Embraer EMB145

Full Narrative

HISTORY OF FLIGHTOn March 4, 2019, about 1129 eastern standard time, CommutAir flight 4933, an Embraer EMB145XR, N14171, was attempting to land on runway 1 at Presque Isle International Airport  (PQI), Presque Isle, Maine, and impacted terrain to the right of the runway. The first officer and 2 of the 28 passengers sustained minor injuries, and the captain, the flight attendant, and 26 passengers were not injured. The airplane was substantially damaged. The scheduled passenger flight was operating under the provisions of Title 14 Code of Federal Regulations Part 121. Instrument meteorological conditions prevailed at the time of the accident.

The first officer’s most recent flight to PQI before the accident was on February 27, 2019. As part of the predeparture briefing for the accident flight, the first officer mentioned that, during the previous flight, the instrument landing system (ILS) localizer for runway 1 was offset when the airplane was aligned with the runway during a visual approach. (A localizer uses a radio beam to provide pilots of landing aircraft with lateral navigation information to align with the runway and is one of the two main components of an ILS; the glideslope is the other main component.) During a postaccident interview, the first officer, who was the pilot monitoring for that flight, stated that both he and the captain of that flight noticed an “incongruency” between the pink needle (which provides guidance from the airplane’s flight management system) and the green needle (which provides guidance from the ILS localizer signal).

The accident flight departed from Newark Liberty International Airport (EWR), Newark, New Jersey, about 1004. The captain was the pilot monitoring, and the first officer was the pilot flying. The en route portion of the flight was uneventful. According to CommutAir, once the airplane was in range of PQI, the flight crew received an updated airport weather report at the time—a special weather observation at 1031. The observation indicated that the wind was from 090° at 5 knots, visibility was 1/2 mile in moderate snow and freezing fog, and the cloud ceiling was broken at 1,100 ft and overcast at 1,800 ft.

According to the cockpit voice recorder (CVR), at 1101:42, a controller from the Boston Air Route Traffic Control Center (ARTCC) cleared the flight for an ILS approach to runway 1, and the captain acknowledged the instruction. At 1105:35, the controller terminated radar services and instructed the flight crew to change to the PQI common traffic advisory frequency (CTAF); PQI did not have an air traffic control tower. The captain acknowledged this instruction and then announced, over the CTAF, that the flight was 2 miles from FEROG (an approach waypoint) and inbound for the ILS approach to runway 1.

A PQI maintenance staff member (later identified as the maintenance foreman) contacted the flight crew at 1105:59, and the captain responded that the flight was 4 minutes away from the airport. At 1106:14, the first officer stated to the captain, “he said…he was out of the way now, so he’s clear,” indicating that the runway was clear of snow removal vehicles. Flight data recorder (FDR) data indicated that, at 1106:58, the airplane began its first approach to PQI. At 1107:50, the captain announced over the CTAF that the airplane was nearing the final approach fix for the approach.

The ILS approach to runway 1 at PQI had a decision altitude of 678 ft, which was 200 ft above ground level (agl), and a visibility requirement of 1/2 mile. The captain made the 1,000-ft callout (indicating that the airplane was 1,000 ft above the decision altitude) at 1108:38 and stated that the approach was stable and that she had “ground contact.” At 1109:03, the captain asked the first officer if he wanted the airport lights to be turned on. (The runway 1 edge lights, runway end identifier lights, and the approach lighting system were pilot controlled on a published frequency.) The first officer’s reply of “yeah. Turn them on” was preceded and followed by a sound similar to five microphone clicks.

The captain made the 500-, 400-, and 300-ft callouts between 1109:20 and 1109:33. The first officer then stated, “autopilot’s coming off,” which the captain acknowledged. At 1109:40, the captain made the 200-ft callout, which was followed by the “approaching minimums” and “minimums” aural annunciations from the enhanced ground proximity warning system. The CommutAir EMB 145 Aircraft Operations Manual stated that pilots should call for a go-around if the runway environment was not in sight by the decision altitude or if the successful completion of the approach was in doubt.

