THY B738 at Pristina on May 2nd 2016, runway excursion on landing

Last Update: April 9, 2020 / 14:06:36 GMT/Zulu time

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Incident Facts

Date of incident
May 2, 2016

Classification
Incident

Flight number
TK-1019

Destination
Pristina, Kosovo

Aircraft Registration
TC-JFY

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
BKPR

A THY Turkish Airlines Boeing 737-800, registration TC-JFY performing flight TK-1019 from Istanbul (Turkey) to Pristina (Kosovo) with 143 passengers and 8 crew, landed on Pristina's runway 35 at 19:32L (17:32Z) but veered left towards the end of the runway and overran the end of the runway and came to a stop about 40 meters past the runway end and about 20 meters left of the paved surface of the runway end safety area. The passengers disembarked onto the soft ground via stairs.

The airline confirmed the aircraft has had a "minor incident", there were no injuries.

The airport re-opened the following day at 13:00L after being closed for about 17.5 hours.

Kosovo's Aeronautical Accident and Incident Investigation Commission (KAAIIC) have opened an investigation into the occurrence. The NTSB (USA), representing the state of manufacture and design of the aircraft, and Turkish DGAC (Turkey), representing the state of operator, have joined the investigation.

On May 4th 2016 The Aviation Herald received information that touch down marks were identified about 1500 meters down the 2500 meter long runway.

On Nov 1st 2016 Germany's BFU reported they have joined the investigation on request by KAAIIC to assist the investigation. The aircraft landed on runway 35 but touched down 1030 meters past the runway threshold, veered left shortly before the runway end and came to a stop on the grass.

In 2018 Kosovo's Aeronautical Accidents and Incidents Investigation Commission (AAIIC) released their final report in multiple languages (English version starting PDF page 52) concluding the probable cause of the accident was:

The cause of this serious incident was the too high runway threshold crossing altitude combined with a long flare and late touchdown beyond the touchdown zone. The outcome was a touchdown approx. 1 030 m beyond the runway 35 threshold. Crew Resource Management was not performed according the SOP by the operator. The flight crew didn´t initiate a go-around procedure timely. This would have prevented the runway excursion.

The AAIIC reported the captain (48, ATPL, 11,099 hours total, 8,090 hours on type) was pilot flying, the first officer (30, CPL, 615 hours total, 335 hours on type) was pilot monitoring.

The AAIC described the sequence of events:

According to the tower recordings, at 1923 h the crew reported to Pristina Radar that they were established on the localizer for runway 35. Pristina Radar asked the crew to change frequency to Pristina Tower. The copilot contacted the tower and shortly thereafter received the landing clearance: “[…] THY97A Pristina Tower good day, wind 150 degrees 06 knots, runway wet, cleared to land runway 35.” At 19:29 h the co-pilot asked the tower controller for the latest wind information. The tower controller answered: “[…] Wind one five zero degrees, zero seven knots.” There was no briefing heard on the Cockpit Voice Recorder (CVR), were the pilots discussed about the tailwind component during landing. The flight crew conducted the approach and landed on runway 35. The aircraft touched down approximately 100 m beyond the runway 35 touchdown zone markings, which equals approximately 1 030 m beyond the runway threshold. The remaining runway length was approximately 1 500 m. During the ground roll the flight crew noticed that the aircraft did not decelerate as much as expected. After touchdown the co-pilot suggested to the pilot in command to stay on the runway. The CVR recorded at 19:32:39 h: “[…] let’s stay on the runway, stay on the runway”.

The aircraft veered left off the runway between the end of the runway and taxiway C and came to a full stop in the adjoining grass approximately 36 m left of the runway.

According to the tower recordings at approximately 19:33 h the tower controller asked the flight crew: “[…] THY97A confirm ready for backtrack, confirm able to backtrack?”

The co-pilot answered that they had veered off the runway: “[…] we are out of runway THY97A.”

According to the FDR the aircraft crossed the runway treshold "at approx. 80 ft higher than normal threshold crossing height." (Editorial note: later comments made clear, the aircraft crossed the threshold at 80 instead of 50 feet, not 50+80=130 feet as the wording would suggest).

