Primera Nordic B738 at Keflavik on Apr 28th 2017, overran runway on landing

Last Update: June 1, 2021 / 16:19:06 GMT/Zulu time

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Incident Facts

Date of incident
Apr 28, 2017

Classification
Incident

Flight number
6F-108

Aircraft Registration
YL-PSH

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
BIKF

A Primera Air Nordic Boeing 737-800, registration YL-PSH performing flight 6F-108 from Alicante,SP (Spain) to Keflavik (Iceland) with 137 people on board, landed on Keflavik's runway 19 in snowfall at 17:21L (17:21Z) but overran the end of the runway and came to a stop about 150 meters/500 feet past the runway end. There were no injuries, the aircraft received minor if any damage.

The passengers disembarked via stairs onto soft ground and were bussed to the terminal.

Position data transmitted by the aircraft's transponder suggest the aircraft crossed both original and displaced runway threshold too high, landed long and could not stop on the remaining runway.

Phase 3 of the Keflavik Airport reconstruction program was in effect, the northernmost 613 meters of runway 19 (threshold) were reconstruction zone and the threshold runway 19 was displaced by 860 meters to just south of the intersection runways 01/19 and 10/28.

Iceland's RNF opened an investigation and dispatched investigators on site, who completed the onsite work over night.

On Jun 1st 2021 Iceland's RSNA (successor of RNF) released their final report concluding the probable causes of the serious incident were:

The causes of the runway excursion were:

- Deviation from snow removal procedures

- The runway conditions had degraded since the last braking action measurement

- The runway not being fully cleared of snow

- The landing performance calculations not being valid for the actual runway condition

- The aircraft float during the last 20 feet AGL down to the runway, resulting in the aircraft touchdown being further down the runway than planned

Contributing factors were:

1) New braking action had not been measured.

The RSNA reported the flight had been delayed in Alicante due to the commander becoming aware of the weather in Iceland deteriorating, so that he changed the alternate airport from Egilsstadir (Iceland) to Glasgow (Scotland), which required a change of the flight plan and more fuel to be loaded. In total, due to late arrival in Alicante, longer than anticipated unload time and the change of flight plan the aircraft finally departed with a delay of 54 minutes. The captain (36, ATPL, 4,700 hours total, 4,400 hours on type) was pilot flying, the first officer (36, CPL, 1,900 hours total, 1,600 hours on type) was pilot monitoring.

The flight to Iceland was uneventul, the crew used the time to monitor the weather development at Keflavik, data received via ACARS suggested there were overcast clouds at 400 feet AGL (which translated to 570 feet MSL) with a decision altitude of 440 feet MSL, the crew thus remained concerned the weather might require them to divert to Glasgow.

During the descent the crew worked the related checklists and set autobrakes to 3. ATIS broadcast regarding braking coefficients amongst other data: "measured 55-50-50 on Mu meter. Braking action ramp and taxiways medium-poor. Available runway length RWY 19 is 2182 meters.” These data suggested to the crew the braking action on the runway was good and runway length was sufficient.

At the time the flight started the descent runway 10/28 was closed due to airport reconstruction work and thus was not available. Due to the works also both ILS runway 01 and runway 19 were not available, RNAV approaches were being used. In addition, the part of runway 01/19 north of runway 10/28 was also under reconstruction and had no runway lighting. The threshold of runway 19 had been displaced as result, there was a long gap between the approach lights to runway 19 and the actual runway lights. Landing distance of the runway thus was reduced to 2182 meters/7157 feet.

However, a NOTAM indicated runway 10/28, which had its runway designators changed to 11/29, would be available on request in low visibility. The crew however did not request runway 10/28.

Just prior to the first approach of YL-PSM a formation of five snowploughs followed by a measurement vehicle cleared 25 meters to the west of the runway center line, then turned around at the intersection with runway 10/28 and cleared 25 meters to the east of the runway centerline, thus clearing a width of 50 meters of the entire landing distance available of the runway. The snow ploughs vacated the runway at the time YL-PSM descended through 2500 feet MSL.

The crew was assigned RNAV-X approach procedure to runway 19, which requires 1300 meters RVR and a decision altitude at 440 feet MSL for LNAV/VNAV approaches. ATIS at that point indicated 1300 meters RVR decreasing, light snow, broken cloud at 700 feet MSL, overcast at 1500 feet. Braking action was indicated good (55-50-50), the flight crew noticed these data were almost 90 minutes old.

