Canada B763 at Halifax on Mar 4th 2019, pirouette on roll out

Last Update: October 9, 2019 / 15:38:57 GMT/Zulu time

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Incident Facts

Date of incident
Mar 4, 2019

Classification
Incident

Airline
Air Canada

Flight number
AC-614

Destination
Halifax, Canada

Aircraft Registration
C-FTCA

Aircraft Type
Boeing 767-300

ICAO Type Designator
B763

Airport ICAO Code
CYHZ

An Air Canada Boeing 767-300, registration C-FTCA performing flight AC-614 from Toronto,ON to Halifax,NS (Canada) with 211 passengers and 8 crew, landed on Halifax's runway 23 at 18:30L (22:30Z) after performing a CAT II ILS approach. ATC had advised that taxiway C and B had not been cleared and were not usable and instructed the flight to vacate the runway via taxiway A at the end of the runway. Subsequently tower advised the end of the runway was "very slippery". About 2570 meters down the runway the aircraft skided, turned around by 180 degrees and came to a stop in a snow bank short of taxiway B. The passengers disembarked onto the runway via stairs and were taken to the terminal.

Ground services reported the runway was 100% ice, the chemical truck had just broken down while trying to spray the runway, "not looking good".

A preceding landing reported the braking action was "very poor".

The aerodrome was closed for about 4 hours as result.

The Canadian TSB have dispatched a team of investigators on site.

The airline reported the aircraft could not taxi to the apron because of poor weather conditions. The aircraft was inspected by maintenance and towed to the apron.

On Mar 7th 2019 NAV Canada reported the aircraft "landed on Runway 23 and, during rollout, slid and turned 180 degrees. Runway 05/23 was closed until the aircraft could be towed off. Operations were impacted due to the concurrent closure of Runway 14/32, resulting in multiple diversions." The runway was closed for 5.5 hours.

On Mar 14th 2019 the Canadian TSB reported: "During the landing rollout on Runway 23, the aircraft encountered a slippery area on the runway and was pushed by the wind, causing it to turn approximately 45° to the right. The nose wheel entered a snow ridge on the edge of the runway, which caused the rear of the aircraft to slide approximately 180°, coming to a stop facing in the opposing direction of travel. Due to the weather conditions, the surface of the runway experienced a flash freeze from a wet condition, and became extremely slippery as ice formed quickly. Passengers were taken to the terminal by bus, and the aircraft was towed to the apron. There was no damage to the aircraft, and no injuries reported by the passengers or crew."

On Oct 9th 2019 the TSB released their final report without a formal conclusion. The report released following safety message:

To ensure the accuracy of runway surface condition (RSC) reports, it is important that a comprehensive runway inspection be performed before a report is issued, especially in times of changing weather.

Monitoring the airfield at all times is important, particularly during rapidly changing weather, when runway surface conditions can deteriorate quickly.

The use of standard phraseology between pilots and air traffic controllers may help reduce the likelihood of misunderstanding the degree to which a runway may be contaminated.

The TSB reported the B763 had entered a holding due to the weather conditions being below minimum. When the weather conditions improved and the aircraft received vectors for an approach to runway 32. The TSB wrote:

At 1817:03, as the aircraft was proceeding to Runway 32, the Halifax terminal controller2 issued the crew the CYHZ aerodrome special meteorological report (SPECI) from 1809, which indicated visibility 1¼ statute miles (SM) in light freezing drizzle and mist; vertical visibility 200 feet above ground level (AGL); temperature and dew point both −1 °C. The controller added the current winds — wind 350° magnetic (M) at 20 knots, gusting to 30 knots, and the altimeter setting of 29.14 inches of mercury. The terminal controller also offered the crew the option of landing on Runway 23, because it had just become available. Runway 23 is longer than Runway 32, and has a precision approach system with lower approach minimums. However, Runway 23 had a crosswind component of 17 knots gusting to 26 knots, and a tailwind of 10 knots gusting to 15 knots. Because of the longer runway and the precision approach, the crew accepted vectors for the category II precision approach to Runway 23. The crew adjusted the aircraft’s instruments to the required settings and briefed the Runway 23 approach.

At 1817:36, the Halifax terminal controller relayed the runway surface condition (RSC) report that was issued at 18083 for Runway 23 to both the occurrence crew and the crew of an Embraer aircraft that was flying ahead of it. Both crews were planning to land on Runway 23. The RSC for Runway 05/23 indicated a 160-foot centreline, 20% compacted snow, 80% bare and wet, remaining width 70% wet snow 1 inch, 30% bare and wet. Based on this RSC, a Canadian Runway Friction Index was not provided, nor was one required.

The Embraer aircraft landed on Runway 23 at 1822. After providing the crew with instructions to exit the runway onto Taxiway A at the end of the runway, the Halifax tower controller4 asked the crew for comments on the approach. The crew replied, “we had the field5 at 300 feet; braking action was very poor, actually”. Once the aircraft was off the runway, the crew switched to the Halifax ground controller’s frequency and reported that the runway was “very, very icy; it’s basically a skating rink“.

