Kalstar E195 at Kupang on Dec 21st 2015, overran runway on landing
Last Update: September 28, 2016 / 14:33:02 GMT/Zulu time
Incident Facts
Date of incident
Dec 21, 2015
Classification
Accident
Airline
Kalstar Aviation
Aircraft Registration
PK-KDC
Aircraft Type
Embraer ERJ-195
ICAO Type Designator
E195
- The steep authority gradient resulted in lack of synergy that contributed to least of alternation to correct the improper condition.
- Improper flight management on approach resulted to the aircraft not fully configured for landing, prolong and high speed on touchdown combined with low brake pressure application resulted in insufficient runway for deceleration.
- The deviation of pilot performance was undetected by the management oversight system.
The NTSC analysed with respect to factors contributing to the runway overrun:
Prior to reaching point SEMAU, the pilots received information that the Kupang was rain from the ATIS and communication between air traffic controller and the other pilot.
When the aircraft arrived at point SEMAU, it was about 2,000 feet higher than the required altitude. During the approach after point SEMAU, the flight crew shortened the approach path by flying direct to the final approach path and used a high speed. This method was intended to minimize the delay of the flight schedule that had been 74 minutes late at the time of the departure from Bali.
The final approach was conducted on a higher profile than the published instrument procedure. The DVDR recorded a rate of descent more than 2,000 feet/minute followed by the activation of the EGPWS warning “TOO LOW TERRAIN”. The high rate of descent was required to gain the correct approach path with the consequences of corresponding high aircraft speed. The flight reached the correct glide path on short final.
The voice recorder data showed that the pilot selected flap to position 2 which was planned with flap position 5. The flaps could not be selected more than 2 since the aircraft speed was above the minima for flap 3 selection of 200 KIAS.
The high approach speed triggered the aural warning “HIGH SPEED” which was continuously active for over one minute prior to touchdown. The flight data indicated that the aircraft speed was approximately 200 knots when the aircraft at altitude 50 feet above runway, which was approximately 62 knots above the speed target.
The high approach speed and the PIC commanded to delay touchdown resulted in the aircraft touching down approximately at the middle of the runway with high speed.
A high speed touchdown and wet runway requires longer ground roll especially on wet runway as the deceleration became less effective.
The flight data revealed that during the landing roll, the thrust reversers were working properly, however the brake pressures indicated below 1,000 psi while the maximum pressure is 3,000 psi. This was due to the autobrake selected on position low and indicated that the anti-skid normal operational to maintain an optimal slip ratio based on the runway friction coefficient.
The aircraft was not fully configured for landing, delayed touchdown and high speed combined with low brake pressure application on wet runway resulting in insufficient runway for deceleration.
With respect to the authority gradients the NTSC analysed:
On the first flight to Ende, the SIC acted as pilot flying and at position about 5 minutes out, the PIC commanded to delay speed reduction and shortened the approach. This action was intended to speed up the flight, considering the Ende airport operating hours. On short final, the PIC reminded the SIC not fly too high. The voice recorder data did not record any SIC comment to those PIC commands.
On the flight to Kupang, the SIC also acted as pilot flying. During commencing the approach after left point SEMAU, the PIC suggested to increase the aircraft speed and shortened the approach path. Both pilots realized that the aircraft altitude was approximately 2,000 feet above the target altitude as described in the instrument approach procedure.
The SIC intended to select the speed brake to compensate the higher approach altitude and speed while the PIC suggested to perform non-standard configuration by selecting the landing gear down, thereafter, the SIC did not comment on the PIC suggestion and followed the PIC suggestion.
The PIC stated that a safe landing can be achieved with the existing approach condition. The SIC did not express any intention to correct the approach condition. The aircraft gained the correct approach path on short final but with speed approximately 40 knots higher than the target.
The voice recorder data indicated that during these flights, especially during approach, the PIC provided lots of suggestions and most of them were followed by the SIC. Particularly during the approach at Kupang when the PIC suggested shortening the approach and to increase the aircraft speed while the aircraft altitude and speed were above the approach profile. There was no rejection by the SIC.
The voice recorder did not record any crew briefings for approach and departure. The absence of the crew briefing might result in both pilots not having an agreed plan of the approach path and this might lead to misunderstanding each other. The misunderstanding was overcome by the PIC suggestion and commands.
Most of the instruction, coordination of the approach task implementations, indicated that the PIC was dominating the coordination in the overall time. There was no indication of the SIC challenging the PIC commands. This might be an indication of steep authority gradient, when a team leader dominant and resulted to the SIC reluctant to expressing concerns, questioning decisions, or even simply clarifying instructions.
The instructions from the PIC without rejection from the SIC, was an indication of steep authority gradients acted as barriers to team involvement, reducing the flow of feedback, halting cooperation, and preventing creative ideas for threat analyses and problem solving. These were indication of ineffective coordination (CRM implementation), and resulted to lack of synergy that might contribute to the lack of alternation to correct the improper condition.
The NTSC analysed that the captain had developed overconfidence into the abilities of the aircraft and his own handling skills and wrote:
The PIC had several experiences of attempting landing with certain target to stop with success and successful landing at airports with relatively short runway including Ende. These experiences might have developed confidence to the aircraft performance and his ability to handle the aircraft.
During approach at Kupang, the aircraft altitude was higher than the approach profile and the speed was approximately 200 knots. The aural warning of “HIGH SPEED” was continuously active on the last one minute prior to touchdown. The aircraft had not been properly configured for landing. These were the Level 1 of the Situational Awareness.
The previous experiences of landing on short runway and successfully landed the aircraft on certain target had developed confidence to the aircraft performance and his ability to handle the aircraft. These were the level 2 of the Situational Awareness that might have affected the pilot judgment.
The result of the projection to the near future as level 3 of Situational Awareness deviated from the pilot prediction. This was due to the current approach condition and warnings were not correctly perceived. Information such as wet runway and aircraft configuration were not considered. The pilot success experiences were conducted on dry runway and aircraft fully configured for landing, while on the accident flight the runway was wet and the flap was selected to position 2 instead of 5.
The decision to land was based on the pilot perceived to their ability to control the aircraft and landed safely on the existing condition without proper risk assessment. The confidence developed along the time of successful landings on short runways.
The NTSC analysed that Chief Pilot and Operations Manager of the operator were both active pilots and performed regular flights. This activity consumed most of their time taking away the time needed to conduct the assigned tasks of overseeing operations. In addition, the airline's flight safety department was staffed with minimum personnel only. The NTSC therefore wrote: "The absence of a system to monitor daily operations was not detected by the safety department. This might be an indication that the safety department was unable to perform the assigned task with the existing number of personnel compared to the amount of task."
Incident Facts
Date of incident
Dec 21, 2015
Classification
Accident
Airline
Kalstar Aviation
Aircraft Registration
PK-KDC
Aircraft Type
Embraer ERJ-195
ICAO Type Designator
E195
This article is published under license from Avherald.com. © of text by Avherald.com.
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