The AAIC further wrote to the FDR recordings:

- At 10 ft Radio Altimeter (RA) the airspeed was at approx. 150 kt Indicated Air Speed (IAS) and the engines reached the “flight-idle” position at approx. 3 ft.
- IAS at touchdown was approx. 145 kt (VREF=141 kt), with ground speed of approx. 162 kt
- The aircraft initiated landing flare at approx. 20 ft AAL
- touched down occurred approx. 1 030 m beyond the runway threshold
- At touchdown vertical acceleration was approx. 1.6 g
- Autobrakes were activated immediately after touchdown
- maximum Thrust-Reverse was applied upon landing
- Manual braking was initiated at approx. 100 kt IAS at a distance of approx. 1 637 m from runway threshold
- Thrust-Reverse was canceled as the aircraft left the paved runway surface
- At the point when the aircraft left the runway, the taxi speed was approx. 50 kt

The AAIIC analysed:

During the flight according to the airline operator Standard Operating Procedures the pilot monitoring should assist the pilot flying with announcing within a non-precision approach the altitudes crossed in relation to the distances shown on the approach chart. The co-pilot in function as the pilot monitoring didn´t announce any of the altitudes. This would have prevented the high sink rates in the end phase of the approach and the EGPWS generated “Sink Rate” alert. Especially when according to the CVR recording both pilots noticed that they were getting too high on the approach path. The vertical sink rate was increased in order to capture the flight path again.

The flight crew didn´t perform a proper approach briefing including the tailwind component, go-around procedure and the runway surface contamination. Due to the long flare and the late touchdown, passing the touchdown markings, both must consider and initiate a go-around and consider conducting another approach.

Even the operator defined in the OM-A, chapter 8.1.2.8 that all landings shall be planned so as to attain a positive touchdown within the first 1 000 ft of the runway with selected landing flaps (as applicable) at the targeted approach speed.”

The runway threshold was passed at approx. 80 ft higher than normal threshold crossing height. This may have increased the landing distance by approx. 450 m. Due to the approx. 30 ft higher crossing of the threshold led finally to a long landing, approximately 100 m beyond the touchdown zone which equals approx. 1 030 m beyond the runway threshold.

As the PIC noticed that the runway length would not be sufficient to stop the aircraft on the runway, he tried to vacate to the left on the taxiway exceeding the maximum taxi speed stated in the Operational Manual OM-B Vol.2, chapter 2.14.1 by the operator.

Related NOTAM:
A0192/16 - RUNWAY CLOSED FOR THE NEXT 1 HOUR DUE TO EMERGENCY IN PROGRESS. 02 MAY 22:20 2016 UNTIL 02 MAY 23:20 2016. CREATED: 02 MAY 22:20 2016

Metars:
BKPR 021900Z 13008KT 9999 -RA SCT015 BKN040 10/08 Q1007 NOSIG
BKPR 021830Z 12011KT 6000 -RA BKN012 OVC025 10/08 Q1006 RERA TEMPO 3500 RA
BKPR 021800Z 13009KT 5000 RA BKN012 OVC025 11/08 Q1006 NOSIG
BKPR 021730Z 08009KT 4000 RA BKN010 OVC025 12/09 Q1006 NOSIG
BKPR 021700Z 02009KT 8000 -RA SCT010 BKN025 11/09 Q1006 NOSIG
BKPR 021630Z 04011KT 9999 -RA SCT012 BKN030 12/09 Q1006 NOSIG
BKPR 021600Z 09011KT 7000 -RA SCT015 BKN030 13/09 Q1006 NOSIG
BKPR 021530Z 09012KT 9999 -RA SCT030 BKN050 14/08 Q1007 NOSIG
BKPR 021500Z 09011KT 9999 BKN035 14/08 Q1007 NOSIG
BKPR 021430Z 09012KT 9999 BKN035 15/08 Q1007 NOSIG
BKPR 021400Z 11017KT 9999 BKN035 15/08 Q1008 NOSIG
Incident Facts

Date of incident
May 2, 2016

Classification
Incident

Flight number
TK-1019

Destination
Pristina, Kosovo

Aircraft Registration
TC-JFY

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
BKPR

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