The Tip of the Arrow
Air Line Pilot, February 2001, p. 30
By Capt. Russell Farris, US Airways
An accident is often said to be the result of an unbroken chain of events. If something breaks the link, disaster is averted. Rarely do pilots get to stand at the edge of the abyss, peer over, and step back, the chain broken at the last moment. It can be a powerful learning experience.
As a fairly new captain for my airline, I was scheduled to take the twin-jet Fokker F-28 to one of our smallest stations—Worcester, Mass.—in the middle of January. Worcester Regional Airport, which is not blessed with overly long runways or impressive facilities, also has the worst weather in the region, especially in winter.
As I talked to the flight dispatcher about conditions at our destination, he assured me that although snow had been falling heavily, the plows were keeping the runway clear. The previous company flight, another F-28, had reported braking action fair, well within our operating limitations.
The wind was from the west at 15 knots, which ruled out the ILS 11 approach, the obvious choice. But the dispatcher helpfully added that the NDB Runway 29 was available, with the weather just above minimums.
I wasn’t too enthusiastic about that idea. Domestic airline jet crews almost never have to fly an ADF approach in the real world, and the two or three a year practiced in the simulator never feel like enough. His parting advice, "It wouldn’t hurt to go take a look," was amusing, because at some critical point "taking a look" becomes either a landing or a diversion, and guess whose decision that would be? Thanking him, I hung up and returned to the airplane.
I found the first officer, relaxing in the passenger cabin, and briefed him
on the situation. Like any captain using his best crew resource management training, I wanted his opinion.
Dave was a conservative, thoughtful airman, and he felt that while conditions were less than ideal, he couldn’t think of any real reason why we shouldn’t launch.
I agreed, but remembered my main concern—the Dutch-built F-28 was the only jet transport this side of the Iron Curtain not equipped with thrust reversers. Short of throwing out an anchor, the only way to stop the airplane was by using its wheel brakes.
The flight to Worcester was uneventful, with the usual light-to-moderate chop present in a Northeast low-pressure system. Listening to the ATIS during the descent, Dave relayed the first piece of interesting news—the NDB was out of service. On questioning the approach controller, we learned that it had been OTS for 3 weeks—a fact somehow unknown to our dispatcher. The other big news was that the wind was now 290 degrees at 10 knots, exactly at limits for landing on Runway 11.
Mulling over this turn of events, I asked for the latest braking action report. The man in the dark room said that an ATR commuter reported fair to good, and the runway had been plowed within the hour. The small-town nature of our destination became apparent when he casually added that an airport authority pickup truck had just finished a mad dash down the runway, weighing in with a report of "good friction." The weather was holding at a 500-foot ceiling, with 4 miles visibility in light snow.
Airline pilots are paid for days like this, and if the captain turned down every less-than-ideal situation, schedules would become a joke, and needlessly so. Taking into account that I had yet to hear the words "poor" or "nil" regarding braking action, I decided to shoot the ILS 11.
During my briefing for the approach, I told Dave that, assuming good visibility on breaking out, I would drop one dot low on the glideslope to ensure touchdown well before the 1,000-foot mark; no sense wasting runway on a day like this. On touchdown and autospoiler extension, I would use maximum braking, and if it didn’t feel right, I would pour on the coal and perform the maneuver known as getting the hell out of there. The Rolls-Royce Spey could spool up from idle to takeoff thrust much more quickly than most jet engines, and this was the procedure in our flight manual for landing on snow- and ice-covered runways.
As we slid down the ILS, everything was routine, except for needing less power than usual to hold the glideslope because of the tailwind. We broke out at 500 feet, and the runway appeared dead ahead. I announced that I was going one dot low. Dave got a final wind check from the tower, 290 at nine; 1 knot to spare. Crossing the threshold right on speed, I made a low flare, landing about 500 feet from the near end of the 7,000-foot-long runway. The spoilers deployed immediately, and when the nosewheel touched down, I applied maximum braking.
We slowed very nicely at first, now committed to a full stop, and then the games began. Suddenly we were no longer decelerating. The change was so abrupt that it felt like taking off. Too late for a go-around, we had run into an ice-covered part of the runway with all the friction of a skating rink. At 90 knots, the Fokker began to slide sideways, and I fought to regain control by releasing the brakes and holding full right rudder. After a few moments, which seemed much longer, we straightened up, and I applied brakes again, desperately hoping the anti-skid system would start to work.
I have heard from pilots involved in accidents that everything moves like a slow-motion dream, and they are right. I found time to reflect about the lack of reverse thrust, and what a stupid place that is to save a few bucks. I also remembered the steep drop-off and rugged terrain waiting past the end of the runway. An accident resulting in a broken airplane and serious injuries or worse would not be a career-enhancing event. All these thoughts drifted through my mind as I heard myself tell Dave to shut down the left engine—at this point we hardly needed its 400 pounds of idle thrust.
The end of the runway was coming up fast, and we were barely slowing. Passing the intersection of Runway 33, I was on the verge of
shutting down the right engine as well, when suddenly we were past the ice. The anti-skid took hold, cycling the brakes as we quickly slowed in the last 1,000 feet. Snow was falling again as I very slowly taxied to the gate, the tarmac so slick the nosewheel slid in the turns.
In a droll manner that made me envious, Dave reported to the tower that the runway "reports" left a lot to be desired, with braking action nil on at least half the runway’s length.
We sat in stony silence as the jetway pulled up, and the 70 passengers deplaned without a single comment. Even the flight attendants apparently did not realize how close we had come to being a headline.
Finally, I turned to Dave and said I was going to inform the dispatcher that we were not taking off until spring. I was joking, but part of me felt that way.
During the postmortem, I discovered a few interesting sins of omission and one of commission—by me. If we had known the ADF approach was OTS, we couldn’t have departed in the first place, since the tailwind made the ILS illegal. The company had the information about the NDB; some electronic gremlin kept us from getting it on our paperwork. Once in the Worcester area, the wind subsided, luring us into a tailwind landing on an ice-covered runway.
Another critical piece of information that we didn’t get was that the ATR braking action report was nearly 3 hours old! Besides, I should have disregarded a braking action report from a truck—stopping a 70,000 pound jet and a pickup being considerably different.
But the fact remained that I had decided to land with a barely legal tailwind. I’m sure the Feds would have jumped immediately on that, and the fact that runway conditions were drastically worse than advertised would have made a nice footnote in the accident report. The accident chain was broken by a quirk of nature that allowed less ice to form on the last portion of the runway. Except for that, I would probably be in another line of work.
When citing pilot error as a probable or contributing cause of an accident, the NTSB often manages to miss the process that went into making a mistake, as if judgment and decision-making exist in a vacuum.
In a tradition dating to sailing ships, we are held accountable for our decisions. Any other way would erode the power we have as pilots to make judgments based on the best available information. But in an imperfect world, that information can sometimes be very wrong. Ernest K. Gann wrote that the pilot is at the tip of the arrow, which is something to remember as we go about our flying business, in airplanes big and small.