Theodore F. Green State Airport
Aircraft Accident/Incident Report

Providence, Rhode Island 02886
Sunday, December 16, 2007 16:48 EST

NTSB Narrative Summary Released at Completion of Accident

The flight crew was conducting a straight-in ILS approach during instrument meteorological conditions with reported cloud ceilings about 100 feet above the decision height. During the descent into the terminal area and initial approach, tailwinds of up to 100 knots were affecting the flight and the crew reported feeling rushed because of the high ground speed. The crew did establish the airplane on the approach course at the proper speed and altitude, however they did not perform a complete approach briefing. The first officer (FO) was the pilot flying, and had very little instrument approach experience in the CRJ-200. Prior to making visual contact with the runway, the FO disengaged the autopilot and flight director, but only mentioned the autopilot in his verbal callout. At the time of the accident, there was no prohibition against making a raw data approach to minimums in the Air Wisconsin (AWAC) flight manual. Subsequently, the airplane drifted left of course and above the glidepath. As the airplane deviated from the approach course the flight was outside stabilized approach criteria, and as the airplane descended beneath the ceiling, both pilots noticed the deviation and misalignment with the runway. At this point, the captain offered to take over control of the airplane and salvage the landing instead of abandoning the approach and executing a missed approach. At the time of the accident, Air Wisconsin procedures provided the crews latitude in determining when a go-around was necessary. As the captain took control of the airplane, the FO misunderstood a statement by the captain and reduced power to idle without the captain’s knowledge. The airplane developed a high sink rate and during the flare likely stalled, impacting the runway at a high vertical rate. The forces developed during the flare and touchdown exceeded the certified limit loads of the landing gear and the gear support trunnion fractured as intended. There was no evidence of any pre-existing damage to the gear components, and the fracture and gear separation occurred as designed. During his postaccident interview, the FAA aircrew program manager discussed the circumstances of some AWAC new-hire pilots who did not successfully complete initial training. Specifically, the FAA official stated that AWAC had changed the simulator time requirements for these pilots because they had completed a type rating course (provided by another training program) before starting AWAC’s training program. AWAC determined that these pilots needed fewer hours of simulator time than other new-hire pilots. However, according to the FAA official, these pilots had high initial operating experience times and “weren’t getting it, so [AWAC] let them go.” It is possible that these pilots might have performed better if they had been more thoroughly trained by the company. A captain who was also a CL-65 flight instructor stated that, because of constraints with simulator time, all pilots needed to complete their training during the time that had been scheduled. The director of flight training stated that the simulator, at full utilization, provided 600 hours of training per month, but that the company needed 1,000 hours of simulator training per month. The amount of IOE time provided to new-hire FOs had significantly increased because AWAC had not revised its simulator training to accommodate the needs of pilots with little or no jet experience. As a result, IOE had to be routinely extended beyond the FAA’s requirement. Since many simulator training scenarios cannot be accomplished in an airplane, particularly during passenger carrying flights, IOE is not an adequate substitute for simulator training exercises. Further, new-hire FOs who completed AWAC’s initial training program were subject to a 1-year probation period. However, unlike other 14 Code of Federal Regulations Part 121 operators, AWAC did not effectively conduct a program to assess the performance of probationary pilots. The accident FO’s training and checkrides did not reveal his weaknesses with automation, pacing, and crew coordination, which rendered him unprepared to properly execute the approach into Providence during the accident flight. In addition, captains did not produce trip reports after flying with first officers, and, according to the Norfolk base manager, meetings to discuss probationary FO’s progress during their first year were no longer held because the base managers were “too busy.” Thus, two potential methods to identify FOs’ weaknesses were not used by AWAC. Because the first officers hired by AWAC in the 2 years preceding this accident had decreased levels of experience, these first officers would have benefited from additional training and oversight. However, AWAC’s training program was ineffective because it did not accommodate these needs. The FAA’s Principal Operations Inspector (POI) was based in Des Planes, Illinois, but AWAC’s primary training center was in Charlotte, NC. The POI stated that providing oversight of AWAC was difficult because of the required travel. Because of the limited on-site oversight of AWAC’s training program of new first officers, the FAA did not identify the shortcomings of AWAC’s program in preparing these less experienced first officers for flying in high-performance jet airplanes.

NTSB Probable Cause Narrative

the captain’s attempt to salvage the landing from an instrument approach which exceeded stabilized approach criteria, resulting in a high sink rate, likely stall, and hard landing which exceeded the structural limitations of the airplane. Contributing to the accident was the first officer’s poor execution of the instrument approach, and the lack of effective intra-cockpit communication between the crew. Additional contributing factors to the accident are the lack of effective oversight by AWAC and the FAA to ensure adequate training and an adequate experience level of first officers for line operations.

Event Information

Type of Event Accident
Event Date 12/16/2007
Event Day of the Week Sunday
Time of Event 1648
Event Time Zone Eastern Standard Time
Event City Providence
Event State RHODE ISLAND
Event Country --
Zipcode of the event site 02886
Event Date Year 2007
Event Date Month 12
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport Theodore F. Green State
Event Location Nearest Airport ID KPVD
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 52
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 2151 Coordinated Universal Time? Same as GMT
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID PVD
Elevation of weather observation facility 52
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation UTC
Lighting Conditions Dusk
Lowest Ceiling Height 300
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 1.5
Air Temperature at event time (in degrees celsius) 3
Dew Point at event time (in degress fahrenheit) 2
Wind Direction (degrees magnetic) 50
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 3
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 28.96
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report RMK AO2 DZE2058RAB2058E39 PRESFR SLP805
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 34
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 24789
NTSB Notification Source FAA
NTSB Notification Date Dec 16 2007 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Dec 13 2008 8:22AM
User who most recently changed record engb
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N470ZW
NTSB Number DCA08FA018
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 BOMBARDIER
Aircraft Model CL600-2B19
Aircraft Series Identifier --
Aircraft Serial Number 7927
Certified Max Gross Weight 53000
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 2
Cabin Crew Seats 1
Passenger Seats 50
Total number of seats on the aircraft 53
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Dec 14 2007 12:00AM
Airframe hours since last inspection 19
Airframe Hours 8929
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name Air Wisconsin Airlines
Aircraft Owner Street Address W6390 Challenger Drive #203
Aircraft Owner City Appleton
Aircraft Owner State WI
Aircraft Owner Country USA
Aircraft Owner Zipcode 54914
Operator is an individual? No
Operator Name Air Wisconsin Airlines
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address W6390 Challenger Drive #203
Operator City Appleton
Operator State WI
Operator Country USA
Operator Zip code 54914
Operator Code A6WA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
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 KPHL
Departure City Philadelphia
Departure State PA
Departure Country USA
Departure Time 1600
Departure Time Zone EST
Destination Same as Local Flt crash at destination city
Destination Airport Code KPVD
Destination City Providence
Destination State RI
Destination Country USA
Specific Phase of Flight Landing
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Dec 1 2008 6:23AM
User who most recently changed record engb
Since inspection or accident Time of Accident
Event Location Runway Number and Location 05
Runway Length 7166
Runway Width 150
Sight Seeing flight No
Air Medical Flight No
Medical Flight --