BOMBARDIER INC DHC 8 402

Full Narrative

HISTORY OF FLIGHT

On December 29, 2017, about 1840 pacific standard time, Horizon Air flight 2184, a Bombardier DHC-8-402, N412QX, landed on a taxiway parallel to runway 6 at Pullman/Moscow Regional Airport (KPUW), Pullman, Washington. Weather at the time of landing was reported as wind from the southeast, light rain, overcast ceiling with 5 miles visibility. There were no injuries to the 42 passengers and crew onboard and the airplane was not damaged. After the airplane landed, the flight crew observed that the runway lights were inoperative. The passenger flight was operating under 14 Code of Federal Regulation (CFR) Part 121 on an instrument flight rules flight plan from Seattle/Tacoma International Airport (KSEA), Seattle, Washington, to KPUW. An instrument flight rules (IFR) flight plan had been filed. Night instrument meteorological conditions (IMC) prevailed at the time of the incident.

The incident flight occurred on the second flight of the day for the flight crew. Both pilots began their duty day at 1513 local time on December 29, 2017, in Missoula International Airport (KMSO), Missoula, Montana. The captain and first officer flew a 2 hour and 10-minute flight from KMSO to KSEA, arriving in SEA at 1630.

According to the flight release for Horizon Air flight 2184, there were no Notice to Airmen (NOTAM) for the runway lights being out of service at KPUW. Horizon Air flight 2184 departed KSEA at 1748 with 2 flight crewmembers, 2 flight attendants and 38 passengers for a planned 1 hour flight to Moscow Pullman Airport.

According to the flight crew, the takeoff, climb, cruise and descent were uneventful. Flight 2184 was then cleared by air traffic control (ATC) for the RNAV (RNP) M instrument approach to runway 06 at PUW. The captain was the pilot flying and the first officer (FO) was the pilot monitoring for the incident flight.

Conditions at the KPUW airport were wind from the southeast, light rain, overcast ceiling with 5 miles visibility, and the captain used the Head-up Guidance System (HGS) installed on the captain's side of the cockpit during the approach. During post accident interviews, the captain stated he attempted to illuminate the KPUW airport lighting via the common traffic advisory frequency (CTAF) prior to the initial approach fix and prior to exiting the clouds.

The captain stated that shortly after crossing the initial approach fix, the airplane exited the clouds and that he observed what he believed was runway 06 and runway lights, though according to his interview he questioned whether the runway lights were on bright or dim. The captain stated he attempted to turn the lights up brighter via the CTAF several times, and it was unclear if they had changed. The captain stated he clearly felt he had the runway in sight and the runway lights were on, and it was just a question of the lights not going up to bright, not to an "on" setting.

The captain stated he checked that the gear was down, and as he looked back out to see the runway and saw nothing but black out in front of the airplane, and he saw identifiable pavement that was lit up. He stated he slid the airplane over a little to line up with the illuminated pavement, but there was no abrupt maneuver. The captain stated he lined up with the pavement and did not notice the taxiway lights and stated that what he saw and aligned with looked like runway pavement.

As the airplane was approaching the ground and while in the flare, the FO stated that he was looking for visual cues and noticed the blue taxi lights. Right before touchdown the FO stated he saw that they were on the taxiway. The airplane subsequently landed uneventfully to the left of runway 06 and on the parallel taxiway at PUW at 1840.

The captain stated that there was nothing in front of the airplane on the taxiway that was of any danger and that he did not see taxiway lights, but saw the pavement and concentrated on stopping the airplane As they slowed down, they taxied on the full length of the taxiway, back-taxied on the runway, then continued to the gate. According to both pilots, they attempted to change the illumination of the taxiway and runway lights via the CTAF during their 6-minute taxi to parking and observed the blue taxiway lights change illumination, but the runway lights did not illuminate.

PERSONNEL INFORMATION

The captain was 49 years old and was based in Medford, Oregon as A Q-400 captain. According to company records and information provided by the captain, he had accumulated 13,528 hours total flight experience, including about 5,997 hours in the Q-400. A review of the FAA Accident/Incident Data System, Enforcement Information System and Program Tracking and Reporting Subsystem (PTRS) database showed no records or reports of any previous aviation incidents or accidents involving the captain.

