Skylease Cargo B744 at Halifax on Nov 7th 2018, overran runway on landing
Last Update: June 29, 2021 / 13:19:13 GMT/Zulu time
Incident Facts
Date of incident
Nov 7, 2018
Classification
Accident
Airline
SkyLease Cargo
Flight number
GG-4854
Departure
Chicago O'Hare, United States
Destination
Halifax, Canada
Aircraft Registration
N908AR
Aircraft Type
Boeing 747-400
ICAO Type Designator
B744
Airport ICAO Code
CYHZ
Emergency services reported the aircraft with 4 crew went beyond the runway end. The airport was closed.
The airport initially reported there were 5 people on board of the aircraft but later corrected there were 4 people on board.
The Canadian TSB have dispatched investigators on site.
According to communication with Halifax tower the aircraft was on an ILS approach to runway 14, tower reported the winds from 260 degrees at 14 knots on initial contact, about 90 seconds later tower reported the winds were now from 260 degrees at 16 knots gusting 21 knots and queried whether runway 14 was still acceptable, the crew confirmed, tower cleared the aircraft to land on runway 14. A short time prior to touchdown tower reported winds from 250 degrees at 15 gusting 21 knots. 5 minutes after initial contact the crew reported they had gone off the runway and needed full emergency support. Tower activated the crash alert. Tower advised responding rescue vehicles the aircraft was at the threshold runway 32. Arriving first vehicles reported there was a small fire at the tail, they needed everyone out. 8 minutes after the first vehicles arrived on scene the fire chief reported the small fire at the tail has been put out, there was no fire on board of the aircraft.
On Nov 8th 2018 the TSB reported in a news conference the aircraft overran the end of the runway by 210 meters and collided with the localizer antenna. All landing gear collapsed, engines #2 and #3 separated, a fire ensued from the #2 engine that came to rest near the tail of the aircraft. The black boxes as well as a other devices recording data are being removed from the aircraft.
On Nov 19th 2018 the TSB reported a Class 3 investigation has been opened.
On Jun 29th 2021 the TSB released their final report concluding the probable causes of the accident were:
Findings as to causes and contributing factors
- The ineffective presentation style and sequence of the NOTAMs available to the crew and flight dispatch led them to interpret that Runway 23 was not available for landing at Halifax/Stanfield International Airport.
- The crew was unaware that the aircraft did not meet the pre-departure landing weight requirements using flaps 25 for Runway 14.
- Due to the timing of the flight during the nighttime circadian trough and because the crew had had insufficient restorative sleep in the previous 24 hours, the crew was experiencing sleep-related fatigue that degraded their performance and cognitive functioning during the approach and landing.
- Using unfactored (actual) landing distance charts may have given the crew the impression that landing on Runway 14 would have had a considerable runway safety margin, influencing their decision to continue the landing in the presence of a tailwind.
- When planning the approach, the crew calculated a faster approach speed of reference speed + 10 knots instead of the recommended reference speed + 5 knots, because they misinterpreted that a wind additive was required for the existing conditions.
- New information regarding a change of active runway was not communicated by air traffic control directly to the crew, although it was contained within the automatic terminal information service broadcast; as a result, the crew continued to believe that the approach and landing to Runway 14 was the only option available.
- For the approach, the crew selected the typical flap setting of flaps 25 rather than flaps 30, because they believed they had a sufficient safety margin. This setting increased the landing distance required by 494 feet.
- The crew were operating in a cognitive context of fatigue and biases that encouraged anchoring to and confirming information that aligned with continuing the initial plan, increasing the likelihood that they would continue the approach.
- The crew recognized the presence of a tailwind on approach 1 minute and 21 seconds from the threshold; likely due to this limited amount of time, the crew did not recalculate the performance data to confirm that the runway safety margin was still acceptable.
- An elevated level of stress and workload on short final approach likely exacerbated the performance-impairing effects of fatigue to limit the crew’s ability to determine the effect of the tailwind, influencing their decision to continue the approach.
- The higher aircraft approach speed, the presence of a tailwind component, and the slight deviation above the glideslope increased the landing distance required to a distance greater than the runway length available.
- After the firm touchdown, for undetermined reasons, the engine No. 1 thrust lever was moved forward of the idle position, causing the speed brakes to retract and the autobrake system to disengage, increasing the distance required to bring the aircraft to a stop.
- The right crab angle (4.5°) on initial touchdown, combined with the crosswind component and asymmetric reverser selection, caused the aircraft to deviate to the right of the runway centreline.