At 1824:22, the Halifax tower controller relayed the braking action report to the crew of a DHC-8 aircraft that was on approach for Runway 32, stating that the Embraer crew reported, “lights in sight at 300 [feet] AGL on that approach, and braking action was poor on Runway 23.”

At 1824:50, the Halifax tower controller called the Halifax Terminal controller to say that, “[the pilot of the Embraer aircraft] says the runway is a skating rink. He barely got stopped by the end of the runway and turned on [Taxiway] A”. After the Halifax terminal controller asked for more information on the conditions, the Halifax tower controller replied, “lights in sight at 300 feet above the ground.”

At 1825:15, the Halifax terminal controller contacted the occurrence flight crew to provide the Embraer’s pilot weather report (PIREP), stating, “we had [the Embraer] roll out on 23, and he said it was very slippery. He barely got stopped towards the end of it. As far as visibility he saw things at 300 feet above the ground.” The crew responded, “thanks for the heads up.”

At 1826:00, the DHC-8 aircraft landed on Runway 32.

At 1826:54, the crew of the occurrence aircraft switched to the Halifax tower controller’s frequency, and was provided information for the planned landing on Runway 23. The Halifax tower controller asked the crew if it had received the comments from the Embraer that had just landed, and the crew responded in the affirmative.

At 1827, the DHC-8’s crew was asked for comments on the approach. The crew reported, in part, that braking was good for them but they could see how it was slippery.

At 1828, the occurrence flight was cleared to land on Runway 23. As part of the clearance, the Halifax tower controller informed the crew that the wind was 350°M at 24 knots, gusting to 31 knots, and instructed it to exit onto Taxiway A, at the end of the runway.

The aircraft landed within the first third of the runway at an airspeed of about 140 knots. After touchdown, the crew used full reverse and auto-braking on the first portion of the runway as they had understood from communications with air traffic control that it was the end portion of the runway that was slippery. As the aircraft slowed and the crew reduced reverse thrust, the braking action was noted to become nil. When the aircraft slowed through about 15 knots, the aircraft began to slide. The captain attempted asymmetrical reverse thrust to correct weathervaning due to a loss of steering authority. The crosswind pushed the aircraft sideways, causing the nose wheel to roll into the snow off the right edge of the runway. This caused the forward motion of the aircraft to be translated into a slow sideways drift and clockwise rotation on the icy runway. Pushed by the crosswind, the aircraft rotated 180°, coming to rest facing the opposite direction, with all the wheels on the paved portion of the runway. At 1831, the crew called the Halifax tower controller to report that the aircraft was stopped on the runway, facing the wrong way (figures 1 and 2). The crew also asked the controller to not allow any aircraft to land on the runway.

At 1835, the Halifax tower controller informed the crew that Runway 23 was closed.

No injuries were reported. There was no damage to the aircraft. The passengers were shuttled to the terminal on airport park and ride buses, and the aircraft was towed to the gate after release by the TSB.

The TSB analysed with respect to the braking:

Standard phraseology for braking action is “good,” “medium,” “poor,” or “nil.” The Embraer crew reported a braking action of “very poor” to the Halifax tower controller immediately after landing. While taxiing, the crew used plain language to describe the condition of the runway in its communication with the Halifax ground controller.

This plain language description was relayed between the Halifax tower and Halifax terminal controllers, and consequently passed on to the crew involved in the occurrence. Even though NAV CANADA permits the use of plain language without altering the sense of the message in any way,8 the words “very poor” were not relayed to the crew.

Before landing, the crew involved in the occurrence had been informed that the runway was very slippery, and that an aircraft that had just landed was barely able to stop by the end of the runway. Therefore, the crew prepared to apply aggressive deceleration early in the landing roll, by using reverse thrust and autobraking, to minimize exposure to the end portion of the runway, which they understood to be very slippery. The aircraft lost deceleration as it passed Taxiway C. As the aircraft was nearing Taxiway B, it was blown sideways on the icy runway, and control of the aircraft was lost.

With respect to monitoring the runway condition the TSB analysed after describing the snow removal efforts:

The airport duty manager (ADM) reviewed the RSC report and communicated to the AMS that the windrows of snow would have to be removed before the runway could be reopened to aircraft. The airfield maintenance crew continued the snow-clearing operation, and at approximately 1807 the windrows had been cleared from Runway 23. The AMS issued another RSC report at 1808, removing the windrows comment, and increasing the available runway width from 140 feet to 160 feet. The runway was then opened for use. No other runway inspection was performed on Runway 23 before issuing the RSC report at 1808.

At about the same time, the entire airfield maintenance crew that had been working the day shift was returning to the maintenance building to prepare the vehicles for the night shift.