The captain began flying a 3-day trip on December 25, 2017. The captain flew from Rogue Valley International-Medford Airport (MFR) to Reno/Tahoe International Airport (RNO) with a stop in SEA. His duty day began at 0445 and ended at 1200. On December 26, 2017, he had a 0515 show at RNO and flew 5 legs followed by a deadhead to Mahlon Sweet Field Airport (KEUG), Eugene, Oregon, for an overnight. His duty day ended at 1611. He did not recall anything of significance about the trip and did not recall what time he went to sleep, but knew he was trying to get to sleep early. On December 27, 2017, he thought he woke up about 0400-0415. His duty day began at 0455. He flew 4 legs (KEUG-KSEA-KMSO-KSEA-KMFR) with an overnight in Medford. His duty day ended at 1355. He was based in Medford, so he stayed at a hotel at his expense. He did routine activities during the day and was in bed between 2100-2300. On December 28, 2017, he woke up between 0700-0900, asked for a late checkout of 1130 and had a 1207 show time. He flew 3 legs (KMFR-KSEA-KRDM-KSEA) and was then paired with the incident FO for a flight from KSEA to KMSO. His duty day ended at 0012 MST on December 29. He thought he went to bed about 0100-0130. On December 29, 2017, he and the incident FO had a show time of 1513 MST, with an hour prior van ride. He was up "way" before then but did not recall the specific time he woke up. He did not have any problems falling asleep the previous night and felt rested. He did routine activities during the day which included walking around outside and did not take a nap. The incident crew flew KMSO to KSEA, and then flew the incident flight from KSEA to KPUW. The incident occurred about 1830.

He had no changes in his health, personal or financial status in the previous 12 months; he rated his health as an 8.5-9 out of 10. He did not take any prescription or non-prescription medication in the 72 hours prior to the event that might have affected his performance. He had never been diagnosed with a sleep disorder.

The FO was 38 years old and was based in Medford, Oregon, as a Q-400 FO. The FO's date of hire with Horizon Air was July 10, 2017, and according to company records, he had accumulated 1,582 hours total flying time, including 95.5 total hours in the Q-400. A review of the FAA Accident/Incident Data System, Enforcement Information System and PTRS database showed no records or reports of any previous aviation incidents or accidents involving the FO.

The FO did not recall when he woke up on Tuesday, December 26, 2017. He thought he had commuted to work that day since he was scheduled to be on reserve for the 27th but did not recall specifics. He stayed at a hotel in Portland, Oregon, that night and thought he went to bed about 2200. On Wednesday, December 27, 2017, the FO thought he woke up about 0430 but possibly a little bit later because he thought he was on hotel reserve. He was on home reserve from 1030 until 1230 and airport reserve from 1230 until 2030. He did not get called to fly that day. He did not recall much of his activities but recalled he exercised. He did not take a nap. He thought he went to bed by 2100. On Thursday, December 28, 2017, the FO thought he woke up about 0430 and was on airport reserve from 1030 until 1429. He sat in the crew room at the airport, walked laps around the airport, and did some people-watching. He did not get called to fly that day. He then deadheaded to KSEA and flew from KSEA to KMSO with the incident captain. He went straight to the hotel and to bed about an hour after getting into the hotel. His duty day ended at 0012 MST on December 29. He was not sure the exact time he went to bed. On Friday, December 29, 2017, the FO slept in and woke about 0900 or 1000. His activities that day included going to the gym, watching TV and preparing for the day's flights since he was still new to the company. He and the incident captain utilized the hotel van services for transportation, and those schedules were pre-arranged by the company. His duty day began at 1513 MST and the incident occurred about 1830. He indicated felt fine that day. He had no problems falling asleep at night, and he had never been diagnosed with a sleep disorder. He characterized his health as "pretty healthy," and he exercised "a lot". He had no major changes to his health, financial situation or personal life in the 12 months prior to the incident. He did not take any prescription or non-prescription medications in the 72 hours prior to the incident that could have affected his performance.

The captain and FO had previously flown together on two flight legs preceding the incident flight. Both pilots were drug tested the day following the incident with negative results. According to Horizon Air, the pilots were not able to get on-site drug testing within a 1-hour window following the incident. Attempts to get a qualified tester to Pullman were made immediately after incident notification to duty officer, without success. The pilots were flown to KPDX the next day, all other testing requirements met the timeline. No alcohol testing was conducted.

