Sriwijaya Air B732 at Jambi on Aug 27th 2008, runway overrun

Last Update: September 10, 2015 / 22:10:46 GMT/Zulu time

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Incident Facts

Date of incident
Aug 27, 2008

Classification
Accident

Aircraft Type
Boeing 737-200

ICAO Type Designator
B732

On Sep 10th 2015 Indonesia's NTSC released their final report concluding the probable causes of the accident were:

When the aircraft approach for runway 31, the Loss of Hydraulic System A occurred at approximately at 1600 feet. At this stage, there was sufficient time for pilots to conduct a missed approach and review the procedures and determine all the consequences prior to landing the aircraft.

- The smooth touchdown with a speed 27 kts greater than Vref and the absence of speed brake selection, led to the aircraft not decelerating as expected.

The NTSC reported the captain (36, ATPL, 7,794 hours total, 6,238 hours on type) was pilot flying, the first officer (34, CPL, 5,254 hours total, 4,143 hours on type) was pilot monitoring.

The left hand engine's (JT8D) driven generator was inoperative, the aircraft was dispatched under MEL requirements, the APU generator was used in flight.

The crew briefed for a landing on Jambi's runway 31 using flaps at 40 degrees, the go around procedure was briefed as well.

The crew was informed that the winds were calm, there was rain over the aerodrome and low cloud in the approach path to runway 31.

The crew positioned the aircraft for a VOR approach to runway 31, intercepted the final approach about 8nm from the VOR, selected flaps to 5, gear down, subsequently flaps to 15 degrees. Descending through 1600 feet, about 13 seconds after flaps 15 were selected, the crew noticed a hydraulic system A low pressure indication, the hydraulic system A quantity indicators showed zero. The captain called for the landing speeds with flaps 15, the first officer reported a threshold speed of 134 KIAS, the captain decided to continue the approach and advised he would fly slightly below the glidepath to get more distance for the landing roll.

The aircraft touched down normally on runway 31, the captain had difficulty however to engage the thrust reversers and applied manual braking, but felt little deceleration followed by a gradual loss of deceleration. The first officer also applied braking after the captain commented about the brakes. The aircraft drifted to the right of the runway center line about 200 meters before the runway end, went past the runway end and came to a stop about 120 meters past the runway end in a rice field 6 meters below the runway level after hitting three farmers working on the field and fatally injuring one and seriously injuring the other two.

The flight crew initiated the emergency ground procedures, the flight attendants, who had noticed a strong impact, were waiting for an evacuation command from the cockpit. The flight crew found the shut off levers could not be moved, nor could they pull the fire handles of engines and APU. The communication systems were all out of service including the communication to the cabin. The passengers, without instruction from flight or cabin crew, began to evacuate through the right overwing emergency exit, cabin crew subsequently executed the emergency evacuation procedure, too.

The left aft cabin door was blocked by the detached left main gear, the door could not be opened. All passengers and finally the crew left the aircraft, a company engineer subsequently entered the cockpit and shut down the APU which was still running.

The aircraft received substantial damage, both engines had detached, all gear had detached from the aircraft, the radome had detached as well.

The NTSC reported that the solid state flight data and cockpit voice recorders were recovered and downloaded, the FDR revealed the aircraft touched down at a speed of 165 KIAS.

The NTSC analysed that cause of the loss of the hydraulic system A could not be determined. The loss of the hydraulic system A at 1600 feet MSL meant however, that the ground spoilers were inoperative, the thrust reversers would deploy at a slower rate than normal, inboard brakes would have accumulator pressure only and the nose wheel steering would be inoperative. The crew briefly discussed the hydraulic failure, however, there was no discussion of a go-around although the remaining fuel endurance was two hours giving the crew at least one hour to work the related checklists.

The NTSC stated: "As a consequence from the loss of hydraulic system A, there were several systems inoperative which reduced the landing performance of the aircraft. However, the pilots did not refer to the QRH which would have assisted them with the details of procedures and steps required, nor were there discussions with all crew members as required using CRM principles before the decision to land was made."

The NTSC analysed that with the loss of hydraulic system A and flaps at 15 degrees the landing distance required at the computed Vref of 138 KIAS was 5,276 feet with 7,283 feet landing distance available, a landing was thus possible. However, the aircraft crossed 500 feet AGL at 171 KIAS and touched down at 165 KIAS, which substantially increased the landing distance needed. The aircraft came to a stop 2,020 meters/6,625 feet after touch down. Computation for a landing at 165 KIAS resulted in a landing distance required of 8,606 feet.
Incident Facts

Date of incident
Aug 27, 2008

Classification
Accident

Aircraft Type
Boeing 737-200

ICAO Type Designator
B732

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