Runway weather information system

CYHZ is equipped with a runway weather information system. The system in use at the time of the occurrence consisted of 6 sensors—3 in each runway—imbedded in the runway centreline. These sensors would relay atmospheric conditions in real time to computer screens in the AMS office in the airside services building. This information is also displayed on screens in the ADM’s office. The information was also available on the AMS’s portable electronic device; however, the device needed to be manually refreshed for the AMS to obtain the most current conditions.

At 1807, the runway weather information system’s status changed from “Wet” to “Ice Warning”. A status of “Wet” means there is a “[c]ontinuous film of moisture on the pavement sensor with temperature above freezing (32°F or 0°C).”10 A status of “Ice Warning” means there is a “[c]ontinuous film of ice and water mixture at or below freezing (32°F / 0°C) with insufficient chemical to keep the mixture from freezing.”

During this time, the ADM was not available to monitor the conditions, and the AMS was returning from the airfield, issuing the 1808 RSC, and preparing for shift change. As a result, the change in the system status that occurred at 1807 went unnoticed.

Related NOTAMs:
A0736/19 NOTAMN
Q) CZQM/QMRLC/IV/NBO/A /000/999/4452N06330W005
A) CYHZ B) 1903042100 C) 1903042300
E) RWY 05/23 CLSD

A0739/19 NOTAMN
Q) CZQM/QMRLC/IV/NBO/A /000/999/4452N06330W005
A) CYHZ B) 1903042300 C) 1903050002
E) RWY 14/32 CLSD

A0741/19 NOTAMR A0738/19
Q) CZQM/QMRLC/IV/NBO/A /000/999/4452N06330W005
A) CYHZ B) 1903042235 C) 1903050200
E) RWY 05/23 CLSD

Metars:
CYHZ 050000Z 31021G28KT 3SM BR OVC002 M05/M05 A2925 RMK ST8 PRESRR SLP914=
CYHZ 042334Z 33020G29KT 4SM BR OVC003 M05/M05 A2922 RMK ST8 PRESRR SLP903=
CYHZ 042300Z 33023G29KT 2SM -FZDZ BR OVC003 M04/M04 A2919 RMK ST8 SLP892=
CYHZ 042240Z 33021G33KT 2SM -FZDZ BR OVC003 M03/M03 A2917 RMK ST8 PRESRR SLP885=
CYHZ 042234Z 32022G31KT 2SM -FZDZ BR OVC002 M03/M03 A2916 RMK ST8 PRESRR SLP882=
CYHZ 042229Z 33024G31KT 2SM -FZDZ BR OVC004 M02/M02 A2916 RMK ST8 PRESRR SLP882=
CYHZ 042209Z 32024G29KT 1 1/4SM R23/3000VP6000FT/U R14/3000VP6000FT/U -FZDZ BR VV002 M01/M01 A2914 RMK FG8 PRESRR SLP875=
CYHZ 042200Z 32019KT 1/4SM R23/3500FT/N R14/3000FT/N -DZ FG VV001 00/00 A2912 RMK FG8 PRESRR SLP869=
CYHZ 042127Z 34013KT 1/4SM R23/2400V4500FT/ R14/1600FT/N FG VV001 01/01 A2911 RMK FG8 SLP864=
CYHZ 042123Z 35011KT 3/8SM R23/2600FT/N R14/2000FT/N FG VV002 01/01 A2911 RMK FG8 SLP864=
CYHZ 042108Z 36009KT 1/2SM R23/2600FT/N R14/3500FT/D FG OVC002 01/01 A2911 RMK FG2ST6 SLP865=
CYHZ 042100Z 01011KT 1SM R23/4500VP6000FT/D R14/3000V4500FT/D -DZ BR OVC002 01/01 A2911 RMK ST8 SLP864=
CYHZ 042049Z 02011KT 2 1/2SM R14/5500VP6000FT/D -DZ BR OVC002 01/01 A2911 RMK ST8 PRESFR SLP865=
CYHZ 042000Z 04004KT 310V080 1 3/4SM R23/4500VP6000FT/D -RA BR OVC004 02/02 A2917 RMK ST8 SLP885=
CYHZ 041922Z CCA 11027G40KT 2SM -DZ BR OVC005 01/01 A2914 RMK ST8 PRESFR SLP876=
CYHZ 041906Z 11021G30KT 1 1/4SM R23/4000V5500FT/D R14/5500VP6000FT/D -RA BR OVC004 01/00 A2918 RMK ST8 PRESFR SLP890=
CYHZ 041900Z 11022G32KT 2 1/2SM R23/5000FT/N -RA BR OVC007 00/00 A2919 RMK NS8 PRESFR SLP894=
Incident Facts

Date of incident
Mar 4, 2019

Classification
Incident

Airline
Air Canada

Flight number
AC-614

Destination
Halifax, Canada

Aircraft Registration
C-FTCA

Aircraft Type
Boeing 767-300

ICAO Type Designator
B763

Airport ICAO Code
CYHZ

This article is published under license from Avherald.com. © of text by Avherald.com.
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