AIRCRAFT INFORMATION





Photo 1: Photo of incident airplane N412QX.





The incident airplane was a Bombardier DHC-8-402, registration number N412QX, serial number 4059. It was a fixed wing multiengine aircraft with two Pratt and Whitney PW150A turbo-prop engines. The airplane was manufactured in 2002, and was registered to BCC Equipment Leasing Corporation in Seattle, Washington.

Per OpSpecs A001, Horizon Air was authorized to conduct operations under the provisions of 14 CFR 119.21(a)(1)-(3) for domestic, flag and supplemental operations. The incident airplane was listed on OpSpecs D085, issued to Horizon Air Certificate number QXEA002A, and authorized to conduct operations under 14 CFR Part 121.

There were no deferred maintenance items related to the avionics, navigation or head-up display on the incident flight.

METEOROLOGICAL INFORMATION

The incident occurred about 0240 UTC. Meteorology Aerodrome Reports (METARs) for KPUW valid at the time of the incident were as follows.

SPEC KPUW 300217Z AUTO 14009KT 5SM RA BR FEW018 BKN025 OVC032 03/02 A2988 RMK AO2 P0004 T00330017=

METAR KPUW 300253Z AUTO 15010KT 5SM -RA BR FEW024 BKN030 OVC035 04/02 A2986 RMK AO2 SLP128 60027 T00440022 58019=


The Terminal Aerodrome Forecast (TAF) for KPUW in effect at time of departure was calling for IFR at time of landing, and recorded as follows:

TAF KPUW 292322Z 3000/3024 07003KT 3SM RA BR BKN006 OVC012 FM300900 24020G30KT P6SM BKN010

FM301800 25016G25KT P6SM BKN030 BKN150



AIRPORT INFORMATION

Pullman/Moscow Regional Airport (KPUW) was located three miles northeast of the central business district of Pullman, Washington, at an elevation of 2,554.9 feet and a latitude/longitude of 46-44-37.9000N / 117-06-34.5000W. The airport had two runways (06/24) and was not served by an ATC control tower (uncontrolled).

Runway 06 had a length of 6,730 feet and was 100 feet wide with a 0.4% gradient. The taxiway at KPUW was approximately 57 feet wide. The wingspan of the Q400 is 93 feet 3 inches and the main wheelbase is 28 feet 10 inches. The distance between the runway centerline, and the taxiway centerline is 200 feet. Based on this distance, KPUW has an operational note stating, "Aircraft must delay taxiing and remain behind the intermediate holding position line when large aircraft operations are in progress."

According to the Executive Director of the Pullman-Moscow Regional Airport, after the incident KPUW operations personnel found flooded electrical wiring vaults associated with the runway lighting system from heavy rains and snow that had occurred on the previous day. NOTAMs were published 43 minutes after the incident reporting the lighting out of service. The lighting system was previously tested at about 1600 local time the day of the incident, and all lights were found to be operational.







Figure 1: PUW Jeppesen 10-9 Airport Chart.



INSTRUMENT APPROACH PROCEDURE

The instrument approach used by the incident crew was the PUW RNAV (RNP) M approach to runway 06. According to the captain, he was not sure if he had flown that actual approach before, but pretty sure he had flown that at least once before. When asked how often he had landed at KPUW, he said it "comes and goes," but maybe about 5 or 6 times each year depending on his monthly schedule. He did not remember the last time he had landed at KPUW.

The approach chart was published by Jeppesen specifically for Horizon Air and Alaska Airlines utilizing proprietary required navigation performance (RNP) data from Alaska Airlines. The PUW RNAV (RNP) M approach to runway 06 was a Special Instrument Approach authorized to be flown by Horizon Air using DHC- 8-402 aircraft per Horizon Air OpSpecs C081. The UNS-1Ew Flight Management System (FMS) onboard the DHC-8-402 was approved for RNAV (RNP) approaches to an RNP level of:



• With Flight Director, 0.30 nm for approach,
• With Autopilot, 0.10 nm for approach, and
• Less than 1.0 for missed approach.
The minimums for the PUW RNAV (RNP) M approach to runway 06 utilizing an RNP value of was 2,858 feet, or 320 feet above the threshold of the runway, and the chart indicated that the RNAV glidepath would continue to bring the airplane to a threshold crossing height (TCH) of 57 feet above the threshold.