At 1109:54, the captain stated, “runway in sight. See it?” to which the first officer responded, “yeah” and “well I got somethin’ [that] looks like a runway up there.” The CVR recorded the aural annunciation “one hundred [ft]” at 1109:59. About 3.5 seconds later, the captain stated, “watch your speed,” which was followed by sounds similar to the stickshaker. At 1110:09, the captain stated, “go missed” twice; less than 1 second later, the first officer stated, “yeah we’re goin’ missed.” During a postaccident interview, the captain stated that she saw the approach lights but that she also saw a tower that looked “very close” to the airplane’s position. The first officer stated that, when he transitioned from looking at the instruments to looking outside, he expected to see the runway but saw what he described as “white on white.” The first officer also stated that he saw a structure with an antenna that was part of the runway environment but not the runway itself, so he executed the go-around. The maintenance foreman stated, during a postaccident interview, that the runway lights were not on after the first approach.

FDR data showed that the airplane had descended to a minimum pressure altitude of 703 ft (169 ft agl) before beginning to ascend. At 1110:33 and 1110:56, the captain stated over the CTAF that the flight was “going missed.” At 1111:05, the captain notified the Boston ARTCC that the flight “went missed…[and] we’re gonna give it another try.” The controller acknowledged the information and then instructed the flight crew to climb to and maintain 3,200 ft. At 1113:28, the captain contacted PQI maintenance and stated that the flight “went missed” and that she would call back again “for another try.”

Between 1113:50 and 1114:08, the captain and the first officer discussed the previous approach. The captain asked the first officer whether he lost the localizer, and he stated, “I don’t think so…I went outside the airplane, too early, and I didn't have the runway.” The first officer continued, “I thought I had the runway then I was like that is not the runway,” to which the captain responded, “yeah I thought that too.” At 1114:13, the first officer stated that, for the second approach, he would “stay inside on the localizer,” and the captain agreed. At 1115:20, the controller provided vectors for the ILS approach to runway 1, which the captain acknowledged.

At 1116:20, the captain contacted PQI maintenance about the second approach to the runway, and the maintenance foreman stated, “we’ll be all clear runway one.” The captain stated, “can you make sure those lights are on for us?” The maintenance foreman replied, “yes we will.” During a postaccident interview, the maintenance foreman reported that he turned on the lights to the high-intensity setting. At 1116:46, the first officer asked the captain, “did you ever see the lights at all last time?” The captain stated that she saw the lights but that “it’s really white down there that’s the problem.” The first officer agreed and stated, “everything is washed out.” The captain also stated, “if we don’t see it we’ll just go to, Vermont.” (The captain was referring to Burlington International Airport, South Burlington, Vermont, which was the alternate airport for the flight.) The first officer replied, “you got it.”

Between 1118:36 and 1118:42, the first officer stated, “so this time I’ll stay on the flight director until things start screaming minimums…then I’ll look up…if there’s nothing there then we’ll go, if there is something there we’ll land.” The captain commented, “yup, sounds good.” The first officer also stated that he would specifically look for the lights that surround the runway and that, during the previous approach, “all I saw was the antennas at the end of the runway.”

Between 1119:00 and 1120:41, the captain and the first officer began discussing the previous approach and the second approach. The captain repeated, “it’s really white down there,” and instructed the first officer to “stay inside and I’ll let you know when you can look up.” The captain also instructed the first officer on the actions to take if she commanded “go missed” again.

The captain contacted PQI maintenance at 1121:46 and stated that the airplane was about 16 miles and 7 minutes away from the airport. The maintenance foreman replied, “we’ll be clear runway one and the lights are on bright.” The maintenance foreman stated he had again activated the lights to high intensity.

At 1123:41, the controller told the flight crew that the airplane was about 8 miles south of the locator outer marker for the ILS runway 1 approach and cleared the flight for the approach. The controller also instructed the flight crew to report when the airplane was established on the localizer. The captain acknowledged this information. At 1125:03, the captain told the first officer, “localizer’s comin’ in alive,” and the first officer responded, “localizer is alive so is the glideslope.” The captain then informed the controller that the airplane was established on the localizer. The controller instructed the flight crew to change to the CTAF, and the captain acknowledged this instruction and notified local traffic that the airplane was inbound for runway 1.

