Berlin A320 at Sylt on Sep 30th 2017, overran runway on landing

Last Update: November 5, 2020 / 17:27:07 GMT/Zulu time

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Incident Facts

Date of incident
Sep 30, 2017

Classification
Incident

Cause
Overran runway on landing

Airline
Air Berlin

Flight number
AB-6880

Departure
Dusseldorf, Germany

Destination
Sylt, Germany

Aircraft Registration
D-ABHO

Aircraft Type
Airbus A320

ICAO Type Designator
A320

Airport
Westerland Sylt Airport, Westerland

Airport ICAO Code
EDXW

An Air Berlin Airbus A320-200, registration D-ABHO performing flight AB-6880 from Dusseldorf to Sylt (Germany) with 82 passengers and 6 crew, landed on Sylt Westerland's runway 32 at 08:19L (06:19Z) but overran the end of the runway and came to a stop about 100 meters/330 feet past the runway end with all gear on soft ground. There were no injuries, the aircraft sustained minor if any damage.

Passenger Claudia Kolvenbach commented: "Have landed..... even though the runway was too short for us today. Everybody's fine"

Germany's BFU opened an investigation into the occurrence.

Sylt Westerland Airport features two runways 14/32 (length 2120 meters/6950 feet) and 06/24 (length 1696 meters/5560 feet). Only runway 32 features an ILS Cat I approach (OCH 199 feet AGL - with overcast cloud at 200 feet the only possible approach). RNP (OCH 380 feet) and NDB approaches (OCH 480 feet) are available for both runways 14 and 32.

On Feb 28th 2018 Germany's BFU reported in their September 2017 Bulletin, that the A320 landed on runway 32 and overran the end of the runway by 80 meters/260 feet. The captain (61, ATPL, about 17,000 hours total, 5,757 hours on type) was pilot flying, the first officer (35, CPL, 6,148 hours total, 4,038 hours on type) was pilot monitoring. Due to the winds being reported from 140 degrees at 12 knots the crew planned a RNP approach to runway 14, however, due to low cloud ultimately decided to perform an ILS approach to runway 32. The crew computed a Vapp of 131 KIAS with a tail wind component of 12 knots, which required a landing distance of 1990 meters. The aircraft was configured for landing with full flaps, the captain instructed to add an additional 5 nots margin onto Vapp (Vls=126 KIAS, Vapp 131 KIAS). Descending through 1000 feet the FDR revealed airspeed was 139 KIAS, ground speed 158 knots, winds from 183 degrees at 22 knots, at 500 feet airspeed was 139 KIAS, ground speed 158 knots, winds from 183 degrees at 22 knots. Tower reported the surface winds from 140 degrees at 10 knots. The captain decided to continue the landing on passing the decision height. The aircraft crossed the runway threshold at 50 feet AGL at 151 KIAS, 163 knots over ground, winds from 144 degrees at 12 knots. The captain commented "Na komm, geh runter!" ("come on, get down!"), the EGPWS sounded "Five", 2 seconds later again "Five".

12 seconds after crossing the runway threshold the aircraft touched down on runway 32, 11 seconds later the captain asked "Schaffen wir das?" (do we make it?), the first officer called "70 knots", the captain answered his own question "nee" (no), pressed down the brakes pedals disconecting autobrakes, the maximum brakes pressure was reached, 23 seconds after touchdown the aircraft crossed the runway end at 44 knots over ground and came to a stop on grass about 80 meters past the runway end.

The BFU reported the captain said in post event interviews that he had a feeling of having flared a bit long. After the spoilers extended and the thrust reversers had been engaged, the anti-skid warning activated, he therefore attempted to manually brake the aircraft but had the feeling that the deceleration did not suffice. He was aware of the possibility of the go around, despite the long flare he did not see a necessity to initate a go around.

The first officer said in post flight interviews that he believed a go around was imminent but did not intervene.

The tower controller stated that there were puddles of water on the runway due to subsidence, he could not state how much of the runway surface was covered by water. He observed the aircraft touching down late and was puzzled that it didn't slow down.

One runway end light was destroyed. The aircraft did not receive any damage.

According to the FDR the aircraft touched down about 930 meters past the runway threshold with 1190 meters of runway remaining. At the time of touchdown the airspeed was 138 KIAS, 150 knots over ground, at that time the wind came from 130 degrees at 13 knots.

On Nov 5th 2020 the BFU released their final report concluding the probable causes of the serious incident were:

The actual approach speed of 151 kt (calculated VAPP of 131 kt) as the airplane crossed the threshold resulted in a longer flare phase and braking distance. The nonperformance of the go-around procedure must be viewed as the cause for the runway excursion.

The BFU analysed that the aircraft or its systems were functioning normally and did not contribute to the occurrence. Although the airport operator stated the runway was damp only, the BFU concludes from statements of tower and pilots the runway was contaminated with water and puddles of water.

