B752, Keflavik Iceland, 2019
B752, Keflavik Iceland, 2019
On 28 October 2019, a Boeing 757-200 bound for Keflavik after an overnight flight was advised that a previously-landed aircraft had partially overrun the end of the only available 3,054 metre-long runway which was therefore closed. With the other runway also not available and braking action at alternate Reykjavik unavailable, the absence of other diversion options with the fuel remaining obliged the flight to commit to landing on the closed runway which was only obstructed at its far end. ATC required an emergency declaration and then gave a ‘land at pilot’s discretion’ clearance and an uneventful landing followed.
Description
On 28 October 2019, a Boeing 757-200 (TF-ISF) being operated by Icelandair on a scheduled overnight international passenger flight from Seattle to Keflavik as FI 680 was advised whilst positioning for approach at destination that holding would be necessary due an HS125 having partially overrun the only available runway. The crew were aware that the weather at their alternate, Reykjavik, was fine but were unable to obtain the runway surface friction measurements. This eventually meant that they had to declare a ‘low fuel’ emergency in order to be permitted to land at pilot’s discretion on the still-closed runway in night VMC. This was achieved uneventfully using little over half the available runway length.
Investigation
A Serious Incident Investigation was carried out by the Icelandic Transportation Safety Board (ITSB) using downloaded flight data and recorded ATC communications and radar. It was noted that the 42 year-old Captain had a total of 7,131 hours flying experience including 6,323 hours on type and had 2,104 hours command experience on all types. The 28 year-old First Officer had a total of 3,350 hours flying experience including 1,258 hours on type.
What Happened
With the Captain acting as PF, the flight departed from Seattle with 30,079 kg of fuel based on an OFP which showed the estimated fuel on arrival at Keflavik as 4,128 kg. A pre flight review of the en route and Keflavik weather forecasts had shown no adverse weather issues for the flight. Reykjavik, 14 minutes flying time away at FL090, was the planned alternate.
Several ATIS broadcasts were received during the cruise which initially included the information that the braking action at Keflavik was poor before it started improving again. The pilots were not too concerned about this because they also noted that there had been significant rain with the temperature around zero and so “assumed the runway(s) needed de-icing”.
The crew noted that as the cruise had progressed, the en-route fuel consumption had become slightly higher than planned and having received the latest ATIS which gave the runway in use 01, a slightly shortened route direct to waypoint ‘RENDU’ (see the approach chart for runway 01 below) was requested but not granted due to conflicting traffic. At the final check prior to beginning descent, it was noted that 800 kg of the 1,272kg planned contingency fuel had been used and the request for direct to RENDU was repeated, ATC responded that they were “working on it” and a transfer to Keflavik APP was given. On checking in there as the flight descended through FL100, it was re-cleared as requested descending to 4,000 feet QNH.
A few minutes later, the crew heard another Icelandair 757 also inbound to Keflavik and ahead in the approach sequence being advised that they must proceed to waypoint ‘SOPAR’ (also shown on the chart reproduced below) as a runway excursion off the active runway had occurred and the same instruction to their flight followed almost immediately. The Captain remarked to the First Officer to the effect that “they did not have much fuel for this” (the holding). A third Icelandair 757 which had been instructed to go around when the aircraft ahead had partially left the runway was then heard asking APP about the status of runway 10 and was told that it was not useable because the most recent measurement showed poor braking action.
The Keflavik runway 01 instrument approach chart. [Reproduced from the Official Report]
The crew noted that they no longer had enough fuel left to divert to Akureyri and agreed that their minimum diversion fuel for Reykjavik was 2.7 tons and that they needed updated weather and braking action. The former was, as forecast, not a problem but after requesting the braking action from Keflavik APP (Reykjavik was at that time not yet open for diversions) they were told that “at the moment there is no one in Reykjavik Tower, we are calling them out and you can expect numbers in half an hour, and someone should be in the tower in ten minutes”. In fact, it was subsequently discovered that unknown to Keflavik Approach, Reykjavik Airport was already being prepared for opening and runway braking action measurements had already been carried out twice although the results - advised after minimum fuel to divert was no longer on board - would not have made a landing there possible.