FDR data showed that, at 1126:51, the airplane started its final descent to PQI. At 1126:51, the captain announced over the CTAF that the airplane was 4 miles from runway 1. The captain made the 1,000-ft callout at 1127:21 and stated that the approach was stable. After the captain made the 500-ft callout at 1127:57, the first officer stated, “five hundred cleared to land. I’m inside you’re outside.” The captain made the 400-ft callout shortly afterward and instructed the first officer to keep the autopilot on until 200 ft agl. The first officer stated, “I will,” which was followed by the captain’s 300-ft callout. At 1128:22, the captain stated, “there’s two hundred, get the autopilot off,” and the first officer stated “off” about 6 seconds later. At 1128:30 and 1128:37, the enhanced ground proximity warning system announced “approaching minimums” and “minimums,” respectively; in between those annunciations, the captain made the 100ft callout.

According to the CVR, about 2 seconds after the “minimums” annunciation, the captain called, “runway in sight twelve o’clock.” During a postaccident interview, the captain stated that the localizer and glideslope needles were centered when she called the runway in sight; also, the CVR did not record any discussion between the flight crewmembers about a localizer or glideslope deviation. Federal Aviation Administration (FAA) automatic dependent surveillance-broadcast data showed that the airplane was aligned to the right of the runway 1 centerline during both approaches (with the last data point for the second approach recorded when the airplane was about 23 ft agl), and FDR data showed that the localizer and glideslope needles were mostly centered with only small deviations consistent with normal piloting.

At 1128:42, the first officer stated, “I’m staying on the flight director ‘cause I don’t see it yet,” which was followed by the captain stating “stay in” several times within a 5-second period. At 1128:53, the captain stated, “what the [expletive],” and the first officer stated, “I don’t know what I’m seein’.” FDR data showed that, at 1128:56, the air-to-ground switch parameter changed from air to ground; about 1 second later, the vertical acceleration parameter reached its maximum value of 3.35 Gs. At 1129:14, the airplane’s groundspeed was 0 knots.

During a postaccident interview, the first officer stated that, when he transitioned from the instruments to the outside during the second approach, he saw “white on white” again and blowing snow. The first officer also stated that it was difficult to comprehend what he was seeing outside the airplane because everything was covered in snow and that, before he could determine what he was seeing, the airplane touched down. The first officer added that he did not see the structure with the antenna during the second approach because the airplane had flown over it by the time that he looked outside. The captain reported that she saw the tower again but that the airplane had leveled off to clear the structure before continuing to descend.

The captain recalled that, after touchdown, the airplane was “bouncing up and down a few times” before coming to a stop. The flight attendant reported that the landing was “rough and violent” with seat cushions and passenger belongings falling into the cabin aisle as the airplane came to a stop. The airplane came to rest in the snow-covered grassy area between runway 1 and a parallel taxiway located about 630 ft to the right of the runway. The airplane’s resting location was about 3,600 ft beyond the runway threshold, about 305 ft to the right of the runway centerline, and about 230 ft from the right edge of runway. Airport personnel estimated that, when the airplane landed, visibility was about 1/2 mile, and about 30 minutes had elapsed since the time that the runway was last plowed.

Postaccident Events

At 1129:18, the captain instructed the passengers to remain seated; 3 seconds later, the flight attendant provided the same instruction. At 1129:24, the captain instructed the first officer to run the engine shutdown checklist, which he did.

The flight attendant reported that, after the airplane came to a stop, she called the flight deck and received no answer, but she could hear the flight crew from her aft-facing jumpseat and decided to wait for the captain to contact her because an immediate evacuation was not necessary. The flight attendant then moved out of her seat, looked outside, and walked through the cabin to check on the passengers and remove items that had fallen into the aisle. When the flight attendant returned to the front of the cabin, the captain opened the flight deck door and told her that an evacuation would be occurring, and the flight attendant relayed that information to the passengers.

After the main cabin door was opened, the flight attendant noticed that the snow reached the bottom of the belly of the airplane. Firefighters came aboard the airplane; one attended to the first officer, who was injured, and one walked through the cabin to check on passengers. A snow plow created a walkway so that the crewmembers and passengers would not have to walk through the snow after exiting the airplane.

