Aero Contractor B735 at Jos on Aug 21st 2010, runway excursion on landing
Last Update: May 21, 2015 / 14:07:34 GMT/Zulu time
Incident Facts
Date of incident
Aug 21, 2010
Classification
Incident
Cause
Runway excursion
Aircraft Type
Boeing 737-500
ICAO Type Designator
B735
Causal Factor
The decision of the crew to continue the approach in an unstabilized condition, coupled with the Captain in-appropriate attempt to take over control of the aircraft.
Contributory Factors
- Fatigue, which impaired the Captain’s performance and reflected the effects of a long, demanding duty day associated with check airman functions.
- Poor Crew Resource Management.
- The prevailing weather condition.
The AIB reported that the aircraft performed a VOR/DME approach to runway 28, the captain (53, ATPL, 13,800 hours total, 2,172 hours on type), fleet captain, pilot monitoring, requested the runway lights to be turned on but was told by tower that they had problems to turn the lights on. The first officer (25, ATPL, 2,869 hours total, 1,670 hours on type) was pilot flying.
There were low cloud, the runway was wet, and the ILS runway 10 was not available.
7nm before touchdown tower advised the runway lights still hadn't been illuminated due to a problem at the FAAN (Airport Authority Nigeria) electrical power supply. The captain advised they had the runway in sight and received clearance to land on runway 28.
According to the observation by tower he got the aircraft in sight about 1nm before touch down, the aircraft struggled to align with the extended runway center line, then touched down about 135 meters past the runway threshold with the right main gear first at 17:38L (16:38Z) in daylight, went off the runway to the left damaging three runway edge lights and uprooting the armoured cables, the right hand engine made contact with the paved surface of the runway resulting in damage to the engine cowling and ingestion of foreign objects causing damage to the fan blades and punctures at the air intake.
The aircraft subsequently returned to the center line of the runway and came to a stop about 2000 meters past the runway threshold, the nose gear shock strut collapsed and both nose wheels were damaged and the tyres deflated. The aircraft was disabled, the captain requested the passengers to disembark. The AIB stated: "Passengers were later evacuated in an orderly manner without injuries or further incident."
The AIB reported, that although the ILS' glideslope had been NOTAMed to now be serviceable, the approach lights and edge lights runway 10 were reported unserviceable. The NDB (270kHz) also was reported not serviceable.
The weather at 16:00Z had been reported with visibility of 2500 meters, broken clouds ceiling 150 meters, few clouds with thunderstorms ceiling 450 meters, winds from 260 degrees at 18 knots, temperature 19 degrees, QNH 1018hPa.
The AIB analysed: "The captain was busy calling Lagos, and the emergency evacuation was not accomplished as required by the Emergency Operation Check List and Company’s Ops Manual see section 1.17.1.4 above. He later requested for step to disembark the passengers as he could not taxi the aircraft off the runway. Passengers were disembarked without injuries or further incident. The investigation revealed that due to the nature of the incident there was a risk of fire outbreak. The crew did not follow the approved emergency and company procedures to mitigate this possibility."
The AIB analysed that another captain had been rosted to perform the flight, the incident captain had been rostered and had flown three sectors early Aug 21st 2010 providing training.
The rostered captain was, off duty, on board of a Chanchangi flight to Lagos when that flight was diverted to Kaduna, the captain of that flight encountered a problem with Nigeria's Civil Aviation Authority resulting in his license being seized and the captain being unable to continue the flight, so that the incident captain did not arrive in Abuja (and instead performed a flight from Kaduna to Lagos).
The AIB analysed: "The captain was hoping to go home, as he had finished his flight for the day when the issue of the stand-by pilot who reported sick came up. The fleet captain (The captain) opted to operate the Jos flight with the rostered First Officer for the flight."
With respect to human performance the AIB analysed: "There was element of organizational pressure to operate the flight, which the Captain accepted as the fleet captain B737 and a management staff of the airline. The Captain had the option to cancel the flight if he so wished based on the company’s standard operating procedures on duty time. He was not rostered for the flight; but accepted to do the flight as all efforts to access another captain failed. The unstabilised approach led to the Captain attempting to make necessary corrections with inappropriate procedure. The correct procedure would have been the Captain announcing that “I have control” which should be responded by the pilot flying “You have control”. The aircraft lost proper control which resulted in the runway excursion. However, good airmanship requires the captain to take control of the aircraft early enough with a standard callout, when he noticed deviation from the runway centerline axis or make the standard call-out for “Go-around” as the PM."
The AIB analysed crew resource management: "The investigation also revealed poor crew resource management precipitated by lack of adequate communication and poor standard call-out. The CVR revealed that during touchdown neither the captain nor the first officer was in control of the aircraft. “I wanted to go-around; I thought you were the one flying”, crew comment captured in the CVR."
The AIB analysed with respect to the continuation of landing and runway lights: "The Duty ATC officer reported the case of approach light to Electrical department of FAAN as evident in the ATC record from June through July to August 2010; but nothing was done to rectify the issue. The aircraft landed without runway approach and edge lights ON on the day of the incident. Approach lights allow the pilot to visually identify the runway environment and align the aircraft with the runway. It is installed on the approach end of an airport runway and consists of a series of light bars, strobe lights, or a combination of the two that extends outward from the runway end. Runway Edge Lights are used to outline the edges of the runways during periods of darkness or restricted visibility conditions. Runway lightings are used at airports for day and night landings. However, NCAR 8.8.4.15 stipulates what a pilot on approach should use as a visual reference. At Decision Height (DH), if the above references are not available, the pilot must call for a missed approach/go-around."
The AIB analysed that the cockpit voice recorder recordings revealed that the crew did not adequately execute the checklists during the approach, in particular no missed approach had been briefed, and there was no call to go around when it became apparent the approach was not stabilized.
Incident Facts
Date of incident
Aug 21, 2010
Classification
Incident
Cause
Runway excursion
Aircraft Type
Boeing 737-500
ICAO Type Designator
B735
This article is published under license from Avherald.com. © of text by Avherald.com.
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