Air Berlin B738 at Nuremberg on Jan 8th 2010, veered off runway

Last Update: April 27, 2012 / 15:42:52 GMT/Zulu time

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Incident Facts

Date of incident
Jan 8, 2010

Airline
Air Berlin

Aircraft Registration
F-GTAT

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

The German BFU released their final report in German concluding the probable causes of the serious incident were:

too high a speed during line up with the snow covered runway.

Contributing factors were:

- the "rolling takeoff" was not conducted in accordance with the operating manual of the airline

- the procedure "static run-up" was not executed although required in the existing weather conditions

- the continuous heavy snow fall resulted in a snow cover on the runway despite continuous snow clearing activity

- the published procedures for "adverse weather" and "initiating takeoff roll" were not executed according to operator's operations manual and flight crew operating manual.

The BFU reported the aircraft departed with a delay of about one hour. Following de-icing procedures the crew reported ready for departure, ground control reported "braking action on runway medium, contact tower". The aircraft was subsequently instructed by tower to "hold short, I'll call you". Some time later the controller queried "ready for rolling", the crew replied "affirm" and was cleared to line up runway 10. About 13 seconds after that instruction the aircraft was cleared for takeoff with the note "company traffic is 6 miles". The aircraft taxied onto the runway with a speed of 21 knots above ground, during the turn onto the runway both main gear came to the left of the runway center line, the crew turned further right to get back onto the runway center line but were unable to steer the aircraft left subsequently.

The flight data recorder showed that during line up, at a heading of about 020 degrees (runway heading 099 degrees) both power levers were increased from about 36 to 46 degrees resulting in the engines accelerating from 21% N1 to 43% N1, the left engine reached 43% N1 when the aircraft turned through 073 degrees at a ground speed of 12 knots. In the next 12 seconds the aircraft accelerated to 19 knots, the aircraft continued to turn right until 112 degrees, the turn continued until reaching 120 degrees at 17 knots ground speed. At that point the power levers were retarded, the engines reduced to 21% N1 and the aircraft stopped within 6 seconds, however not without leaving the right runway edge at a ground speed of 17 knots. About 15 meters after exiting the runway the aircraft stopped with the left main gear on the runway, nose and right main gear off the paved surface about 5 meters off the runway edge at a heading of 107 degrees.

The captain (50, ATPL) had a total experience of 5,291 hours and 3,720 hours on type, the first officer (39, CPL) had a total experience of 4,603 hours and 1,738 hours on type.

At the time of the serious incident the runway was covered with wet snow of 2 millimeters (0.08 inches), the braking action was medium.

The BFU analysed that the thrust was increased too early when the aircraft turned through heading 020. With the existing runway conditions - a snow cover was visible throughout the runway - the crew must have anticipated that the gear would skid. The large angle to the runway center line, the high speed and the power increase caused the aircraft to skid with both main gear beyond the runway centerline, the crew attempted to compensate by increased deflection of nose wheel steering, however due to the slippery runway surface, increasing speed and increasing thrust a controlled line up was no longer possible also resulting in the impossibility of a controlled and safe takeoff run.

The crew did not adhere to the rolling takeoff requirements which would have required the nose wheel steering position at center. With the difficult surface conditions steering of the aircraft with nose wheel steering was more difficult.

In any case, under the existing weather conditions and the fact that engine anti-ice was activated, the crew would have been required to use "static run up" (stop the aircraft holding the brakes while engines accelerate to 70% N1), which however did not happen.
Incident Facts

Date of incident
Jan 8, 2010

Airline
Air Berlin

Aircraft Registration
F-GTAT

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

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