Emergency personnel took the first officer off the airplane, and the flight attendant then directed the passengers to exit the airplane via a ladder that firefighters had brought to the airplane. After the passengers had exited, the flight attendant checked to make sure that no one was left behind, and the captain and the flight attendant then exited the airplane. A bus transported the captain, flight attendant, and passengers to the terminal.

PERSONNEL INFORMATIONThe Captain

The captain began working for CommutAir in March 2013 as a first officer on the De Havilland Canada DHC8 airplane. The captain left the company in November 2015 and joined another air carrier. In May 2016, the captain left that air carrier and returned to CommutAir as a first officer on the DHC-8. The CommutAir vice president of flight operations stated that, while the captain was a DHC-8 first officer in 2016, she received a disciplinary letter from the company and agreed to forgo an upgrade to captain and be monitored for 9 months.

During September 2017, the captain received a notice of disapproval from the FAA for her EMB145 type rating due to difficulties in performing steep turns and an engine failure takeoff. She received an EMB145 type rating in October 2017 and upgraded to captain shortly afterward.

In addition, twice in September 2017, the company placed the captain under “increased scrutiny” due to training failures, including a failed proficiency check, on the EMB145. The captain received remedial training to address these failures in March 2018. (See the Organizational and Management Information section of this report for more information about the company’s increased scrutiny policy.)

On March 1, 2019, the captain reported to work at 1115. She flew three flight legs and finished her workday at 2044, after which she commuted home, arriving about 0000 on March 2. The captain was off duty that day. She was also off duty on March 3 and commuted to EWR for the flight to PQI the next day. She arrived at a local hotel about 2200 and went to sleep about 2330. The captain reported that she slept well and had no problems falling or staying asleep. On March 4, the captain awoke about 0700 and started her workday at 0830. The captain reported that she felt “great” when she awoke. The captain reported that she had no sleep disorders or issues.

The First Officer

The first officer began working at CommutAir in May 2018 as a first officer on the EMB145. He received his airline transport pilot certificate and EMB145 type rating in July 2018.

The first officer called in sick after a flight from PQR to EWR on February 28, 2019. He flew home afterward (to Palm Beach, Florida) and was subsequently diagnosed with the flu. The first officer reported that he felt “much better” on March 3. That night, he commuted to EWR for the flight to PQI the next day, arriving at a local hotel later than expected—about 0000 on March 4—due to flight and ground transportation delays. The first officer went to sleep about 0100 and awoke about 0600; he reported that he felt “normal” and “rested” but that he was still coughing.

The first officer also reported that he normally slept 7 to 8 hours and that he used a continuous positive airway pressure (CPAP) machine. (The first officer was diagnosed with moderate obstructive sleep apnea after a sleep study in 2012.) The daily-use graphic provided in the CPAP machine download showed that the first officer used the device for less than 1 hour on February 26, 2019; did not use the device between February 27 and March 2; and used the device for about 1 hour 30 minutes between 1200 on March 3 and 1200 on March 4. The first officer stated that he did not think that he used his CPAP machine during the early morning hours of March 4 because he had arrived in his hotel room later than planned and wanted to go to sleep.
METEOROLOGICAL INFORMATIONPQI had an automated weather observing system that provided meteorological aerodrome reports each hour (at 56 minutes past the hour) with special weather observations as conditions warranted. The weather conditions at 1118 (11 minutes before the accident) included wind from 060º at 4 knots, visibility 1/2 mile in moderate snow and freezing fog, temperature 3ºC, dew point temperature -4ºC, and altimeter 29.68 inches of mercury. The remarks section indicated that the hourly precipitation was less than 0.01 inch (a trace).

The weather conditions at 1143 (14 minutes after the accident) included wind from 070º at 5 knots, visibility 3/4 mile in light snow, scattered clouds at 800 ft agl, ceiling overcast at 1,300 ft agl, temperature -1ºC, dew point -4ºC, and altimeter 29.67 inches of mercury. The remarks section indicated that the hourly precipitation since 1056 was less than 0.01 inch (a trace).