Upcon contacting tower the controller indicated the visibility from the tower was 700 to 800 meters and overcast at 1100 feet, which permitted the crew to continue the approach. ATIS still indicated 1300 meters RVR. The crew had computed they would need 1692 meters for max manual braking, 1799 meters for max automatic braking and 2168 meters for autobrake 3. With the landing distance of 2182 meters available autobrakes 3 was sufficient though very close.

The final approach was stabilized, the crew was able to establish visual contact with the approach lights, however, could not see the runway lights. 3 seconds prior to the "MINIMUMS" call the autopilot was disengaged, autothrust and flight directors remained engaged. At the MINIMUM call the aircraft began to level off, 4 seconds later the first officer saw the PAPI lights all indicating white. The crew had forgotten to set the go around altitude, the aircraft although levelling off descended through the minimum altitude as the captain still followed the flight director. 11 seconds after the MINIMUM call the captain called go around, TOGA was activated and the aircraft began to climb after descending to 163 feet AGL.

Following the go around tower inquired with the snow ploughs, who had vacated onto runway 28, about their intentions and they indicated they would clear runway 10/28 now and did so in the following 4 minutes.

A number of aircraft were cleared for takeoff from runway 19 while YL-PSH was re-positioning for another approach to runway 19.

After finishing clearing runway 10/28 the snow ploughs again proceeded onto runway 19, however, only cleared a combined width of 25 meters around the runway center line, then according to tower's assumption vacated onto taxiway E at the far end of runway 19. The snow ploughs now cleared taxiway E northbound.

YL-PSH joined another RNAV-X approach to runway 19 and verified autobrakes 3 were still set. During final approach tower indicated ceiling was now 1200 feet and visibility from the tower was 700-900 meters.

The final approach again was stable, the crew established visual contact with the approach lights at 600 feet MSL. When the MINIMUM call occurred, no visual contact with the runway lights had been established, the first officer saw the PAPI lights (three red, one white) 13 seconds after the MINIMUM call, the aircraft descended through 100 feet AGL, the captain saw the runway lights 15 seconds after the MINIMUM call. The captain later stated when he saw the runway it was completely white covered with snow. The aircraft touched down, autobrakes activated, the aircraft started drifting sideways which needed to be corrected. Deceleration during the first 3-4 seconds was normal, hence the crew was not concerned. About 5 seconds after touchdown the crew noticed deceleration had decreased and recognized braking was insufficient, 300 meters before the runway end the captain recognized they would not be able to stop before the end of the runway. The aircraft crossed the runway end at 48 KIAS (according to FDR). The captain recognizing they would also not stop before the localizer structure for runway 01 and noticing a soft clearance to their left decided to steer the aircraft left onto the soft gravel. The left main landing gear sunk into the gravel increasing deceleration, the aircraft came to a stop just short of the localizer structure.

The RSNA analysed they could not determine how the crew had determined that 750 meters visibility from the tower were sufficient to conduct the approach. It is possible to convert the required RVR to visibility using the factot of 1.5 in daylight, but then the required 1300 meters RVR would have been 900 meters visibility.

the RNSA analysed that tower was not aware that the snow ploughs had actually vacated the runway at taxiway S-2, clearing only 1070 meters length with 12.5 meters either side of the center line. The snow removal supervisor thought tower had instructed them to vacate on taxiway Sierra, however, a review of the ATC tapes did not show any such instruction.

The RSNA stated:

It had been snowing extensively and snow had accumulated on the runway, contaminating it very quickly. This made it particularly difficult to maintain the braking action (BA) over 40, or as GOOD.

The ITSB therefore determined that the snow removal procedure was not adhered to when the snowplows vacated the runway at taxiway Sierra-2 to start snow removal at taxiway Echo, after having only cleared 25 meter wide runway around the centerline of the first 1070 meters of the 2182 meter long runway.

The RSNA analysed further that during the second approach there was no stabilised call by the pilot monitoring upon descending through 500 feet AGL.

The RNSA analysed that with flaps 30 the approach speed (Vref30+5) was 152 KIAS, the aircraft touched down at 145 KIAS at less than 200 fpm rate of descent, which explains the floating, about 765 meters past the displaced runway threshold leaving only 1417 meters for the rollout. The aircraft had floated for about 310 meters.

The RSNA computed that with autobrakes 3 the roll out distance would have been 1713 meters (in addition to 455 meters assumed air distance from 50 feet AGL to touchdown).

However, as the runway was contaminated the landing performance computations were invalid.

The RNSA analysed:

According to the PF, when he finally saw the runway, he noted that the runway was completely white and covered with snow. The ITSB determined that the fact that the runway was completely covered in snow, along with the fact that it was snowing during the approach and landing, explains why the flight crew had such difficulties seeing the runway.

