Charlotte Douglas Intl Airport
Aircraft Accident/Incident Report

Charlotte, North Carolina
Sunday, December 13, 2009 22:46 EST

NTSB Narrative Summary Released at Completion of Accident

Both pilots indicated that they had set up the navigation systems and briefed to fly an ILS Category III instrument approach to an autoland to runway 36C. The captain stated that,"sometime below 300 feet," he disconnected the autopilot and took manual control of the airplane, noting that the airplane was slightly right of the centerline of the runway with the nose pointed to the left and the airplane was drifting toward the left. As the captain maneuvered to correct the airplane's track, the bank angle aural alert sounded three times, once as the airplane descended below about 300 feet AGL, again at an altitude of about 200 feet AGL, and the last time at about 30-32 feet AGL. During the landing, the right wing tip, right slat and a landing light were damaged. The operator's Flight Manual states, in part, that autolands may be conducted to CAT I / II / III designated runways provided that the procedure does not have a chart note or NOTAM which renders the localizer unusable inside the runways threshold. The 11-5A Jeppesen approach chart for the ILS 36C approach had a note listed on the chart face that stated: IDQG LOC 36C unusable for rollout guidance. Relevant sections of the operator's Operating Manual stated that all Category III approaches are to be flown by the autopilot and to an autoland. In interviews with the MD80 Fleet Training Manager, the MD80 Fleet captain, and an MD80 APD (Aircrew Program Designee), each stated that the operator trains its MD80 crews to autoland all Category III approaches, rather than manually flying the airplane during the final descent to the runway. According to the operator's DC-9 Operating Manual, the following conditions would require a go around from a Category III Approach: 1. Below 300 feet (RA), if satisfactory tracking performance was not maintained. 2. Failure of required airplane or ground equipment prior to DH (Cat II) or prior to touchdown (Cat III). FAA Advisory Circular (AC)120-71A "Standard Operating Procedures for Flight Deck Crewmembers" Appendix 2, states in part: An approach is stabilized when all of the following criteria are maintained from 1000 feet height above touchdown (HAT), or 500 feet HAT in VMC, to landing in the touchdown zone: 1. The airplane is on the correct track. 2. After glide path intercept, or after the FAF, or after the derived fly-off point (per Jeppesen) the pilot flying requires no more than normal bracketing corrections to maintain the correct track and desired profile (3° descent angle, nominal) to landing within the touchdown zone. A stabilized approach means the airplane must be: • At Approach Speed (VREF + additives). • On the proper flight path at the proper sink rate. • At stabilized (spooled up) thrust. These requirements must be maintained throughout the rest of the approach for it to be considered a stabilized approach. If the stabilized approach requirements cannot be satisfied by the minimum stabilized approach heights or maintained throughout the rest of the approach, a go-around was required. The FAA Advisory Circular appendix goes on to state in part that normal bracketing corrections relate to bank angle, rate of descent, and power management and recommends ranges for the various parameters, noting that operating limitations in the approved airplane flight manual must be observed, and may be more restrictive. For bank angle the AC recommends a maximum bank angle permissible during approach is specified in the approved operating manual used by the pilot, and is generally not more than 30°; the maximum bank angle permissible during landing may be considerably less than 30°, as specified in that manual. According to the operator's Flight Manual Supplement,there were six modes of the Ground Proximity Warning System (GPWS)function. Mode 6 provided optional callouts for descent through predefined radio altitudes between 2,500 and 10 feet AGL and excessive roll or bank angle warning. Bank angle warning provided over-banking protection during approach, climb out, and cruise. Additionally, the warning protected against wing or engine strikes during the landing. Further, the operator's DC-9 Operating Manual also stated in part that with the main landing gear compressed, the landing light will strike the runway at approximately eight and one-half degrees of bank, and that excessive bank angles should be avoided at low altitudes. The operator had a no-fault go-around policy. Pilots were told to execute every approach with the presumption that a missed approach was a successful outcome, and asked to plan each approach through the missed-approach procedure and make the decision to land only when all criteria are safely satisfied. According to the operator's Flight Manual, the captain "should give every consideration to a recommendation by another cockpit crewmember that a missed approach be executed." The American Airlines MD80 Fleet Captain told investigators that the first officer could also call for a go around, and did not have to explain why. During post-incident interviews, the first officer stated that during the approach, neither pilot mentioned a go around. The captain stated in his interview that he did not consider a go around.

NTSB Probable Cause Narrative

The Captain's failure to initiate a go-around from a Category III approach when satisfactory tracking performance was not maintained below the required altitude resulting in excessive bank angle maneuvers at low altitude. Factors contributing to the incident were: The Captain's decision to execute a Category III autoland approach on a runway without rollout guidance contrary to company Flight Manual guidance, the Captain's decision to deviate from the Category III approach and continue it manually contrary to the company Operating Manual, and the First Officer's failure to call for a go-around when the approach became unstable.

Event Information

Type of Event Incident
Event Date 12/13/2009
Event Day of the Week Sunday
Time of Event 2246
Event Time Zone Eastern Standard Time
Event City Charlotte
Event State NORTH CAROLINA
Event Country --
Zipcode of the event site --
Event Date Year 2009
Event Date Month 12
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 352150N
Event Location Longitude 0805635W
Event Location Airport Charlotte Douglas Intl
Event Location Nearest Airport ID CLT
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 748
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID --
Elevation of weather observation facility --
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation --
Lighting Conditions Night
Lowest Ceiling Height 300
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) 1400
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) --
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator --
Wind Gust Indicator --
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) --
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 115
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) --
NTSB Notification Source NTSB Communications Center
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 27 2011 12:07PM
User who most recently changed record schd
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N483A
NTSB Number DCA10IA015
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Minor
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name BOEING
Aircraft Model MD
Aircraft Series Identifier 82
Aircraft Serial Number --
Certified Max Gross Weight --
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 3
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft --
Number of Engines 2
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection --
Date of Last Inspection --
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name American Airlines
Aircraft Owner Street Address 4333 Amon Carter Bvd.
Aircraft Owner City Fort Worth
Aircraft Owner State TX
Aircraft Owner Country USA
Aircraft Owner Zipcode 76155
Operator is an individual? No
Operator Name American Airlines
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 4333 Amon Carter Bvd.
Operator City Fort Worth
Operator State TX
Operator Country USA
Operator Zip code 76155
Operator Code AALA
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 AALA025A
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 DFW
Departure City Fort Worth
Departure State TX
Departure Country USA
Departure Time 2035
Departure Time Zone EST
Destination Same as Local Flt crash at destination city
Destination Airport Code CLT
Destination City Charlotte
Destination State NC
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Mar 30 2011 2:03PM
User who most recently changed record benr
Since inspection or accident --
Event Location Runway Number and Location 36C
Runway Length 10000
Runway Width 300
Sight Seeing flight No
Air Medical Flight No
Medical Flight --