- During the landing roll, the pilot monitoring’s attention was focused on the lateral drift and, as a result, the required callouts regarding the position of the deceleration devices were not made.
- The pilot flying focused on controlling the lateral deviation and, without the benefit of the landing rollout callouts, did not recognize that all of the deceleration devices were not fully deployed and that the autobrake was disengaged.
- Although manual brake application began 8 seconds after touchdown, maximum braking effort did not occur until 15 seconds later, when the aircraft was 800 feet from the end of the runway. At this position, it was not possible for the aircraft to stop on the runway and, 5 seconds later, the aircraft departed the end of the runway at a speed of 77 knots and came to a stop 270 m (885 feet) past the end of the runway.
- During the overrun, the aircraft crossed a significant drop of 2.8 m (9 feet) approximately 166 m (544 feet) past the end of the runway and was damaged beyond repair. While this uneven terrain was beyond the 150 m (492 feet) runway end safety area proposed by Transport Canada, it was within the recommended International Civil Aviation Organization runway end safety area of 300 m (984 feet).
Findings as to risk
- If the pilot monitoring does not call out approach conditions or approach speed increases, the pilot flying might not make corrections, increasing the risk of a runway overrun.
Other findings
- The investigation concluded that there was no reverted rubber hydroplaning and almost certainly no dynamic hydroplaning during this occurrence.
- Although viscous hydroplaning can be expected on all wet runways, the investigation found that when maximum braking effort was applied, the aircraft braking was consistent with the expected braking on Runway 14 under the existing wet runway conditions.
The TSB summarized the accident:
The crew conducted the Runway 14 instrument landing system approach. When the aircraft was 1 minute and 21 seconds from the threshold, the crew realized that there was a tailwind; however, they did not recalculate the performance data to confirm that the landing distance available was still acceptable, likely because of the limited amount of time available before landing. The unexpected tailwind resulted in a greater landing distance required, but this distance did not exceed the length of the runway.
The aircraft touched down firmly at approximately 0506 Atlantic Standard Time, during the hours of darkness. After the firm touchdown, for undetermined reasons, the engine No. 1 thrust lever was moved forward of the idle position, causing the speed brakes to retract and the autobrake system to disengage, increasing the distance required to bring the aircraft to a stop. In addition, the right crab angle (4.5°) on initial touchdown, combined with the crosswind component and asymmetric reverser selection, caused the aircraft to deviate to the right of the runway centreline.
During the landing roll, the pilot monitoring’s attention was focused on the lateral drift and, as a result, the required callouts regarding the position of the deceleration devices were not made.
Although manual brake application began 8 seconds after touchdown, maximum braking effort did not occur until 15 seconds later, when the aircraft was 800 feet from the end of the runway. At this position, it was not possible for the aircraft to stop on the runway and, 5 seconds later, the aircraft departed the end of the runway at a speed of 77 knots and came to a stop 270 m (885 feet) past the end.
The aircraft struck the approach light stanchions and the localizer antenna array. The No. 2 engine detached from its pylon during the impact sequence and came to rest under the left horizontal stabilizer, causing a fire in the tail section following the impact. The emergency locator transmitter activated. Aircraft rescue and firefighting personnel responded. All 3 crew members received minor injuries and were taken to the hospital. The passenger was not injured.
During the overrun, the aircraft crossed a significant drop of 2.8 m (9 feet) approximately 166 m (544 feet) past the end of the runway and was damaged beyond repair. While this uneven terrain was beyond the 150 m (492 feet) runway end safety area proposed by Transport Canada, it was within the recommended International Civil Aviation Organization runway end safety area of 300 m (984 feet). In 2007, the Board recommended that
"the Department of Transport require all Code 4 runways to have a 300 m runway end safety area (RESA) or a means of stopping aircraft that provides an equivalent area of safety. TSB Recommendation A07-06"
In addition, runway overruns is one of the issues on the TSB’s Watchlist 2020. The TSB Watchlist identifies the key safety issues that need to be addressed to make Canada’s transportation system even safer.
The investigation included a thorough fatigue analysis, which identified the presence of 2 fatigue risk factors that would have degraded the crew’s performance during the approach and landing: the timing of the flight and insufficient restorative sleep in the 24-hour period leading up to the occurrence. Fatigue management is also one of the safety issues on the TSB’s Watchlist 2020.