The Captain said to the First Officer that they did not have that much time available to await braking action at Reykjavik and that Keflavik was therefore their only option. The APP controller was asked if the runway excursion was close to the end of the runway and advised that they understood that was the case. The Captain then advised that they would have to commit to a landing at Keflavik and could only continue holding for another 5/6 minutes. A couple of minutes later, when the crew stated that after the current hold, they would have to “proceed inbound for runway 01”, the controller asked if they were declaring an emergency and was told not yet but that only ‘minimum fuel’ remained. He then asked if they could accept a landing with vehicles on the runway and the crew responded by asking for confirmation that the activity was only at the far end of the runway.
Descent in the hold to 3,000 feet was subsequently given and on being asked if the flight was cleared to commence an approach, the controller stated that this could be given at the pilot’s discretion and confirmed that the aircraft and the vehicles attempting to remove it were indeed at the far end of the 3,054 metre-long 60 metre-wide runway. He then called to say that he had received the Reykjavik braking action figures and passed them but the crew confirmed they were now inbound for runway 01 and were then cleared for the approach at the pilot’s discretion.
Just over a minute later, the APP controller called to say that “the tower is not willing to give you a landing clearance. Runway is occupied. We need an emergency declared and then land at your discretion”. The Captain responded by declaring a MAYDAY which was acknowledged and the flight was transferred to TWR where an acceptable braking action report was received. Having then advised that the excursion aircraft was about 15-20 metres from the threshold of the northern end of the runway, the flight was informed “landing approved at the pilot’s discretion”.
The aircraft exited via RET A-1 which was just over half way along the runway and arrived at the gate with 2.4 tonnes of fuel remaining which was 0.3 tonnes below their minimum diversion fuel. The runway was re-opened 54 minutes after the runway excursion had occurred and 31 minutes after the closed runway landing had been made. It was confirmed that Cat 7 RFFS cover had been available at the time of the landing as declared.
The exit route taken by the 757 after landing on the closed runway (the location of the runway excursion aircraft and recovery vehicles is shown inset). [Reproduced from the Official Report]
The Investigation made a number of Findings from which Conclusions followed in respect of the situation which had ultimately led to the requirement to land on an officially closed runway, including, in summary, the following:
Systematic Failures in Diversion Response at the four international airports
Although Keflavik, Reykjavik, Akureyri and Egilsstaðir all had contingency plans in the event of runway/airport closure resulting in diversions these “were only looking at it from their point of view”. Following this Serious Incident, it was noted that many but not all of the gaps identified have been closed by safety measures taken.
- Keflavik had not kept braking action on runway 10/28 during the night sufficient for it to be useable because the applicable procedure at the time of the investigated event only permitted use of de-icing fluid on the runway in use and taxiways required for its use.
- Reykjavik only used sanding to improve braking action on runways, taxiways and aprons during slippery conditions - runway de-icing fluids were not used. The consequence of this is that “it can take much longer to improve the runway braking condition than if de-icing fluid was used”. On the morning of 28 October 2019, the first braking action measurement was completed for runway 01/19 at 05:49 and preparation of an early opening of the airport started at 06:06 which took a little longer than usual - 24 minutes - even though no snow removal was necessary because only two rather than the usual three people were on duty. Had snow removal been necessary, runway preparation may have taken up to an hour, which is information that is not included in the Iceland AIP.
- Akureyri and Egilsstaðir also only used sanding to improve braking action on runways, taxiways and aprons during slippery conditions and they were also able to be open within a maximum of an hour’s notice although this response time was not mentioned in the Iceland AIP.
Rescue and Fire Fighting (RFFS) Capability
- Keflavik was listed as CAT-9 RFFS capability but has since been downgraded to CAT-8 between 0500 and 1900 and to CAT-7 between 1900 and 0500.
