Crash During Landing Executive Airlines (doing business as American Eagle) Flight 5401 Avions de Transport Regional 72-212, N438AT San Juan, Puerto Rico May 9, 2004 Aircraft Accident Report NTSB/AAR-05/02 PB2005-910402 Notation 7650A National Transportation Safety Board Washington, D.C. Aircraft Accident Report Crash During Landing Executive Airlines (doing business as American Eagle) Flight 5401 Avions de Transport Regional 72-212, N438AT San Juan, Puerto Rico May 9, 2004 RAN S P T O L R A T LUR IBUS A N P UNUM E O T I I O T A N N S A D FE R NTSB/AAR-05/02 T Y B OA PB2005-910402 National Transportation Safety Board Notation 7650A 490 L’Enfant Plaza, S.W. Adopted September 7, 2005 Washington, D.C. 20594 National Transportation Safety Board. 2005. Executive Airlines (doing business as American Eagle) Flight 5401, Avions de Transport Regional 72-212, N438AT, San Juan, Puerto Rico, May 9, 2004. Aircraft Accident Report NTSB/AAR-05/02. Washington, DC. Abstract: This report explains the accident involving Executive Airlines (doing business as American Eagle) flight 5401, an Avions de Transport Regional 72-212, which skipped once, bounced hard twice, and then crashed at Luis Muñoz Marin International Airport, San Juan, Puerto Rico. Safety issues discussed in this report focus on flight crew performance, the lack of company bounced landing recovery guidance and training, and malfunctioning flight data recorder potentiometer sensors. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. 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Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2005-910402 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. iii Aircraft Accident Report Contents Figures . v Abbreviations . vi Executive Summary . viii 1. Factual Information . 1 1.1 History of Flight . 1 1.2 Injuries to Persons . 5 1.3 Damage to Airplane . 5 1.4 Other Damage . 5 1.5 Personnel Information . 5 1.5.1 The Captain . 5 1.5.2 The First Officer . 6 1.5.2.1 The First Officer’s Medical History and Prescription Drug Use . 7 1.5.3 The Flight Attendants . 8 1.6 Airplane Information . 8 1.6.1 Pitch Control System . 9 1.6.2 Landing Gear System . 10 1.6.3 Cockpit Seats . 11 1.7 Meteorological Information . 11 1.7.1 Airport Weather Information . 11 1.7.2 Additional Wind Information . 11 1.8 Aids to Navigation . 12 1.9 Communications . 12 1.10 Airport Information . 12 1.11 Flight Recorders . 13 1.11.1 Cockpit Voice Recorder . 13 1.11.2 Flight Data Recorder . 13 1.11.2.1 Validation of Flight Data Recorder Data . 13 1.11.2.2 Aileron Surface Position Sensors . 14 1.12 Wreckage and Impact Information . 15 1.12.1 General Wreckage Description . 15 1.12.2 Fuselage, Wings, and Engines . 16 1.12.3 Landing Gear System and Components . 17 1.12.4 Elevator and Rudder Control Systems . 18 1.12.5 Cockpit Seats . 19 1.13 Medical and Pathological Information . 19 1.14 Fire . 19 1.15 Survival Aspects . 19 1.15.1 General . 19 1.15.2 Evacuation of Passengers and Crewmembers . 20 1.15.3 Emergency Response . 21 1.16 Tests and Research . 21 Contents iv Aircraft Accident Report 1.16.1 Airplane Performance Study . 21 1.16.2 Air Traffic Control Radar Data Study . 22 1.16.3 Cockpit Seat Assembly Metallurgical Examinations . 23 1.16.3.1 Accident Airplane Cockpit Seat Assemblies . 23 1.16.3.2 FAA Vertical Drop Test of ATR-42 Cockpit Seats . 24 1.17 Organizational and Management Information . 25 1.17.1 Flight Crew Training . 25 1.17.1.1 Simulator Flight Training . 25 1.17.1.1.1 Observations of Simulator Sessions . 26 1.17.1.2 Crew Resource Management . 27 1.17.1.3 Bounced Landing Recovery Training . 27 1.17.2 Operational Guidance . 28 1.17.2.1 Approach Airspeed Guidance . 28 1.17.2.2 Before Landing Checklist . 29 1.17.2.3 Evacuation Procedures . 30 1.18 Additional Information . 31 1.18.1 Additional Information About Ipeco Cockpit Seats . 31 1.18.1.1 General Information . 31 1.18.1.2 Ipeco Cockpit Seat Tensile Strength Testing . 32 1.18.1.3 Ipeco’s Postaccident Actions . 32 1.18.2 Previous Bounced Landing Recovery Guidance and Training-Related Safety Recommendation . 33 1.18.3 Previous Flight Data Recorder Potentiometer Sensor-Related Safety Recommendations . 34 2. Analysis . ..