Related NOTAMs:
A3259/18 NOTAMN
Q) CZQM/QMRLC/IV/NBO/A /000/999/4452N06330W005
A) CYHZ B) 1811071230 C) 1811072000
E) RWY 14/32 CLSD
A3286/18 NOTAMR A3268/18
Q) CZQM/QMDCH/IV/NBO/A /000/999/4452N06330W005
A) CYHZ B) 1811071115 C) 1811082100
E) FIRST 1767 FT RWY 23 CLSD. THR 23 IS RELOCATED 1767 FT
MARKED WITH BANNERS AND TEMPO RTHL.
DECLARED DIST:
RWY 05 TORA 8733 TODA 9717 ASDA 10140 LDA 8733
RWY 23 TORA 8733 TODA 9422 ASDA 8733 LDA 8733
A3279/18 NOTAMN
Q) CZQM/QFFAS/IV/NBO/A /000/999/4452N06330W005
A) CYHZ B) 1811070940 C) 1811080000
E) FIRE AND RESCUE OUT OF SERVICE
CYHZ ILS 23 U/S
1811062155-1811082100
A3268/18 NOTAMR A3251/18
Q) CZQM/QMDCH/IV/NBO/A /000/999/4452N06330W005
A) CYHZ B) 1811062030 C) 1811071230
E) FIRST 1767 FT RWY 23 CLSD. THR 23 IS RELOCATED 1767 FT
MARKED WITH BANNERS AND TEMPO RTHL.
DECLARED DIST:
RWY 05 TORA 8733 TODA 9717 ASDA 10140 LDA 8733
RWY 23 TORA 8733 TODA 9422 ASDA 8733 LDA 8733
A3280/18 NOTAMN
Q) CZQM/QFALC/IV/NBO/A /000/999/4452N06330W005
A) CYHZ B) 1811070950 C) 1811080000
E) AD CLSD DUE TO INCIDENT
Metars:
CYHZ 071023Z 23013KT 12SM SCT007 SCT015 BKN070 OVC090 13/13 A2967 RMK SF3SC1AC3AC1 SLP050 DENSITY ALT 700FT=
CYHZ 071000Z 23012G19KT 12SM -RA SCT006 BKN036 OVC070 13/13 A2967 RMK SF3SC2AC3 SLP051 DENSITY ALT 700FT=
CYHZ 070950Z 23013G18KT 12SM -RA SCT006 BKN036 OVC070 13/13 A2967 RMK SF3SC2AC3 SLP051 DENSITY ALT 700FT=
CYHZ 070912Z 23011G18KT 8SM -RA BR SCT005 BKN012 OVC049 14/14 A2967 RMK SF4SC2SC2 SLP050 DENSITY ALT 800FT=
CYHZ 070900Z 23013KT 7SM -RA BR BKN005 OVC013 14/14 A2967 RMK SF5SC3 SLP050 DENSITY ALT 800FT=
CYHZ 070800Z 21010KT 7SM -RA BR BKN005 OVC036 15/15 A2968 RMK SF5SC3 PRESRR SLP052 DENSITY ALT 900FT=
CYHZ 070754Z 21011G17KT 7SM -RA BR BKN005 OVC036 15/15 A2967 RMK SF5SC3 PRESRR SLP049 DENSITY ALT 900FT=
CYHZ 070719Z 19013KT 2SM -RA BR OVC003 15/15 A2966 RMK ST8 PRESFR SLP046 DENSITY ALT 900FT=
CYHZ 070700Z 20012KT 8SM -RA BR OVC003 15/15 A2968 RMK ST8 PRESFR SLP054 DENSITY ALT 900FT=
CYHZ 070600Z CCA 22018G28KT 6SM -RA BR OVC005 15/15 A2969 RMK ST8 /R23/ SLP056 DENSITY ALT 900FT=
CYHZ 070500Z 21018G31KT 5SM -SHRA BR OVC003 15/15 A2969 RMK ST8 CVCTV CLD EMBD SLP058 DENSITY ALT 900FT=
Aircraft Registration Data
Incident Facts
Date of incident
Nov 7, 2018
Classification
Accident
Airline
SkyLease Cargo
Flight number
GG-4854
Departure
Chicago O'Hare, United States
Destination
Halifax, Canada
Aircraft Registration
N908AR
Aircraft Type
Boeing 747-400
ICAO Type Designator
B744
Airport ICAO Code
CYHZ
This article is published under license from Avherald.com. © of text by Avherald.com.
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