OFXEF was the initial approach fix (IAF) with a minimum crossing altitude of 5,400 feet msl (mean sea level), and located 11.8 miles from the end of the runway. FITEL was the final approach fix (FAF) with a minimum crossing altitude of 4,100 feet msl and located 4.7 miles from the end of the runway. The chart indicated that the runway had REIL lighting and a precision approach path indicator (PAPI) on the left side of runway 06, and pilot-controlled lighting, activated on the KPUW Unicom frequency.

The Horizon Air Q-400 Flight Standards Manual, page 3.1.11 stated the following in part:

Approaches

Approaches with Vertical Guidance



• Except as provided below, only approaches with vertical guidance shall be used inside the FAF. Vertical guidance is provided by any ILS and by FMS VNAV on all approaches with a runway designated in the approach title (e.g., RNAV (GPS) Rwy 14, VOR 14).
• Approach selection should satisfy the minimums required for weather conditions, provide an optimal descent profile, and reduce track miles. Because of their efficiency, predictability, and stability, RNAV approaches are the preferred approaches. With these considerations, if practical, the following approach priority should be followed:
1. RNAV (RNP) (RNP approaches provide the most stable approaches and are often the most efficient).

2. RNAV (GPS).

3. ILS.

4. If an RNAV or ILS approach is not available to the intended runway, a LOC or VOR based approach may be flown via the FMS.


HIGH INTENSITY RUNWAY LIGHTS (HIRL)

Runway 06 at KPUW was equipped with runway edge lights used to outline the edges of the runways during periods of darkness or reduced visibilities. The KPUW runway light system was an HIRL system, with colored white edge lights. The lights marking the ends of the runway emitted red light toward the runway to indicate the end of the runway to a departing aircraft and emit green light outward from the runway end to indicate the threshold to landing aircraft.

Radio control of lighting was available at KPUW to provide airborne control of lights by keying the microphone. According to the captain, he keyed the radio in an attempt to illuminate the runway lights when just outside of OFXEF, and he believed he clicked on the CTAF to illuminate the field, even though they were still flying in the clouds. He stated that he was doing that to have the lights available when they broke out of the clouds. Shortly after crossing OFXEF, he had the runway in sight, and called the "runway in sight and landing." He said it was clear as day at that time, though it was nighttime. They proceeded inbound, and he questioned whether the lights were on bright or dim. He keyed the radio to "turn the brights" up more, but was unclear if they had changed intensity.

With FAA-approved systems, various combinations of approach lights, runway lights, taxiway lights, VASI [visual approach slope indicator] and/or REIL may be activated by radio control. Runways without approach lighting may provide radio-controlled intensity adjustments of the runway edge lights, and the taxiway lights may be controlled with the runway edge lights or controlled independently of the runway edge lights.

According to the Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25A), page 13-8, HIRLs had variable intensity settings. At selected nontowered airports, the pilot may be able to control lighting by selecting a specified frequency and clicking the radio microphone.





Figure 2: Runways without Approach Lights chart. Source: AIM page 2-1-13.

Taxiway edge lights, like those installed at KPUW, were used to outline the edges of taxiways during periods of darkness or restricted visibility conditions. Taxiway lights emitted blue lights, and the captain stated that all the taxiway lights appeared to be working after he landed on the taxiway.

The captain also stated that he did not believe the runway lights were as bright as they should have been. When he said he saw the runway surface, he thought he also saw lights on the side of the runway. When he looked down, then up, during the approach, he did not see any lights. He did not know if they were failed then or prior. He called the runway in sight to the FO, and thought he saw the actual runway, but landed on the taxiway. According to the FO, the captain tried to illuminate the runway lights with the microphone after landing, which increased the intensity of the taxiway lights, but no other lights increased. He did not know if the runway lights had shorted out or not.