This, along with the fact that the temperature was 0°C, for an experienced pilot landing on snow covered runways, should have been an indication that the landing performance calculations, which were based on uncontaminated runway, were not valid for the a runway covered in snow.

The investigation revealed that the Commander (PF) did not have experience landing on snow covered runways.

Only when the aircraft had already passed the intersection with taxiway S-2 the crew applied maximum manual braking - which on a dry runway would have been sufficient to stop - however the aircraft now was on the portion of the runway that had not been cleared again prior to their second approach.

Relevant NOTAMs:
A0156/17 - REF AIP ICELAND BIKF AD 2.24.10.5-13/14 RNAV Z RWY 19 NOT IN USE. 06 APR 18:00 2017 UNTIL 29 MAY 23:59 2017 ESTIMATED. CREATED: 06 APR 16:00 2017

A0157/17 - REF AIP ICELAND BIKF AD 2.24.10.3-1/2 ILS OR LOC Z RWY 19 NOT IN USE. 07 APR 14:00 2017 UNTIL 29 MAY 23:59 2017 ESTIMATED. CREATED: 06 APR 16:09 2017

A0158/17 - BIKF AD 2.24.10.3-3 ILS OR LOC Y RWY 19 NOT IN USE. 07 APR 14:00 2017 UNTIL 29 MAY 23:59 2017 ESTIMATED. CREATED: 06 APR 16:17 2017

A0160/17 - RWY 19. DME IKO 110.300 MHZ UNSERVICEABLE. REF: AIP BIKF AD 2.19. 07 APR 14:00 2017 UNTIL 31 MAY 23:59 2017. CREATED: 06 APR 16:32 2017

A0174/17 - RWY 01/19. RWY 01 TDZ MARKINGS PARTLY IN PLACE. RWY 01/19 EDGE MARKINGS IN PLACE BUT MISSING ON RWY 01 THE FIRST 150M FROM THR ON BOTH SIDES. REF AIP ICELAND BIKF AD 2.9. 12 APR 07:59 2017 UNTIL 12 JUL 23:59 2017. CREATED: 12 APR 08:00 2017

A0175/17 - TOUCHDOWN LIGHTS ON RWY 19 NOT AVAILABLE. REF: AIP BIKF 2.14. 12 APR 08:11 2017 UNTIL 12 JUL 23:59 2017. CREATED: 12 APR 08:12 2017

A0176/17 - CENTERLINE LIGHTS ON RWY 01/19 NOT AVAILABLE. REF: AIP BIKF 2.14. 12 APR 08:13 2017 UNTIL 12 JUL 23:59 2017. CREATED: 12 APR 08:14 2017

A0236/17 - RWY RECONSTRUCTION WORK PHASE 3 ACTIVATED RWY 01/19 TORA (M) 2182, LDA (M) 2182 REF: AIP ICELAND SUP 004/2017. 28 APR 00:00 2017 UNTIL 01 MAY 23:59 2017. CREATED: 26 APR 18:02 2017

Metars:
BIKF 282000Z 21021KT 9999 VCSH FEW004 SCT008 BKN015TCU 01/01 Q0985=
BIKF 281930Z 22017KT 2500 R19/P1500U -SN SCT003 BKN007 OVC015 00/00 Q0984=
BIKF 281900Z 23015KT 0600 R19/0800N SN VV003 M00/M00 Q0983=
BIKF 281830Z 24016KT 0600 R19/0750N SN VV003 M00/M00 Q0982 R19/590137=
BIKF 281800Z 25013KT 0500 R19/0750N SN VV004 00/00 Q0982 R19/590137=
BIKF 281730Z 25007KT 210V310 0800 R19/0750N SN VV005 00/00 Q0982 R19/590137=
BIKF 281700Z 24006KT 0800 R19/0800U SN VV005 M00/M00 Q0983 R19/590137=
BIKF 281630Z 29002KT 1200 R19/1300D -SN BKN007 OVC015 00/00 Q0983=
BIKF 281600Z 02001KT 0900 R19/1200N -SN OVC007 00/00 Q0985=
BIKF 281530Z 06006KT 0900 R19/1100N -SN OVC005 00/00 Q0985=
BIKF 281500Z 06005KT 2000 -SN SCT005 OVC015 01/00 Q0986=
BIKF 281430Z 11004KT 9000 -RASN OVC011 02/01 Q0986=
Incident Facts

Date of incident
Apr 28, 2017

Classification
Incident

Flight number
6F-108

Aircraft Registration
YL-PSH

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
BIKF

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