Luis Munoz Marin Intl Airport
Aircraft Accident/Incident Report

San Juan, Puerto Rico
Tuesady, September 5, 2006 17:01 UTC

NTSB Narrative Summary Released at Completion of Accident

The crew elected to conduct a practice autoland approach during a scheduled airline flight in order to recertify the airplane for category 3 (CAT III) autoland procedures. Airline procedures permit crews to conduct such approaches when weather is at category 1 (CAT I) minimums or better. Weather at the time of the accident included good visual conditions, and was not a factor in the accident. Additionally, wake turbulence was not a factor in the accident. The airline's flight operations manual stated: "Except for facilities that have a restrictive note, autoland approaches are permissible to all [instrument landing system (ILS)] facilities. When a restrictive note regarding the localizer or glide slope appears on [an approach chart], autoland is not authorized." The ILS runway 8 approach chart was notated "unusable from 0.8 nm to threshold." The crew reported, and the flight data recorder (FDR) confirmed, that the airplane began to drift off the centerline of the approach at about three-quarters of a mile from the runway threshold. The drift was consistent with the direction of the wind and the ILS chart notation. Additionally, both Federal Aviation Administration (FAA) advisory material, and the airline's flight operations manual direct pilots to advise air traffic control (ATC) when conducting an autoland approach, to allow ATC to ensure that appropriate areas are clear of vehicles or other obstructions which may affect the localizer signals. The flight crew did not advise ATC of the autoland approach. After the airplane drifted off the centerline, the first officer disconnected the autopilot and hand-flew the airplane back to the center of the runway, thereby prolonging the flare. Airline training material noted that a prolonged flare is a risk factor for tailstrikes. The airplane did not touch down until approximately 4,000 feet from the landing threshold. Recovering from the drift off-centerline led to the first officer prolonging the flare, and landing long, at a lower speed than nominal. FDR information indicated that during the landing flare, the horizontal stabilizer moved to a position that would command full nose up trim. During the landing, the tail struck the ground, and the airplane received substantial damage. An assessment of the Boeing 757 horizontal stabilizer trim control system indicated that the rate of trim change seen during the flare could only be achieved by operating the control yoke stabilizer trim switch, or by using the stabilizer trim control levers on the center pedestal. Post-accident tests of the trim system revealed no anomalies. During a post-accident training session, the first officer was noted to handle the yoke such that he inadvertently activated the trim switch to the nose-up position. Airline training material noted that use of nose-up trim during the flare is a risk factor for tailstrikes. Analysis of the evidence indicates it is likely that during the flare, the first officer inadvertently activated full nose up trim, resulting in abnormal control forces on the yoke and a higher than normal pitch attitude, leading to the tailstrike.

NTSB Probable Cause Narrative

the first officer's inadvertent application of full nose-up trim during a prolonged flare, resulting in an excessive pitch angle during landing and subsequent tailstrike. Contributing to the accident was the flight crew's failure to correct the airplane's drift from the centerline approach course during short final approach, leading to the prolonged flare, and their improper decision to perform a practice autoland approach using a restricted procedure.

Event Information

Type of Event Accident
Event Date 9/5/2006
Event Day of the Week Tuesday
Time of Event 1701
Event Time Zone Coordinated Universal Time? Same as GMT
Event City San Juan
Event State PUERTO RICO
Event Country --
Zipcode of the event site --
Event Date Year 2006
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport LUIS MUNOZ MARIN INTL
Event Location Nearest Airport ID SJU
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 0
Degrees magnetic from airport --
Airport Elevation 10
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1256 Atlantic Daylight Time
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID TJSJ
Elevation of weather observation facility 10
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation ADT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 2600
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling --
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 31
Dew Point at event time (in degress fahrenheit) 24
Wind Direction (degrees magnetic) 50
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 13
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 17
Altimeter Setting at event time (in. Hg) 29.97
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 116
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 23212
NTSB Notification Source FAA
NTSB Notification Date Sep 5 2006 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Mar 31 2008 11:52AM
User who most recently changed record NTSB\johb
Basic weather conditions Visual Meteorological Cond
FAA District Office AAI-100

Aircraft Involved

Aircraft #1

Aircraft Registration Number N622DL
NTSB Number DCA06FA068
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Boeing
Aircraft Model B757-232
Aircraft Series Identifier --
Aircraft Serial Number 22912
Certified Max Gross Weight 233000
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 191
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Sep 1 2006 12:00AM
Airframe hours since last inspection --
Airframe Hours 65019
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Wilmington Trust
Aircraft Owner Street Address --
Aircraft Owner City Wilmington
Aircraft Owner State DE
Aircraft Owner Country USA
Aircraft Owner Zipcode 19890
Operator is an individual? No
Operator Name DELTA AIR LINES INC
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Atlanta
Operator State GA
Operator Country USA
Operator Zip code 30354
Operator Code DALA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code ATL
Departure City ATLANTA
Departure State GA
Departure Country USA
Departure Time 950
Departure Time Zone EDT
Destination Same as Local Flt crash at destination city
Destination Airport Code SJU
Destination City San Juan
Destination State PR
Destination Country USA
Specific Phase of Flight Landing
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Dec 10 2007 11:20AM
User who most recently changed record SCHD
Since inspection or accident Last Inspection
Event Location Runway Number and Location 8
Runway Length 10000
Runway Width 200
Sight Seeing flight No
Air Medical Flight No
Medical Flight --