Title 14 CFR 121.590(d) stated the following in part:

(d) An air carrier, a commercial operator, and a pilot being used by the air carrier or the commercial operator - when conducting a passenger-carrying airplane operation under this part that is not a domestic type operation, a flag type operation, or a supplemental type operation - may operate at a land airport not certificated under part 139 of this chapter only when the following conditions are met:



The airport is adequate for the proposed operation, considering such items as size, surface, obstructions, and lighting.


(1) For an airplane carrying passengers at night, the pilot may not take off from, or land at, an airport unless -


(i) The pilot has determined the wind direction from an illuminated wind direction indicator or local ground communications or, in the case of takeoff, that pilot's personal observations; and


(ii) The limits of the area to be used for landing or takeoff are clearly shown by boundary or runway marker lights. If the area to be used for takeoff or landing is marked by flare pots or lanterns, their use must be authorized by the Administrator.


The Horizon Air Flight Operations Manual, page 2.3.16, stated the following in part:

Pilot Controlled Lighting

Radio control of lighting is available at selected airports. Airborne control of lights is accomplished by keying the aircraft's microphone with the radio tuned to the designated frequency (usually the CTAF).


Suggested use is to always key the mike seven times (within five seconds); this assures that all controlled lights are turned on to the maximum available intensity. Adjustment can then be made, where the capability is provided, to a lower intensity (or REIL turned off) by keying five and/or three times. Fifteen minutes of lighting is available from the last keying event.


Unlighted Fields

Flights are not authorized to land or takeoff at night when all runway lights are inoperative or where there are no lights installed.

If a portion of the runway lights are inoperative for night operations but the remaining lights or runway marking provide adequate visual reference to continuously identify the runway surface and maintain directional control throughout the takeoff or landing run, operations on that runway may proceed.


NOTE: Use of flare pots or lanterns in lieu of runway lights is not authorized.


The Horizon Air OpSpecs C060-3(g) stated the following in part:

g. Missed Approach Requirements. A missed approach shall be initiated when any of the following conditions exist:


(1) If the pilot determines that touchdown cannot be safely accomplished with the TDZ.


(2) When any of the required runway lighting elements becomes inoperative prior to arriving at the DH [decision height] or AH [alert height], or prior to touchdown for aircraft without a rollout system.


As previously stated, there were no NOTAMs indicating the runway lights were inoperative at the time the incident flight landed. After the incident, the following NOTAMs were issued at PUW:

PUW 12/220 PUW RWY 06/24 REDL OUT OF SERVICE 1712300323-1712310321 CREATED: 30 Dec 2017 03:23:00 SOURCE: PUW

PUW 12/227 PUW RWY 06 RWY END ID LGT OUT OF SERVICE 1712300518-1801010518 CREATED: 30 Dec 2017 05:19:00 SOURCE: PUW



RUNWAY END IDENTIFIER LIGHTS (REIL)

Runway End Identifier Lights (REIL) were installed on runway 06 at KPUW to provide rapid and positive identification of the approach end the runway. The system consisted of a pair of synchronized flashing lights located laterally on each side of the runway threshold. REILs may be either omnidirectional or unidirectional facing the approach area. According to the AIM, REILs were effective for: identification of a runway surrounded by a preponderance of lighting, identification of a runway which lacks contract with surrounding terrain, and identification of a runway during reduced visibility.



PRECISION APPROACH PATH INDICATOR (PAPI)

Runway 06 at KPUW was equipped with a PAPI, located to the left of the approach end of the runway. According to his interview, the captain stated that during the visual portion of the approach, he noticed the PAPI "pretty far out, and it was directly in front of them," and he was aware that the PAPI should have been on the left of the runway but did not think about that aspect when he briefed the approach as PF. He further stated he thought he was on the PAPI, but could not remember the last time he observed the PAPI prior to the landing.

According to the AIM, page 2-1-4, a PAPI used lights similar to the VASI but were installed in a single row of either two or four lights. These lights were visible from about 5 miles during the day and up to 20 miles at night. The visual glide path of the PAPI typically provided safe obstruction clearance within plus or minus 10 degrees of the extended centerline and to 4 statute miles from the runway threshold. Descent, using the PAPI, should not be initiated until the aircraft is visually aligned with the runway. Lateral guidance is provided by the runway or runway lights.





Figure 3: Precision Approach Path Indicator (PAPI). Source: AIM, Figure 2-1-5.



