Solitaire B733 at Aqaba on Sep 17th 2017, runway excursion on landing
Last Update: December 21, 2018 / 17:13:09 GMT/Zulu time
Incident Facts
Date of incident
Sep 17, 2017
Classification
Incident
Cause
Runway excursion
Airline
Solitaire
Flight number
RJ-6888
Departure
Amman, Jordan
Destination
Aqaba, Jordan
Aircraft Registration
JY-SOA
Aircraft Type
Boeing 737-300
ICAO Type Designator
B733
Airport ICAO Code
OJAQ
The airline confirmed a runway excursion disabling the aircraft to continue the flight to Dubai (United Arab Emirates) as scheduled. The aircraft sustained minor damage to its exterior. The passengers disembarked normally and were taken to hotels to await continuation of the flight to Dubai.
The airport reported the aircraft was unable to stop before the end of the runway and overran the end of the runway.
On Sep 24th 2017 Royal Wings reported the aircraft was leased in from Solitaire, also known as Fly Jordan, and was operated by Solitaire crew. The aircraft touched down in the second half of the runway and overran the end of the runway coming to a stop on the extended runway center line about 200 meters past the runway end.
On Nov 29th 2017 Royal Wings told The Aviation Herald, that the Civil Aviation Authority declared the occurrence was the result of Pilot Error.
Jordan's Civil Aviation Regulatory Commission (CARC) released their final report concluding the probable cause of the serious incident was:
The cause of this Incident was Flight Crew failure to discontinue the Unstabilized Approach and their persistence in continuing with the landing despite 8 numbers of warning from EGWPS
CONTRIBUTING FACTORS
The following factors are believed to be the main causal factors of the occurrence:
- The delay on ground OJAI for 47 minutes influenced crew decision to land on RWY19 at OJAQ to save time.
- The straight in, unstabilized approach was the main result of the Aircraft high energy for the consecutive phases out from 1000 ft down to the touchdown point.
- The higher than allowed tailwind component that recorded an average of 16 knots during final approach and landing phases.
- Incorrect landing configuration was a contributing factor for Aircraft high speed and explain pilot flying inability to control the prolonged float of the Aircraft and the ability to roll it out.
- The pilot monitoring (Captain) was aware of the tailwind, however he accepted the prevailing conditions without discussing the operational limitations of the Aircraft with the pilot flying.
- Crew inaction to discontinue the unstabilized approach and make a go around helped in the developed situation.
- Crew poor situational awareness and lack of coordination.
- Deliberate Disregard of the aural warnings without correcting the Aircraft attitude.
- Lack of cockpit management (CRM) for task sharing and decision making. Crew resource management (CRM) was not evident during the approach phase of flight
- Failure of the airline to provide its pilots with clear and consistent guidance and training regarding company policies and procedures related to stabilization criteria and the necessary actions to be followed including the conduct of go around.
- inability to recognize the two critical elements, namely fixation and complacency that affected pilot decision to land the aircraft while the approach was not meeting the stabilization criteria
- Negative organizational factors were evidenced in terms of operational pressure that was exerted by the management of Solitaire air.
- Inadequate risk management by the operator as the repeated reports of duty time exceedances were not known or observed by the operational safety management
- Noncompliance to state regulations regarding the proper training of crews was found a contributing factor as the PIC CRM conversion training was not completed in a correct way.
- Non availability of customized flight safety documents (FCOM, FCTM and QRH) which includes the manufacture recommended standard operating procedures.
The CARC summarized the sequence of events stating the first officer (29, ATPL, 1,662 hours total, 1,469 hours on type) was pilot flying, the captain (43, ATPL, 7,102 hours total, 6,973 hours on type) was pilot monitoring:
During cruise the crew realized that the delay before departure will negatively affect their duty time and consequently asked for straight approach on runway 19 to save time. The ATC Controller informed the crew that the wind is varying with speeds between 10 - 12 knots and another traffic was expected to depart runway 01 within short time. The Captain of the flight accepted the prevailing wind condition at runway 19, however, no agreement was made yet to land runway 19.
