Korean B738 at Guam on Jul 5th 2015, runway excursion on landing

Last Update: November 2, 2016 / 15:31:27 GMT/Zulu time

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Incident Facts

Date of incident
Jul 5, 2015

Classification
Incident

Flight number
KE-2115

Destination
Guam, Guam

Aircraft Registration
HL8224

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
PGUM

A Korean Airlines Boeing 737-800, registration HL8224 performing flight KE-2115 from Busan (South Korea) to Guam (Guam) with 75 passengers and 7 crew, had gone around on approach to runway 06R from about 850 feet MSL at 02:48L (16:48L Jul 4th) due to turbulence/weather, positioned for another approach and landed on Guam's runway 06R at 03:06L (17:06Z Jul 4th) following an ILS approach, the aircraft slowed down but then the crew requested a tow advising they were unable to taxi, they might be "a little bit" outside the runway, and requested someone to have a look at the aircraft. An airport operations vehicle drove onto the runway and reported there was grass up the side of the nose gear, tower requested the crew to shut the engines down. There were no injuries, the aircraft sustained minor damage (a dent in the left engine cowl).

The airline reported flight KE-2115 temporarily veered off the runway while landing in Guam but managed to return to the runway center line. An investigation is under way, a slippery runway is suspected as cause of the runway excursion.

On Jul 6th 2015 the FAA reported flight KE-2115, B738 HL8224, went off the runway and struck a sign, no injuries, the damage to the aircraft is being assessed.

A typhoon warning for typhoon Chan-Hom was in effect for the region, a storm warning had been issued for Guam shortly after the runway excursion.

South Korea's ARAIB have released their final report in Korean. Due to the wording and the construction of the report it is impossible, even with various different software translation packages, to determine what the ARAIB is concluding, hence The Aviation Herald is currently unable to provide any meaningful translation or summary (an inquiry with the ARAIB is under way).

On Nov 2nd 2016, while still waiting for reply by the ARAIB, native Korean reader Seohong Choi offered his help and provided The Aviation Herald with the necessary summaries and translations.

The ARAIB concluded the probable causes of the incident were:

- Erroneous judgement by the flight crew of HL8224 while landing in Guam in night conditions and heavy rain showers under the influence of a typhoon, that resulted in a temporary runway excursion on Guam's runway 06R.
- Continuation of landing instead of a go-around although proper visual references were not established.

The ARAIB reported that the captain (43, ATPL, 7,933 hours total, 1,884 hours on type) was pilot flying, the first officer (39, CPL, 2,865 hours total, 205 hours on type) was pilot monitoring. The crew performed an ILS approach to runway 06R, the captain disconnected the autopilot at 600 feet AGL and spotted the runway approach lights at 500 feet AGL. Descending through 300 feet AGL the first officer called out that the aircraft was slightly to the right of the localizer, descending through 200 feet AGL the first officer called the aircraft was below glideslope, descending through 100 feet AGL the first officer the aircraft was above glideslope. The captain continued the descent until 30 feet AGL at which point he initiated a go-around subsequently stating he couldn't see anything anymore due to heavy rain even with the windshield wipers at maximum speed. Following the go around and repositioning for another approach another aircraft landed and provided a pilot report of weather conditions permitting landing. While on the second approach the captain disconnected the autopilot and autothrottle at 500 feet AGL, descending through DH the captain announced the aircraft and approach was stabilized, at 150 feet radio altitude the first officer called the aircraft was below glideslope, at 100 feet radio altitude the first officer called four reds (PAPI indications, significantly below glideslope). Just before touchdown a gust, sudden crosswind from the left, caused the aircraft to veer right, the aircraft touched down on the right hand edge of the runway about 2000 feet past the runway threshold. The first officer called twice to steer the aircraft left, the aircraft continued right off the runway departing the paved surface 2200 feet past the runway threshold. Both main gear were off the paved surface about 3000 feet past the runway threshold before the aircraft began to turn left and returned onto the paved surface about 4400 feet past the runway threshold. The aircraft stopped on the runway, the right hand engine was shut down and the aircraft was towed to the apron after inspection by emergency services.

The ARAIB analysed that dispatch considered the typhoon affecting Guam to be 130nm eastnortheast of Guam, according to meteorologic services strong winds were to be expected 80nm around the storm center, the dispatcher therefore assumed normal operation for Guam. Noentheless, an additional 4000lbs of fuel were uplifted in addition to cater for adverse weather conditions. Dispatch assigned Osaka Kansai (Japan) as alternate airport as the usual alternate Saipan, 165nm from Guam, was expected to be affected by the typhoon, too. With the resulting fuel on board it was possible to perform two missed approaches at Guam before diverting to Osaka.