The Horizon Air Flight Operations Manual, page 10.1.6, stated in part that for visual approaches:

When an electronic glideslope or FMS VPATH is available to the runway of intended landing, pilots shall tune, identify, and monitor the appropriate navigational aid. Pilots should fly the higher of: ILS glideslope, VPATH, VASI, PAPI or PLASI when available, using normal procedures and rates of descent, until a lower altitude is necessary for a landing within the touchdown zone.



COMPANY INFORMATION

Horizon Air was founded in September 1981 and was headquartered in Portland, Oregon, and Seattle, Washington. Alaska Airlines' holding company, Alaska Air Group, purchased Horizon Air in 1986. The company had 52 DHC-8-402 aircraft and 10 ERJ-170-200LR aircraft. Their crew bases were in Anchorage, Alaska; Boise, Idaho; Medford and Portland, Oregon; Seattle and Spokane, Washington. The airline had 3,970 employees and 747 flight crewmembers. Horizon pilots were represented by the International Brotherhood of Teamsters.

According to the Director of Regulatory Compliance, Horizon Air had completed all levels of implementing Safety Management System (SMS). Horizon Air also utilized a Flight Operational Quality Assurance (FOQA) program, an Aviation Safety Action Program (ASAP) for flight operations, maintenance, inflight and dispatch, and a Line Operations Safety Audit (LOSA) audit program. Horizon Air also had a Fatigue Risk Management Program (FRMP) defined in OpSpecs A317, and an FAA-approved fatigue education and awareness training (FEAT) program defined in OpSpecs A319. The airline had been IOSA certified since 2008.



RELEVANT COMPANY PROCEDURES

Approach Briefing

The approach briefing for the Horizon Air Q-400 occurred as part of the Descent Checklist. Approach briefing guidance was provided in the Horizon Air Flight Operations Manual, Descent/Approach/Landing, page 10.1.7, and stated the following in part:

Approach Briefing – General

When possible, the approach briefing shall be accomplished before beginning the descent from cruise altitude. The briefing shall be conducted in a thorough, unhurried manner. Both pilots shall have the appropriate chart displayed while the pilot who will be flying the approach briefs. (Whenever a Captain Monitored Approach will be flown, the First Officer shall conduct the approach briefing.) If the autopilot is not engaged, control of the aircraft shall be transferred to the other pilot. Transfer is not necessary if a visual approach briefing is conducted.

All flightdeck distractions shall be removed or managed properly prior to the approach briefing. Do not begin an approach briefing if flightdeck distractions are diverting the attention of either pilot.


NOTE: At pilot's discretion, crew should also brief familiarity items, including AIC, hot spots, taxi/parking expectation, and restrictions.

Approach Briefing Items

The following items shall be briefed:

1. Approach plate number and approach name, (e.g., 11-1; ILS 16).

2. FMS – Verify approach name:



• Q400 – Flight Plan CLEARANCE page on both FMSs.
• E175 – ACT RTE page on PF FMS.
3. Briefing Strip – approach frequency (except RNAV approaches); final approach course; glideslope intercept altitude or FAF altitude.

4. Visibility Requirements and Minimums: DA, RA, or MDA, as appropriate.



• Brief 100' above TDZE MSL altitude (if Captain Monitored or where "continue" call is possible.
5. Missed approach procedures (MAP):



• At a minimum, brief the initial MAP items in the briefing block. The full MAP may be briefed at Captains' discretion.
• LNAV is the assumed nav source for the missed approach.
- I LNAV is not used, brief nav source to be used and brief full MAP.

6. Operator Notes.

7. Any other items considered pertinent to the safe conduct of the approach and landing.



• FMS – If any approach procedure altitudes have been modified, verify FMS waypoints and altitudes to ensure compliance with published procedure.
Visual Approach Briefing Items

Whenever planning a visual approach, the following shall be briefed:


1. Approach plate number and approach name of planned visual approach.

2. Approaches used for vertical guidance backup.

3. FMS – Verify backup approach name:



• Q400 – flight Plan CLEARANCE page on both FMSs.
• E175 = ACT RTE page on PF FMS.
4. Pattern altitude, entry, and any other items considered pertinent to the safe conduct of the visual approach and landing.

NOTE: Missed approach does not need briefed for a visual approach.