At 35 miles from AQB VOR the ATC contacted the crew and asked them if they there are able to maintain their speed to continue landing on runway 19, the crew accepted and continued to a straight in approach.
During final and after dropping the landing gear, the Aircraft was not configured to the correct landing configuration, the flaps were set to configuration one at height of 650 ft AGL, multiple GPWS aural warning were triggered but disregarded by the crew. the high speed approach was not corrected by the crew efficiently and the aircraft continued to landing runway. the Aircraft passed the threshold at 115 ft radio altitude at flaps 5 and continued along the runway to the point when the flaps were selected to 30 at 90 ft radio altitude.
The Aircraft floated over the runway and pilot flying was unable to land it. The Captain took the controls over and managed to put the Aircraft on the runway but with relatively higher than normal speed. The Aircraft touched down at 7400 ft beyond the runway threshold. The airplane came to a stop 10,600 feet beyond the runway threshold (600 feet inside the soft area), and around 200 feet right of the extended runway centerline.
The CARC reported the aircraft sustained substantial damage (yet rated the occurrence a serious incident!) including damage to both engines due to ingestion of foreign objects (the left hand engine due to impact with approach lights, the right hand engine due to ingestion of sand), both engines were replaced, all landing gear struts needed to be replaced (following a ferry fligh to Amman with special permit - the airline argued the gear struts were due for replacement anyway), various dents and cracks to fuselage, wings and flaps.
The CARC analysed:
By analyzing the significant data retrieved from the Flight Data Recorders on approach and landing, it was found that 2 minutes before the top of descent, the captain asked the co-pilot about the runway he would like to use and the copilot answered that they would ask for RWY 19. Both pilots knew that the delay at AMM for 45 minutes would affected the duty time limitations rules and that was the reason for asking the controller the possibility to use RWY 19 to save time. The condition to have a permission to land RWY 19 was to maintain high speed as another aircraft was preparing for departure. The captain of the incident flight accepted RWY 19 although the prevailing wind condition was exceeding the aircraft operational limitations. A chain of multiple errors took place right from the top of descent. The copilot set up the FMS for RWY 19 and tuned the ILS frequency. Both pilots confirmed the ILS frequency not working, and the captain told the copilot to keep on VNAN and to continue the approach. Since they selected RWY 19, the crew did not make the required checklists properly. The Auto Pilot was disconnected as the airplane descended through 1215 feet radio altitude.
...
As the airplane descended below 500 feet radio altitude the computed airspeed was 218 knots (VREF+85) and decreasing. The airplane was configured at flaps 1 with the speedbrakes extended, and the calculated sink rate was approximately 1200 fpm. As such, the approach did not adhere to several of the recommended stabilized approach criteria.
...
The FDR data also indicate the occurrence of several GPWS cautions and warnings, including the alert “TOO LOW TERRAIN”. The CVR confirms the occurrence of “TOO LOW TERRAIN”, and also identifies the occurrence of the “SINK RATE” aural alert.
...
Analysis of the data indicate that the runway overrun occurred due to the airplane touching down an estimated 7400 feet beyond the runway threshold (2650 feet prior to the end of the paved surface) at a computed airspeed of 158 knots (VREF+25). Despite prompt use of deceleration devices upon touchdown, the airplane overran the runway, coming to a stop around 600 feet beyond the end of the paved surface.
