Greenland DH8B at Ilulissat on Jan 29th 2014, runway excursion on landing
Last Update: October 25, 2014 / 15:49:35 GMT/Zulu time
Incident Facts
Date of incident
Jan 29, 2014
Classification
Accident
Cause
Runway excursion
Aircraft Registration
OY-GRI
Aircraft Type
De Havilland DHC-8-200 Dash 8
ICAO Type Designator
DH8B
Airport
Ilulissat Airport, Ilulissat
Airport ICAO Code
BGJN
Adverse crosswind conditions at BGJN led to flight crew target fixation, a flight crew divergence from the operator’s stabilized approach parameters and a mental blocking of an appropriate decision on going around.
The flight crew divergence from the operator’s stabilized approach parameters induced a non-stabilized approach, which in combination with power levers retarded below flight idle in flight resulted in an accelerated rate of descent leading to a hard landing, with side load on the left main landing gear at touchdown.
The left main landing gear structural fuse pin sheared as a result of lateral and vertical overload stress.
Cycling the power levers between ground and flight range prevented an appropriate deceleration of the aircraft and prolonged the landing roll.
The prolonged landing roll combined with the application of full left rudder and no decisive use of reverse thrust on the side with the unaffected main landing gear made it impossible for the flight crew to maintain directional control.
The lack of directional control resulted in the aircraft running off the side of the runway and the safety zone, respectively.
The HCL analysed that there was disagreement over the commander's experience level, which permitted the crew to accept 31 knots of cross wind limit instead of 25 knots according to the company procedures. This would also have required to assign two alternate aerodromes instead of just one as happened on the occurrence flight.
The HCL analysed: "During descent to BGJN, the flight crew asked Ilulissat AFIS for a confirmation of whether or not the cross wind of 24 knots included the gusting wind conditions up to maximum 33 knots. Ilulissat AFIS replied that the maximum wind was 35 knots and the cross wind was 26 knots. The reported ATS crosswind was based on a two-minute mean wind and did not take into account an actual gusting spot wind. The flight crew did not challenge the reply on crosswind from Ilulissat AFIS and from that point, the flight crew apparently uncritically accepted further ATS crosswind reporting." and continued: "On short final to runway 07, the wind conditions were reported to be 140° magnetic and 25 knots - maximum to 39 knots. The combination of the ATS phraseology (“maximum to…… three niner knots) and at that time an increasing flight crew work load might have triggered the first officer’s perception of an ATS wind speed reporting of “maximum two niner knots”, which was below the flight crew agreed cross wind limitation of 31 knots."
When the aircraft descended through 996 feet AGL on a 5.1 degrees steep approach (on the high side of the PAPIs), making it difficult to maintain the operator's stabilized approach criteria, the aircraft was at 144 CAS 21% above the maximum speed permitted for a stabilized approach. Descending through 500 feet AGL the aircraft was about 27% in excess of the operators maximum speed while slowing through 138 CAS. At 200 feet AGL the power levers were retarded resulting in a high rate of descent at more than 1000 fpm and a descent below the PAPI glide angle of 5.1 degrees. Descending through 50 feet AGL the rate of descent was more than 1100 fpm at 128 CAS 22% above Vref+5.
The HCL analysed: "With reference to the operator’s stabilized approach parameters, the final approach to runway 07 was not stabilized. Though the flight crew had briefed on a visual missed approach procedure and taken into consideration a potential go-around, no flight crew call out on stabilized approach and no appropriate in-flight risk assessment by mutual verbal challenges were made, which had a direct influence on the sequence of events."
The HCL further analysed: "This non-stabilized approach was not an isolated operator event."
The HCL analysed: "A non-stabilized approach in crosswind conditions above the aircraft and the operator’s crosswind limitations combined with the actual crosswind landing technique and the power levers retarded below flight idle in flight resulted in an accelerated rate of descent leading to a hard landing, with side load on the left main landing gear at touchdown. According to its design, the left main landing gear structural fuse pin sheared as a result of lateral and vertical overload stress."
During the landing roll "the combination of applying full left rudder and no use of decisive reverse thrust on the side with the unaffected main landing gear made it impossible for the flight crew to maintain directional control. ... At the latest OPC, both the commander and the first officer had trained how to handle a main landing gear collapse emergency. However, the flight crew did not succeed in transferring the training experience of handling a main landing gear collapse into an actual emergency."
Incident Facts
Date of incident
Jan 29, 2014
Classification
Accident
Cause
Runway excursion
Aircraft Registration
OY-GRI
Aircraft Type
De Havilland DHC-8-200 Dash 8
ICAO Type Designator
DH8B
Airport
Ilulissat Airport, Ilulissat
Airport ICAO Code
BGJN
This article is published under license from Avherald.com. © of text by Avherald.com.
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