On October 27, 2016 a chartered Eastern Airlines Boeing 737 carrying Vice Presidential candidate Mike Pence and 36 others skidded off a wet runway at LaGuardia Airport on a rainy fall night. The incident gained some notoriety, not only because the candidate was aboard, but also because the cockpit voice recorder transcript revealed that, after the incident, the captain said, “My career just ended,” and the co-pilot said, “We should have went around.”

Although the National Transportation Safety Board has not yet issued a final report and probable cause determination, it has released the cockpit voice recorder transcript and other factual information about the accident. It is worth examining this information to better understand the circumstances of the incident, and lessons to be learned from it.

Although conditions were well above instrument approach minimums, it was a thoroughly miserable night. The wind was from the southeast, but landings were being made to the southwest on Runway 22, and braking action was less than ideal due to the wet runway. On final approach the co-pilot, who was flying, commented, “nice crosswind,” and the captain said, “raining like a mother * * *” Seconds before touch down, the captain said, “Down, down, down, you’re three thousand feet [of runway] remaining.” The plane finally touched down more than half way down the runway. “Stop, Eastern, stop!” called the tower, but to no avail. The 737 went off the end of the runway and came to rest in the engineered materials arresting system (a crushable surface specifically designed for such overruns) a short distance from the Grand Central Parkway.

The NTSB factual report found that the plane went above the glide slope on final approach, and was in a “turbulent atmosphere” with an increasing tail wind at touch down. Once down, the captain tried to turn right as the runway end approached, while the co-pilot, who could not understand why the plane was pulling to the right, attempted steer left to stay on the runway. Ideally, following crew resource management principles, the captain should have monitored the approach, advised the co-pilot of the deviation, and called for a go-around if it persisted, and he should have told the co-pilot that he was taking over control before doing so. NTSB simulations suggested that the aircraft could have been stopped on the runway had the speed brakes and reverse thrust been timely deployed.

The crew conducted a remarkably candid in-cockpit review of their performance while the emergency response was in progress. “See unfortunately, I should have gone straight ahead and we would have been fine,” said the captain. “When I made the turn is when I screwed up.” The co-pilot replied, “I was fighting you, because I was trying to stay on the centerline.” They activated the auxiliary power unit, performed the shutdown checklist, and calmly advised a Secret Service agent that there was no need for an emergency evacuation. No one died or was seriously injured as a result of the runway excursion.

Much emphasis has been placed on the importance of stabilized approaches where defined speed, altitude, and flight path criteria are established which require a go-around if not maintained. But go-arounds are also fraught with hazards, and can have tragic outcomes if not flown correctly. Boeing test pilot Dave Carbaugh has said that excessive focus on complying with stabilization can result in gaps in aircrew situational awareness, that each crew must objectively judge its own performance, and that the timing of the go-around decision can be critical to the outcome. It often requires a split-second, high stakes judgment call.

Airports like LaGuardia and Chicago Midway, with short runways, hemmed in by built up areas and obstructions, and subject to bad weather conditions, are a challenge both to pilots and to the air traffic controllers who choreograph the intricate airborne minuets needed to get aircraft safely to and from them. These airports provide no margin for error. Systems and procedures play a vital role, but they depend on people to make them work. The fact that accidents are exceedingly rare is a tribute to the skill, dedication and professionalism of pilots and controllers.