Enerjet B737 at Fort Nelson on Jan 9th 2012, overran runway on landing
Last Update: April 26, 2013 / 15:26:17 GMT/Zulu time
Incident Facts
Date of incident
Jan 9, 2012
Classification
Incident
Aircraft Type
Boeing 737-700
ICAO Type Designator
B737
Findings as to Causes and Contributing Factors
- The captain did not attain appreciable sleep in the 24 hours preceding the flight and was fatigued, likely resulting in attention decrements.
- The captain continued the approach when the aircraft was not in a stabilized configuration, consistent with fatigue-induced reduction in forward planning and a focus of attention towards salvaging the flight.
- On short final the captain pitched the aircraft nose-down in an attempt to capture the glideslope which was below their flight path. The nose-down attitude increased the airspeed resulting in a longer flare and a touchdown beyond the recommended 1000-feet mark, thus reducing the amount of available runway for stopping.
- The autothrottle system was not disengaged below 50 feet, which resulted in the A/T system increasing thrust in order to maintain the selected airspeed. This increase in thrust delayed the deployment of the speed brakes and thrust reversers, which left insufficient runway in which to stop.
Findings as to Risk
- If flight crews are not given training on fatigue and fatigue countermeasures, they risk not having the tools they need to deal with fatigue.
- If flight crew are required to assess their own level of fatigue and the effects it will have on their performance, they may not identify unacceptable levels of fatigue.
Other Findings
- The conditions experienced on landing were equal to or better than the runway surface condition report and Canadian Runway Friction Index readings indicated.
The captain had spent the night prior to the flight in a bedroom located above the boiler room of an apartment complex, the bedroom was warm and noisy, the captain thus had little or no sleep in the 24 hours prior the incident flight. He therefore considered to call in sick, but decided not to as it could have appeared unfavourable on him (the TSB annotated: "There were no indications that the culture at Enerjet was punative towards crew calling in sick for fatigue.")
The first officer had well rested the night before the flight.
The captain (ATPL, 7,500 hours total, 2,000 hours on type, 50 hours in command) was pilot flying, it was his first flight as pilot in command with a line first officer (5,600 hours total, 700 hours on type). About 25 minutes prior to landing the captain conducted an aproach briefing indicating a visual landing on runway 03 with ILS backup, full flaps landing and autobrakes at 3. A Vref of 128 knots was computed, Fort Nelson flight service provided a runway condition reporting indicating 60% of the runway were bare and dry 120 feet around the center line, 30% ice patches and 10% frost, remaining width 100% frost, the runway friction index at -9 degrees C was 0.43. Still on autopilot the approach mode was armed, the aircraft began to turn onto final about 1nm outside the final approach fix, about 5nm before touchdown descending through 1850 feet AGL. Established on final, descending through 1000 feet AGL and 5nm before touchdown, the captain called for the final landing checklist, the aircraft was configured with gear down, flaps at 15 degrees. The autopilot was disconnected with autothrottles left engaged, flaps 30 and flaps 40 were called, the captain selected 133 knots (Vref+5) into the master control panel, the first officer completed the landing checklist.
40 seconds before touchdown, at 420 feet AGL, the aircraft intercepted the glideslope, the flight directors were cycled off and on resulting in all modes changing to their defaults (altitude acquire, hold heading) and the flight directors reappeared indicating such modes.
The aircraft encountered a decreasing tailwind of 10 knots and go high on the glideslope reaching about one dot above glide. In response the captain pitched down, the aircraft accelerated to 142 knots and the rate of descent increased to 975 fpm.
The automatic call outs 50, 40, 30, 20, 10 (feet) sounded, however, the autothrottles were not disengaged at 50 feet as per procedures, the aircraft touched down at 134 knots 1800 feet past the threshold with 4600 feet of runway remaining. When the captain moved his hand to pull the thrust levers into reverse, autothrottle responded and moved the thrust levers forward to maintain 133 knots as instructed by the MCP, this thrust lever advance preventing spoiler extension. The captain repositioned his hand, disconnected the autothrottle, brought the thrust levers to idle and into reverse, there were no call outs by the first officer like "no speedbrakes", "no reverse" or "autobrakes disarm" during roll out as would have been required. Deceleration began with about 2500 feet of runway remaining 5 seconds after touchdown, full manual braking was applied, maximum reverse was selected and the speed brakes were fully extended. The aircraft slowed at -0.35G consistent with a bare and dry runway surface condition. The aircraft overran the end of the runway at about 10-15 knots and came to a stop 230 feet past the runway end and about 20 feet left of the center line. The main landing gear came to a stop on frozen soil and the nose gear in 18 inches of snow. About 70 seconds after the aircraft came to a stop the engines were shut down.
The TSB reported: "Initially, Fort Nelson Fire Rescue responded with one 1500 gallon water pump truck, a rescue truck, and a pickup truck from town, 9 kilometres from the airport. They were turned back when the flight crew identified that they did not need emergency assistance as there were no indications of fire, damage, or injuries to passengers or crew."
The TSB analysed that the approach was not stabilized as it did not conform to a 3 degrees glidepath. The crew elected to continue the approach as the speed was stable, the aircraft's tendency was towards the glideslope, the aircraft was being configured for landing and the approach appeared salvageable. However, on short final and into the flare the aircraft was flying at 140 knots (Vref+12), the extra speed was carried over the runway threshold and resulted in a longer flare with a touchdown about 800 feet beyond Boeing's recommended touchdown (1000 feet past threshold). Autoththrottles were still operating to the commande mode maintaining the selected speed of 133 knots resulting in a thrust increase shortly after touchdown, the speed brakes did not deploy as result with the full weight of the aircraft not resting on the landing gear decreasing the brakes efficiency and producing little drag, in addition the thrust reversers were deployed with a delay requiring additional runway length.
The TSB stated: "The length of the runway was appropriate to the operation but afforded little room for deviation from aircraft speed on landing and the touchdown point. The runway surface condition was as issued and may have even been better in terms of braking friction given the deceleration forces that were realized in the last 2500 feet of the landing roll, and accounts for the aircraft stopping in 6632 feet rather than the 7168 feet predicted by the landing distance chart."
Incident Facts
Date of incident
Jan 9, 2012
Classification
Incident
Aircraft Type
Boeing 737-700
ICAO Type Designator
B737
This article is published under license from Avherald.com. © of text by Avherald.com.
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