An automated weather observing system wind sensor pole was located about 325 ft to the right of the runway 1 centerline and about 870 ft past the runway 1 threshold. The pole was about 30 ft tall and had a lightning arrester at the top.
WRECKAGE AND IMPACT INFORMATIONPostaccident examination found that the airplane’s nose was damaged through the first bulkhead at the top and was either damaged or missing through the nose gear position at the bottom. The nose cone, radar, glideslope antenna, and nose gear doors were all missing. The nose gear wheels were found aft of their normal position. The right-side nose gear door actuator was broken at the door attachment point; the leftside gear door actuator was still attached to the door attachment point, but the door was missing.

The left main gear was lodged between the left engine nacelle and fuselage. The fuselage structure in the area of the gear was ripped and damaged, and the fuselage around the gear wheels was distorted. The landing gear trunnion had penetrated the left engine gear box.


Figure 2: Left main landing gear lodged between left engine nacelle and the aircraft fuselage

The left-wing inboard flap was shifted aft, and the flap trailing edge was found above the fully retracted position. The right-wing outboard flap appeared to be extended (the extension angle could not be determined), the inboard jackscrew was broken, and the aft-most flap panel (close to the outboard edge) was cracked. The right-wing inboard flap and inboard jackscrew were missing, and the outboard jackscrew was broken.

The left engine inlet and nacelle were distorted around the wheel location. The right engine inlet was damaged on the inboard side. Both engine inlets had rotational scoring in the area of the fan blades. About one-half of the fan blades on both engines had leading-edge damage (nicks or gouges).

The aft fuselage appeared to be undamaged. The left and right sides of the vertical stabilizer and the localizer antenna appeared to be intact and undamaged.

Examination of the airplane’s interior found two small penetration holes on the cabin wall near a seat on the left side of the aft cabin. The corresponding interior cabin wall panel seams were distorted on both the forward and aft sides. Five of the 50 passenger seats were found with a broken recline actuator hinge.

The lightning arrester at the top of the automated weather observing system wind sensor pole was found bent after the accident. The FAA installed a new wind sensor pole on March 13, 2019.
ADDITIONAL INFORMATIONConfirmation Bias

Confirmation bias is an unconscious cognitive bias that involves a tendency to seek information to support a belief instead of information that is contrary to that belief. As a result of confirmation bias, pilots might continue with an original plan despite changing conditions. Thus, confirmation bias can negatively affect aeronautical decision-making.

Airport Winter Operations Safety

FAA Advisory Circular (AC) 150/5200-30D, “Airport Field Condition Assessments and Winter Operations Safety,” dated July 29, 2016, provided guidance to airports for developing a snow and ice control plan (an FAA-approved document). Although the AC stated that any snow or ice that affects the signal of an electronic navigational aid should be removed, the ILS guidance discussed snow clearance areas only for the glideslope.

On October 29, 2020, the FAA issued a revision to AC 150/5200-30D. The revised AC incorporated additional guidance for airport operators about snow removal around navigational aids. Regarding the localizer, the AC stated the following:

The accumulation of large amounts of snow can change the surface area in front of the Localizer and consequentially may affect its radiated signal. A snow accumulation level of two (2) feet is the limit at which point the [FAA] system [ILS] specialist needs to start observing the condition of the Localizer signal.

The guidance also noted, “when a determination is made that snow or ice accumulations jeopardize signal strength from the Localizer or GS [glideslope] antenna, ensure a NOTAM is issued by the individual with NOTAM authority.” This guidance in the revised AC was aligned with the interim change to FAA Order JO 6750.49B, “Maintenance of Instrument Landing Systems (ILS) Facilities,” which was transmitted with a November 1, 2019, letter to airport sponsors.

In addition, FAA guidance published in November 2015 provided engineering tips for snow removal at ILS facilities. This guidance, which was for FAA technical operations personnel, stated that ILS specialists should conduct a ground check to determine the effects that a ground contour change resulting from snow could have on a localizer’s radiated signal.
MEDICAL AND PATHOLOGICAL INFORMATIONAfter the accident, the captain and the first officer were tested for drugs and alcohol in accordance with 14 Code of Federal Regulations Part 120, Drug and Alcohol Testing Program. The test results were negative.
ORGANIZATIONAL AND MANAGEMENT INFORMATIONCommutAir was founded in 1989. According to its website (accessed June 23, 2022), CommutAir “is a regional airline operating flights on behalf of United Airlines as a United Express partner.” At the time of the accident, CommutAir’s fleet consisted of 32 EMB145 airplanes.