The casual tone in the cockpit was evident with inadequate briefing and not following the SOP properly. The copilot had possibly been affected by this casual atmosphere in the cockpit. It was evident that there was lack of CRM and crew coordination, as both pilots had been aware of incorrect parameters and unstabilized approach However, after the GPWS aural warnings and instantaneously, the captain was showing a steep trans-cockpit authority gradient that had resulted in the captain overruling the decision to continue the approach and disregard the aural warning without considering the multiple deviations of being at high speed and with an excessive sink rate in addition to the incorrect landing configuration of the flight controls. Both pilots continued the faulty approach and landing, possibly due to incorrect assessment of their ability to restrain the high energetic aircraft and this could be attributed to their determination to land the aircraft within the first attempt to compensate the lost time as a result of the delay at origin airport, and this is also an indication of complacency, which is one of the critical elements of the situational awareness. The roles in cockpit were not followed correctly, the copilot who was flying the aircraft was not assertive against the captain intentions and continuation calls even after the GPWS warnings that gave them a clear indication of the unstabilized situation they were encountering. The situation had clearly indicated ineffective CRM skills and resulted in the incorrect decision of the eventful landing.
The CARC analysed with regards to rest time and rest quality of the captain:
The captain of the flight also stated that on 15 Sep 2017 he was operating a four sectors flight before the incident flight and arrived from it at midnight and until he reached his house it was approaching 2:30 am LT. the captain added that he slept at 4:30 am till 3:00 pm at which he received a phone call from company crew scheduling informing him that he has to report to a flight at 2:00 am next day 17 Sep 2017 (the incident flight). The captain stated that he could not sleep after the call. The aviation medicine doctor analyzed that the captain has to act against the natural body clock to modify his sleeping disorder. At the time of the departure the captain of the incident flight had been awake for 11 hours before the departure. Personal readiness of the captain was not observed as he did not manage his off duty activities and rest requirements. The captain of the incident flight did not make an optimum use of the opportunity for rest provided. The investigation committee concluded that the personnel readiness of the captain was not observed as he was not able to manage his off-duty and rest time before the commencement of that flight, in addition to what has been discussed earlier in subsection 1.13 regarding the captain physical status after using the medicines and acting against his natural body clock.
With respect to supervision within the operator the CARC analysed:
Within the course of investigation it was evidenced that there was no adequate planning for this operation in terms of operational risk assessments and duty time planning. The lease operation was not introduced to flight operations department according to the captain of the incident flight who was the flight operations post holder at the time of the incident. Planning of such operations requires an operational assessments to identify the organisation limitations and preparedness in order to conduct a safe operation. That was not exercised systematically by the solitaire air departments.
The unsafe supervision was also evident when the management of the operator did not react with the identified deficiencies reported by the captain of the incident flight regarding safety related issues, such as the flight safety manuals that were found not relevant for the operated airplanes as in 1.17.4 and the duty time issues described in 1.17.5. these unsolved problems created an atmosphere in the company in which reporting is believed to be discouraged in contrary to the safety policy of the company, and that in turn created mistrust problems between the operating crew and their management.
Related NOTAM:
A0264/17 - AD WILL BE CLOSED DUE TO DISABLED AIRCRAFT ON THE RUNWAY. 17 SEP 17:02 2017 UNTIL 18 SEP 05:00 2017. CREATED: 17 SEP 17:03 2017
Metars:
OJAQ 170800Z 36012KT CAVOK 31/17 Q1011=
OJAQ 170600Z 36012KT CAVOK 28/17 Q1011=
OJAQ 170500Z 34009KT CAVOK 26/17 Q1010=
OJAQ 170400Z 32006KT CAVOK 25/17 Q1010=
OJAQ 170300Z 36008KT CAVOK 26/17 Q1010=
OJAQ 170100Z NIL=
OJAQ 170000Z 35014KT CAVOK 27/17 Q1009=
Incident Facts
Date of incident
Sep 17, 2017
Classification
Incident
Cause
Runway excursion
Airline
Solitaire
Flight number
RJ-6888
Departure
Amman, Jordan
Destination
Aqaba, Jordan
Aircraft Registration
JY-SOA
Aircraft Type
Boeing 737-300
ICAO Type Designator
B733
Airport ICAO Code
OJAQ
This article is published under license from Avherald.com. © of text by Avherald.com.
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