The BFU analysed:

The CVR contained the approach briefing for runway 32 including a possible goaround procedure. The MCDU calculated the approach speed (VAPP) based on the actual aircraft mass.

After he had disengaged autopilot and auto-thrust during the approach the PIC instructed the co-pilot to add 5 kt to the approach speed (VAPP) in the approach menu of the MCDU. He did not explain this instruction. The airplane crossed the 50 ft radio altitude point at the threshold with about 151 kt IAS and a ground speed of about 163 kt. The software on the EFB had calculated a VAPP of 131 kt. It could not be determined which speed the MCDU had calculated.

Due to the added speed of 5 kt the landing distance required increased. The landing
distance calculation was not updated. This resulted in an approach speed which was
too high and inappropriate given the circumstances. The BFU does not understand
the added speed because of the prevailing tailwind during the approach with no gusts
speed increase was not required.
The added speed was an essential contributory factor which resulted in the runway
excursion.
The high speed, the long flare phase and the prevailing tailwind resulted in a late
touchdown. The touchdown point was about 930 m beyond the threshold and
therefore about 330 m outside the stipulated touchdown zone. The remaining landing
distance was approximately 1,130 m.
Given the prevailing limiting conditions an additional risk assessment would have
made sense. It would have been advisable to conduct a detailed approach briefing
including the individual actions during a go-around procedure.
Both pilots used the Runway Condition Assessment Matrix for Landing. Based on the
degree of the runway surface contamination the respective brake performance
classification was determined. The pilots classified the runway contamination as 4 -
Good to Medium. The landing distance calculation based on this classification.
Comparison of landing distance required and landing distance available showed a
safety margin of 130 m.
The aircraft manufacturer calculated the landing distance for the area where the PIC
had applied manual brake pressure. It showed that the pilots’ calculation of the
landing distance required was close to the actual values.

The airplane touched down about 330 m after the touchdown zone marking. At that time, both pilots were probably not aware that they were already in the second half of the runway.

After the ground spoilers had deployed the auto brake system activated about 2 s later with a mean deceleration of about 0.3 g. By activating the pedal in the cockpit the auto brake system was deactivated. Mean deceleration rate fluctuated between 0.19 g and 0.32 g. According to the FDR, brake pedal position was about 80°, which is the maximum possible angle. This shows that the PIC tried to achieve the highest possible deceleration.

The brake pressure, which was generated through the auto brake system with the switch position Medium, was between about 550 psi and about 2,200 psi. Due to the runway contaminated with standing water braking action was reduced. The fluctuating brake pressure can be explained by the opening and closing of the antiskid valves13. It is hard to say if the airplane could have been stopped prior to the end of the runway if maximum manual brake pressure had been applied after touchdown.

Based on the calculation of the landing distance required (1,990 m) both pilots must have been aware that the safety margin was extremely small and about 130 m long.

Especially with short runways, which in this case was also covered with water, a socalled positive touchdown, without long flare phase, would have been necessary. The PIC should have considered this in a risk assessment and included it into the approach briefing.

Crew Resource Management is one safety mechanism in aviation. The fundamental point is that the flight crew members monitor and observe each other and share which actions deviate from the standard procedure and give correction instructions.

Teamwork in the cockpit also means that the other person is included in the decision making process. The co-pilot would have had the option to initiate a go-around procedure by using the callout Go-Around according to the Standard Callout Procedure of the operator.

Given the circumstances one of the pilots should have made the callout Go-Around and therefore initiated the go-around procedure. Had the go-around procedure been initiated in due time the runway excursion would have been prevented.

Related NOTAMs:
B1540/17 - WESTERLAND DME WES 111.50/CH52 OUT OF SERVICE. 30 SEP 08:50 2017 UNTIL 30 SEP 23:59 2017. CREATED: 30 SEP 08:51 2017

C2814/17 - ILS RWY 32 OUT OF SERVICE. 30 SEP 08:48 2017 UNTIL 30 SEP 23:59 2017. CREATED: 30 SEP 08:48 2017

C2812/17 - RWY 14/32 CLOSED FOR LANDING. TAKE OFF RWY 14 POSSIBLE. 30 SEP 09:00 2017 UNTIL 30 SEP 23:59 2017. CREATED: 30 SEP 08:42 2017

Metars:
EDXW 300750Z 14011KT 2000 BR OVC003 15/14 Q1015=
EDXW 300720Z 14012KT 1800 BR OVC002 15/14 Q1015=
COR EDXW 300620Z 14011KT 1200 R14/P2000N RA BR OVC002 15/14 Q1015=
EDXW 300550Z 14011KT 1800 BR OVC003 15/14 Q1015=
EDXW 300520Z 14011KT 2500 BR OVC004 15/14 Q1015=