Calling Airport in Sight

Horizon Air Flight Operations Manual, Descent/Approach/Landing, page 10.1.8, stated the following in part:

It is the Captain's decision on when to report the airport in sight for a visual approach clearance. Both pilots shall have the airport in sight. When accepting a visual approach, ensure that the flight can adhere to the requirement specified in the Visual Approaches, this section.


Runway Alignment Verification

Runway alignment verification guidance on landing was provided in the Horizon Air Flight Operations Manual, page 2.3.18, and stated in part:

Prior to landing:



• The PF shall restate the landing clearance and runway after the PM acknowledges clearance from ATC.
• Both pilots observe the runway environment and verify (silently):

The runway is correct by reference to runway markings, navigational aids, HIS headings, etc.

The runway is clear of traffic.

Either pilot shall immediately state any discrepancy in ATC clearance, intended runway, or traffic threat.


NOTE: IMC conditions and reduced visibilities will hamper the ability to verify runway selection and that it is clear of traffic. As the runway comes into view on an instrument approach, both pilots shall verify, to the extent possible, it is clear of traffic conflicts.


The Horizon Air OpSpecs C300-3(9) stated in part:

Flightcrews are expected to maintain procedure centerline (CL), as depicted by onboard lateral deviation indicators, displays, and/or flight guidance, during all operations described in this operations specifications unless otherwise authorized to deviate by ATC in the instance of an emergency condition.



Go-Around Policy

Horizon Air had a No-Fault Go-around policy, defined in the Q-400 Flight Standards Manual, page 3.17.6, which stated the following:

No Fault Go-around Policy

The importance of a stabilized approach and a safe touchdown in the touchdown zone for short field landings cannot be over-emphasized. If at any time during the approach and landing it becomes apparent that the flight path is too high, approach speed is excessive, or the aircraft will not touchdown by the 1,000'-point, the Captain SHALL initiate a missed approach. Either pilot may call "Missed approach."

It is also important that pilots should not be concerned about having their judgement questioned regarding their decision to go around. As such, the FOM no fault go-around policy applies particularly for short field landings. This policy applies to all types of approaches in any weather conditions. Pilots are encouraged to go around anytime the landing conditions are uncertain. Pilots will not be reprimanded or questioned for this action.


The Horizon Air Flight Operations Manual, page 10.3.1, stated the following in part:

Missed Approach Policy

If either the PF or PM believes an unsafe condition exists for landing, either pilot shall call "Missed approach," and the missed approach shall be executed. In all circumstances, the good judgement of the PF and PM is sufficient base for initiating a go-around/missed- approach. Horizon Air maintains a "no fault go-around" policy.


The Horizon Air Q-400 Flight Standards Manual, page 3.16.1, stated the following in part:

Missed Approach Requirements

A missed approach shall be accomplished for the following reasons:



• If the approach is not stabilized (see Descent and Approach in FOM, section 10, Descent/Approach/Landing) or if at any time during the approach or flare, the airplane becomes unstable, or a high rate of descent develops.
• If either the PF or PM believes an unsafe condition exists for landing (see Missed Approach in FOM, section 10, Descent/Approach/Landing) or if a successful landing in the touchdown zone becomes uncertain.
• Instrument Approach:
Unless the visual references required to continue to the intended runway have been acquired and the aircraft is in a position to allow a safe continuation to a normal landing, a missed approach shall be initiated:

If any approach requirements are not met or exceeded (as appropriate to the approach flown) On all instrument approaches, regardless of minimums, if a required approach equipment failure occurs at or below 500' AFE, or when the instrument crosscheck shows significant disagreement. Upon reaching minimums
Stabilized Approach

Horizon Air stabilized approach criteria was defined in the Horizon Air Flight Operations Manual, page 10.1.1, and stated the following:

Q400 Stabilized Approach

A Q400 stabilized approach consists of:



• The airplane in approach configuration for the applicable approach profile IAW the FSM.
NOTE: Momentarily exceeding these limits does not require a go-around as long as prompt, positive correction is taken to return to a stabilized condition
• Instrument approach with vertical guidance (ILS or FMS VNAV):

Course deviation of one dot or less Glidepath up to one dot above or ½ below.
• Visual approach:
If electronic course or glidepath information is available, no more than one dot deviation from course or glidepath.
• 1,000 feet AFE:

Configured for landing as defined in the FSM Rate of descent as necessary to maintain published glidepath or, if none available, not in excess of 1,000 fpm [feet per minute].
• Below 500' AFE

Bank angle 15° or less The aircraft on profile speed within -5/+10 knots of target speed.
• Deviations form stabilized approach:

PM shall call out any exceedance to these limits. PF shall respond "Correcting" and shall correct the condition as necessary, in a timely manner, to establish or regain a stabilized approach. If the approach is not stabilized or if a successful landing in the touchdown zone becomes uncertain, either pilot shall call "Missed approach" and the missed approach shall be executed. For example, "Airspeed – missed approach" or "Sink rate – missed approach." See Missed Approach later this section for more information.
WARNING: Do not attempt to land from an unstabilized approach.



Radio Remote

According to the Horizon Air Services Manual, company specific air/ground communications (radio remote) were used at certain Horizon Air facilities specifically identified by the FAA. These stations generally lacked a control tower or flight service station for all or parts of the day. PUW was listed in the Horizon Air Flight Operations Manual as requiring a radio remote observer, and pilots arriving or departing PUW were required to monitor a separate radio remote frequency for advisories from the radio remote for observed aircraft on the ground at the airport.

The Horizon Air Flight Operations Manual, page 4.1.18, stated the following in part:

Radio Remote

Air/Ground communication (radio remote) is required for certain Horizon Air stations identified by the FAA. The list of cities requiring radio remote communication is listed in Authorizations, section 2, Policy.


NOTE: Station personnel are not trained to serve in an ATC role and therefore do not provide air traffic separation advisories. This type of request is out of the scope of their duties. Crew can expect station personnel to provide ground and runway traffic advisories only.


Arriving using radio remote communications:



• Station personnel will monitor ground traffic of airport area and be available for radio contact ten minutes prior to estimated time of arrival.
• Flight crew will contact station requesting ground traffic advisories when switching over to CTAF.
• Station personnel will continue observation and radio contact with flight crew until aircraft has landed and is clear of all active runways.


According to the Horizon Air Services Manual, page 6.26, the following procedures were required to be followed by the radio remote observer:



• Initiate traffic monitoring of airport area and be available for radio contact ten minutes before actual flight arrival.
• Viewpoint for observations should be the nearest elevated area available that will give the observe a clear, unobstructed view of the total runway and complete 360° view of the traffic pattern (roof, deicing tower, etc.)
• Observer will continue observation and radio contact with the incoming flight crew until the aircraft has landed an is clear of all active runways.
According to the radio remote observer at KPUW on the day of the incident, at 1825 the captain called the radio remote observer to advise they were 71 miles west of the airport and would be landing at 1840. About 1833, the flight called back for advisories, and the radio remote observer replied that there was no visible ground traffic at the airport. The radio remote observer noticed that about 1834, the only lights on the airport surface illuminated were the blue taxiway lights (the radio observer's only responsibility was to relay known ground and runway traffic information to the pilot).

NTSB SAFETY LETTER

Following the January 12, 2014, incident involving Southwest Airlines flight 4013, a Boeing 737-7H4 landing at the wrong airport, and the November 21, 2013, incident involving a Boeing 747-400 LCG (Dreamlifter) which also landed at the wrong airport, the NTSB published Safety Alert "Landing at the Wrong Airport" which provided suggestions for pilots to mitigate the risks of landing at the wrong airport.

On February 7, 2018, the NTSB sent a letter to the Horizon Air Director, Regulatory Compliance & Fleet Technology, along with the Safety Alert, with suggestions to increase pilot awareness with not only the airport of intended landing, but also with the runway aids available to the pilot, and applicability to verifying the correct airport and runway for landing.

On March 22, 2018, Horizon Air responded to the NTSB letter, and stated that a joint Horizon Air and Alaska Airlines review team that included representatives from both airline's Flight Operations Compliance, Flight Standards and AAG (Alaska Air Group) Safety groups met and "unanimously agreed to proceed with the development of a new philosophy towards approach briefing." The letter indicted that both airlines would develop a policy to "incorporate approach and runway lighting as one of the relevant briefing items and emphasized in flight training.