The ARAIB analysed there was no effective measurement of braking coefficients available for the runways.

The captain had been to Guam three times, the first officer had been to Guam one time prior to the incident flight.

The ARAIB analysed that the captain's remark following the go-around suggests that he had lost visual reference with the runway disabling him to maintain the runway center line. Another Korean Airlines flight landed subsequently and reported that the lights became visible at 500 feet, visibility 1nm, braking action fair, heavy rain. The aircraft positioned for a second approach, winds from 350 degrees at 13 knots, and received landing clearance. At 500 feet the captain disengaged automation stating runway was in sight, maintained runway center line although flying below glideslope and maintained 28 feet AGL at 155 KIAS, 9 knots above Vapp. The captain subsequently perceived the aircraft was sinking, overflared and caused the aircraft to float down about 2000 feet and subsequent touchdown on the right runway egde, the captain was unable to steer the aircraft back towards the center line with his inputs to rudder and ailerons, presumably because of the wind gust.

The ARAIB analysed that the captain felt pressure to succeed with the second landing, otherwise a diversion to Osaka would have been necessary. The pressure was increased by the successful landing just prior to their second approach.

The ARAIB analysed that automatic landings to runway 06L/06R were discouraged by the operator after experiences of excessively high pitch attitudes commanded by the autopilot, in 2013 the use of autoland on runway 06L/06R was prohibited by the operator. Following the occurrence test flights were conducted which showed normal pitch attitudes, consequently the ban of using autoland on runways 06L/06R was lifted in 2015.

The ARAIB analysed that there is need to improve training of flight crew in order to permit them land the aircraft safely in difficult conditions like low ceiling, low visibility, slippery runway and crosswind using the full flight simulator of the Boeing 737.

Metars:
PGUM 041901Z 31013G19KT 8SM -RA SCT009 BKN049 OVC095 26/25 A2946 RMK AO2 P0001 $
PGUM 041854Z 31010KT 9SM -RA SCT006 BKN013 OVC090 25/25 A2947 RMK AO2 SLP971 P0044 T02500250 $
PGUM 041817Z 29013G18KT 3SM RA BR FEW004 OVC009 25/25 A2947 RMK AO2 P0039 $
PGUM 041805Z 30013KT 1 1/4SM +RA BR OVC009 25/25 A2947 RMK AO2 P0025 $
PGUM 041754Z 30014G25KT 3/4SM +RA BR VV009 25/25 A2948 RMK AO2 WSHFT 1735 SLP974 P0197 60482 T02500250 10267 20239 55017 $
PGUM 041741Z 30012G23KT 3/4SM +RA BR VV009 25/25 A2949 RMK AO2 P0138 $
PGUM 041719Z 30011KT 1SM +RA BR VV009 25/25 A2949 RMK AO2 P0079 $
PGUM 041654Z 31009KT 1 1/4SM +RA BR OVC010 25/25 A2947 RMK AO2 SLP973 P0097 T02500250 $
PGUM 041645Z 31009KT 1SM +RA BR VV010 24/24 A2947 RMK AO2 P0076 $
PGUM 041631Z 31012KT 1SM +RA BR VV008 25/25 A2949 RMK AO2 P0035 $
PGUM 041601Z 30009KT 2SM RA BR SCT004 BKN009 OVC014 25/25 A2949 RMK AO2 P0005 $
PGUM 041554Z 31008KT 2SM RA BR SCT004 BKN010 OVC041 25/25 A2950 RMK AO2 SLP980 P0033 T02500250 $
PGUM 041511Z 32010KT 2SM +RA BR FEW006 BKN012 OVC022 24/24 A2952 RMK AO2 P0016 $
PGUM 041454Z 32010KT 6SM RA BR SCT012 BKN048 BKN075 24/24 A2953 RMK AO2 WSHFT 1338 SLP991 OCNL LTGICCC DSNT NE P0122 60155 T02390239 58011 $
PGUM 041430Z 34005KT 7SM -RA SCT020 BKN075 BKN100 23/23 A2953 RMK AO2 WSHFT 1338 P0120 $
Incident Facts

Date of incident
Jul 5, 2015

Classification
Incident

Flight number
KE-2115

Destination
Guam, Guam

Aircraft Registration
HL8224

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
PGUM

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