Flight Procedures

The CommutAir EMB145 Aircraft Operations Manual stated that, for a normal instrument approach, the pilot flying would “monitor the instruments until the callout ‘Runway in sight,’ then transition to outside references no later than 100 feet above the touchdown zone (TDZ) elevation.” The manual also stated that the pilot monitoring would “monitor the approach, deliver the proper callouts and visually acquire the runway.”

As previously stated, the CommutAir EMB145 Aircraft Operations Manual stated that pilots should call for a goaround if the runway environment was not in sight by the decision altitude or if the successful completion of the approach was in doubt. The manual also noted that either flight crewmember could call for a missed approach/goaround at any time during the approach and transition to landing and that, upon that call, the pilot flying must execute the maneuver without hesitation.

The CommutAir General Operations Manual stated that, during a straightin instrument approach, the pilot can continue the approach below the decision altitude to touchdown if the airplane can land within the touchdown zone using normal maneuvers and a normal descent rate, the visibility is not less than the visibility prescribed in the approach procedure, and a visual reference for the intended runway is visible and identifiable. The manual also stated that the pilot must execute a missed approach upon reaching the decision altitude or missed approach point if any of the required conditions for a straight-in approach are not met.

Aviation Safety Action Program

CommutAir had an aviation safety action program (ASAP). The CommutAir General Operations Manual stated that the program “fosters a voluntary, cooperative, non-punitive environment for the open reporting of safety of flight concerns.” The CommutAir director of operations stated that a company flight data analyst reviews deidentified ASAP reports “right away” and notifies the appropriate managers and directors about any time-critical information that warrants action.

According to a postaccident interview with the CommutAir safety program manager, four ASAP reports involving the ILS runway 1 localizer misalignment at PQI were submitted after the accident. Two of the reports were submitted by the flight crewmembers of CommutAir flight 4939 on March 2, 2019 (referenced in the Airport Information section of this report). Two other ASAP reports were filed by the flight crewmembers of a CommutAir flight on March 1, 2019. The safety program manager thought that visual conditions prevailed during both of these flights to PQI and that the airfield was seen “well above minimums.”

The captain of the March 1 flight to PQI stated that the flight was his first time at the airport and attributed the localizer misalignment to a lack of familiarity with the airport and the approach. The first officer of that flight stated that he and the captain both noted that the airplane appeared to be flying to the right of the runway, even though the ILS needles were centered. Neither ASAP report mentioned whether the flight crew notified air traffic control about the misalignment. The first officer of the accident flight reported that he did not complete an ASAP report after his previous trip to PQI (February 27, 2019) because the captain of that flight stated that they did not need to submit a report about the inconsistency between the flight management system and ILS localizer indications.

The CommutAir managing director of safety stated that he did not know why the ASAP reports were not filed before the accident. He thought that the pilots might not have recognized the importance of a misaligned localizer signal or did not know that such a misalignment needed to be reported. The managing director of safety further stated that, after the accident, navigational aid discrepancies became a mandatory reporting item.

Increased Scrutiny Policy

The CommutAir General Operations Manual discussed that low-time pilots (as defined in the manual) would be subject to increased scrutiny if they failed one checking event or one remedial training event. The manual also stated that pilots who are not considered to be low time but have repetitive failures would be subject to increased scrutiny if they failed any checking event or two remedial training events during a 2year period. (Remedial training was defined as required additional training to complete a regular training event.) In both cases, increased scrutiny included the following:

A 6-month recurrent ground school cycle for a period of 1 year for any failure of a ground school written exam and/or a failure of an oral checking event.

A 6-month line check cycle for a period of 1 year for any failure of a practical checking event.

Postaccident Actions

After the accident, CommutAir implemented several actions to increase safety. These actions are detailed in the docket for this accident investigation.