Smartwings B738 at Pardubice on Aug 1st 2018, overran runway on landing

Last Update: July 20, 2019 / 20:32:40 GMT/Zulu time

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Photo of Smartwings N624XA, Boeing 737-800 — Smartwings N624XA, Boeing 737-800 (Photo credit: Alec BHX/KKC / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Aug 1, 2018

Classification
Incident

Cause
Overran runway on landing

Airline
Smartwings

Flight number
QS-1903

Departure
Heraklion, Greece

Destination
Pardubice, Czech Republic

Aircraft Registration
N624XA

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport
Pardubice Airport, Pardubice

Airport ICAO Code
LKPD

A Smartwings Boeing 737-800, registration N624XA performing flight QS-1903 from Heraklion (Greece) to Pardubice (Czech Republic) with 120 people on board, landed on Pardubice's runway 27 (length 2500m/8200 feet) at 18:12L (16:12Z) but overran the end of the runway and came to a stop about 20 meters/70 feet past the end of the runway with all gear on soft ground (no paved runway end safety area available). There were no injuries, the aircraft sustained minor if any damage.

On Oct 26th 2018 Czechia's UZPLN reported the aircraft was on final ILS approach to runway 27, winds were reported from 060 degrees at 4 knots, runway was wet. The first officer, pilot flying, proposed to use a higher autobrakes setting, the captain however insisted on using reversers and lower autobrakes setting. The aircraft crossed the runway threshold at 67 feet AGL, touched down 967 meters/3170 feet past the runway threshold and was unable to stop before the end of the runway. There were no injuries, there was no damage.

On Jul 19th 2019 Czechia's UZPLN released their final report in Czech only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Czech only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe). The report concludes the probable causes of the serious incident were:

The crew did not follow sterile flight deck procedures which led to loss of situational awareness and non-compliance with procedures set out in the Flight Crew Training Manual, failure to calculate landing performance and failure to assess risks and possible errors during landing.

The UZPLN analysed that the crew did not perform a landing performance calculation. They selected flaps 30 and autobrakes setting 2, presumably based on estimations and previous experience on landing in Pardubice. The first officer raised the questions of whether autobrakes 3 should be used but was overruled by the captain stating this wouldn't really matter if reverse thrust is being used. There was slightly stronger tail wind during landing than reported. Had the crew calculated the landing performance with these data they had recognized, for the landing distance available of 2500 meters they'd require a stopping distance only 46-97 meters less than the landing distance available (with a touchdown inside the touch down zone), which might have warned them. However, the aircraft touched down 965 meters past the runway threshold, past the touch down zone.

Dynamic hydroplaning did not occur during the roll out the UZPLN continues analysis. Although the captain took control of the aircraft as it slowed through 80 knots, his actions too could not prevent the runway overrun, the aircraft came to a stop with its main gear 12 meters past the end of the paved surface.

Prior to landing both crew were engaged in a lively discussion about matters not related to the conduct of flight which diverted attention from their functional obligations.

Late Jul 19th 2019 the UZPLN also released the English Version of the final report, the report states the probable causes as:

The flight crew failed to comply with sterile flight deck procedures, which resulted in the loss of situational awareness SITAW, which lead to non-compliance with the procedures stipulated by FCTM, failure to calculate aircraft landing performance, and failure to assess risks and vulnerabilities during landing.

Related NOTAMs:
M0415/18 - AD CLSD. 01 AUG 18:31 2018 UNTIL 02 AUG 10:00 2018 ESTIMATED. CREATED: 01 AUG 18:31 2018

M0414/18 - RWY 09/27 CLSD. 01 AUG 16:29 2018 UNTIL 02 AUG 10:00 2018 ESTIMATED. CREATED: 01 AUG 16:30 2018

Metars:
LKPD 011800Z 05003KT 9999 FEW050CB SCT110 29/18 Q1017 NOSIG=
LKPD 011700Z 05002KT 9999 FEW050CB SCT100 30/19 Q1017 NOSIG=
LKPD 011600Z VRB02KT 9999 VCTS FEW040CB SCT080 28/20 Q1017 NOSIG=
LKPD 011503Z 24003KT 9999 TS FEW046CB SCT120 29/19 Q1017 RMK BLU=
LKPD 011500Z 23004KT 9999 FEW046CB SCT120 28/19 Q1017 RETS NOSIG=
LKPD 011400Z 21005KT 9999 TS FEW042CB SCT050 28/19 Q1017 NOSIG=
LKPD 011349Z 20005KT 9999 TS FEW041CB SCT048 28/19 Q1017 RMK BLU=
LKPD 011340Z 18006KT 9999 VCTS FEW046CB SCT100 27/20 Q1017 RMK BLU=
LKPD 011307Z 13010KT 9999 -TSRA FEW044CB SCT050 29/20 Q1017 RMK BLU=
LKPD 011300Z 11013KT 9999 VCTS -SHRA FEW044CB SCT050 31/17 Q1017 NOSIG=