- Reykjavik was listed as CAT-6 with upgrade to CAT-7 with “30-60 minutes prior notice”. This meant that at the time its use as the flight planned alternate would have required up to an hour’s prior notice and as the shift on the day was one person short, even 60 minutes for an upgrade would not have been enough. It was noted that since the event under investigation, the airport had been downgraded from CAT-6 RFFS capability to CAT-3 outside its operational hours with upgrade to CAT-7 not available at these times unless it was “a significant snow day” which would result in additional staff being on duty which did not apply.
- Akureyri was listed as having CAT-6 RFFS with only 10 minutes notice required to upgrade to CAT-7 and it was noted that the two other Icelandair 757’s which had been unable to land at Keflavik because of the same runway closure had filed Akureyri as their alternate and diverted there. However, it was noted that although upgrade to CAT-7 RFFS with 10 minutes prior notice had been achieved for the two 23 October diversions, this had only been possible because one of the night shift personnel was still present. It was noted that since the event under investigation, the airport had been downgraded from CAT-6 RFFS to CAT-3 outside its operational hours with upgrade to CAT-7 not available at these times unless it was “a significant snow day” which would result in additional staff being on duty. At the same time, the prior notice time for CAT-7 upgrade within operating hours had been increased from 10 minutes to 30 minutes. Egilsstaðir was not filed as an alternate by any of the aircraft involved and although the Iceland AIP stated that its CAT-5 RFFS capability could be upgraded to CAT-7 with 10 minutes prior notice, between 0200 and 0700, this was found not to be possible and the error had only been corrected shortly prior to the completion of the Investigation.
- It was accepted that any airport offering CAT-6 RFFS capability (i.e. Reykjavik, Akureyri and Egilsstadir) and having no more than 700 movements (landings and takeoffs) in the three busiest months of the year could be used by a CAT-7 aircraft.
Air Navigation Services Communications
- The Investigation revealed a lack of communication and/or information flow between Reykjavik Airport and Keflavik Approach outside of the former’s normal operating hours and within the Reykjavik ACC, between Keflavik APP and the Flight Data Section (FDS). The controllers in Keflavik APP believed that Reykjavik Airport was closed when one of the other 757s that diverted to Akureyri requested the latest Reykjavik braking action whereas the FDS had already activated the airport due to a Coastguard flight (although the flight under investigation could not have landed at Reykjavik with the runway conditions eventually advised).
- It was also found that when the controller in the Keflavik TWR position was changed one minute after the flight under investigation had declared an emergency in order to obtain a landing clearance, the controller handing over “had forgotten to pre-brief his replacement (the TWR Supervisor) on the fuel status of flight” with the handover briefing being limited to the fact that the flight “was going to land”. The content of the conversation between Keflavik APP and TWR about “land at your discretion” occurred only when the handover took place. It was concluded that until after the Serious Incident was over, it would have been good practice for the outgoing Tower controller to remain in position with the incoming controller supporting him instead of taking over.
The AIP
It was found that the AIP contained entries for the three diversion airports if Keflavik was unavailable which differed in respect of how long it took to man the TWR with an ATCO or to provide Aerodrome Flight Information Service (AFIS) and how long it would take to upgrade the RFFS capability. There was also a lack of information in the AIP on how long it can take to clear, sand and carry out braking action measurements. It was concluded that these deficiencies could “lead aircraft operators to assume that an airport will be readily available when that might not be the case”. It was noted that many of the findings had been corrected in an amendment issued on 2 December 2022.
Icelandair
It was observed that the time it takes for an aircraft such as the Boeing 757-200 involved in the Serious Incident to divert from Keflavik to Reykjavik Airport (the company assumed 14 minutes diversion time) is less than the time it takes to get Reykjavik ready for operation if this is required during the times when it is closed. The ETA of the flight under investigation was 06:05 so with the airport being closed until 0700, the various AIP requirements were:
- An AFISO in position (15 minutes)
- CAT-7 RFFS Capability (30-60 minutes since reduced to 45 minutes)
- A useable runway available (not stated but found to be 20-60 minutes)
The Flight Plan filed took no account of the time it takes to make Reykjavik available during its closing hours and it was concluded that the crew’s decision to commit to land on the closed runway 01 at Keflavik Airport and declaring minimum fuel was likely to have been the safest option for the flight at that time, taking into account that the crew needed to know the Reykjavik braking action but had been told it would be 30 minutes until it could be provided.
