a mile from CUTMO cleared ILS runway one left approach.

2259:29: RDO-2: all right cleared for the ILS one left Flagship twenty (eight)

twenty three.

2259:33 HOT-1: okay glide slope is armed.

2259:34 HOT-2: roger LOC two * swap.

2259:35 HOT-1: gear down. flaps thirty.

2259:37 CAM: [sound similar to gear extension].

2259:37 HOT-1: bug one sixty.

2259:39 APR: and Flag uh Flagship twenty eight twenty three I appreciate

your patience you are cleared to land runway one left the

wind is ah two niner zero at one zero remain this frequency.

2259:50 RDO-2: all right thank you sir ah cleared to land ah one left Flagship

twenty (eight) twenty three.

2259:54 HOT-1: cleared to land.

2259:55 HOT-2: cleared to land.

2259:56 HOT-1: glideslope active.

2259:57 HOT-2: roger.

2259:57 HOT-1: flaps forty five ref plus factor.

2259:58 HOT-2: 'kay.

2259:59 HOT-1: before landing checklist.

2300:01 HOT-2: speed. ah... one thir

NTSB Probable Cause

the captain's failure to adequately compensate for the crosswind conditions, and his failure to maintain directional control during landing. Contributing factors include the captain's failure to land at the nearest suitable airport after an in-flight mechanical problem, the airport operation's failure to conduct runway friction tests and to issue NOTAMS in accordance with existing regulations, the crosswind, the snow-covered runway, the runway sign, and night conditions.