The Safety hazards in the current Icelandic alternate airport system
- Keflavik Airport is the only CAT-8 RFFS-capable airport in Iceland. According to the AIP, the other three international airports can be upgraded to CAT-7 RFFS on request. However, in many situations, such upgrading is not possible and instead CAT-6 RFFS capability is provided based on each of these airports having less than 700 movements in their three busiest months.
- In the case of Reykjavik, it was clear that the airport cannot accomplish this for diversions prior to 0700 because of the short diversion time and insufficient manpower.
- In the case of Akureyri, it was clear that the airport cannot accomplish this for diversions prior to 0600 within the expected flight time for flights diverting to the airport prior to that time because of insufficient manpower.
- In the case of Egilsstaðir, it was clear that the airport cannot accomplish this within the expected flight time for diversions to the airport at any time except when the three four-man shifts overlap due to insufficient manpower.
The formally documented Causes were as follows:
- The earlier runway excursion on runway 01 by a previous landing aircraft which resulted in the closure of that runway.
- Insufficient alternate designation given the time it takes to make Reykjavik operational during its closing hours.
- The runway conditions at Reykjavik.
- The fact that runway 10 at Keflavik had not been maintained overnight.
- A lack of communication between Keflavik Approach and Reykjavik Airport which meant that:
- Keflavik Approach was unaware of Reykjavik Airport opening early on the morning of the event under investigation.
- Keflavik Approach was unaware of the braking action measurements taken at 05:49 and 06:03.
Two Contributory Factors were also identified:
- Keflavik Approach statement to the inbound 757 that they would not have the braking action numbers for Reykjavik Airport for half an hour.
- Unclear information in the Iceland AIP as to how long it took to make Reykjavik available for landing.
Six Safety Recommendations were made as a result of the Investigation as follows:
- that Icelandair ensures that in flight planning, the alternate fuel includes the time that is required to open a nominated alternate airport for operation, if closed during the expected time of use. [19-159F044 T1]
- that Isavia Regional Airports ensures that there is an established communication link between the Reykjavik Airport Operations department and Keflavik Approach Control outside Reykjavik’s normal opening hours. [19-159F044 T2]
- that Isavia Regional Airports reviews the rescue and fire-fighting staffing at Reykjavik, Akureyri and Egilsstaðir with respect to this report’s findings, or advertise in the AIP that CAT-7 aircraft can land under the airport’s CAT-6 capability as the airport has fewer than 700 movements (landings and takeoffs) in the three busiest months at the airport. [19-159F044 T3]
- that Isavia Air Navigation Services reviews if it would be feasible to install a procedure regarding broader information sharing and activation protocol, between the four international airports (Keflavik, Reykjavik, Akureyri and Egilsstadir) Approach Control, and the Reykjavik Area Control Centre, in the event of one of those airports closing. [19-159F044 T4]
- that Isavia Air Navigation Services reviews the feasibility of having a shift manager, or train his deputies (shift supervisors), on duty during night time in the Reykjavik Area Control Centre for strategic oversight. [19-159F044 T5]
- that the Icelandic Transport Authority reviews whether there is a need to issue guidance or instructions to operators with an Icelandic AOC regarding fuel requirement to alternate airports in Iceland, for flights planned during the hours of closure at Reykjavik, Akureyri and Egilsstadir considering the time required to open these airports. [19-159F044 T6]
The Final Report was approved on 7 December 2023 and released online on 12 December 2023.
Related Articles
- Fuel - Flight Planning Definitions
- Fuel - Diversion to Weather Alternate
- Fuel Emergencies: Guidance for Controllers
- Aeronautical Information Publications (AIPs)
- Flight Plan
- Pre-flight Preparation
- Alternate Aerodrome
- Runway Surface Friction
- Runway De-icing
- The Handover-Takeover Process (Operational ATC Positions)
- Runway Excursion
- Rescue and Fire Fighting Services
- Emergency Communications