Accident and Serious Incident Reports: RE

Definition

Reports relating to accidents which include Runway Excursion as an outcome.

The reports are organised in two sections. In the first section, reports are organised according to the sub-categories Overrun on Take OffOverrun on Landing, and Veer Off. In the second section, events are organised according to the tagging system currently employed on Runway Excursion events in our database.

Events by Sub-Category

Overrun on Take Off

On 19 January 2010, PSA Airlines CRJ 200 began take off from Charleston with an incorrect flap setting. After late crew recognition, a rejected take off was commenced at V1+13KIAS and an overrun into the EMAS bed at approximately 50knots followed. It was noted that had the overrun occurred prior to installation of the EMAS bed, the aircraft would probably have run down the steep slope immediately after the then-available RESA. The flap setting error was attributed non-adherence to a sterile flight deck. The late reject decision to an  initial attempt to correct the flap error during the take off.

On 16 August 2008, an AMC Airlines Boeing 737-800 inadvertently began a night take off from an intersection on runway 27L at Paris CDG which left insufficient take off distance available before the end of the temporarily restricted runway length. It collided with and damaged obstructions related to construction works in progress on the closed section of the runway but sustained only minor damage and completed the intended flight to Luxor. The context for the flight crew error was identified as inadequate support from the Operator and inadequate airport risk assessment for operations with a reduced runway length.

On 9 August 2012, a serviceable Cobham Leasing Fan Jet Falcon overran the 2291 metre long runway at Durham Tees Valley after beginning rejecting take off from above V1 because of a suspected bird strike. The crew believed there was a possibility of airframe damage from a single medium sized bird sighted ahead which might have been hit by the main landing gear. It was found that the overrun distance had been increased by low friction on the stopway and noted that the regulatory exemption issued for operation without FDR and CVR was no longer appropriate.

On 5 February 2012, an Airbus A340-300 started its takeoff from an intermediate point on the runway for which no regulated takeoff weight information was available and had only become airborne very close to the end of the runway and then climbed only very slowly. The Investigation found that as the full length of the planned departure runway was not temporarily unavailable, ATC had offered either the intersection subsequently used or the full length of the available parallel runway and that despite the absence of valid performance data for the intersection, the intersection had been used.

On 11 March 2017, contrary to crew expectations based on their pre-flight takeoff performance calculation, an Airbus 340-300 taking off from the 3,800 metre-long at Bogata only became airborne just before the end of the runway. The Investigation found that the immediate reason for this was the inadequate rate of rotation achieved by the Training Captain performing the takeoff. However, it was also found that the operator’s average A340-300 rotation rate was less than would be achieved using handling recommendations which themselves would not achieve the expected performance produced by the Airbus takeoff performance software that reflected type certification findings.

Overrun on Landing

On 4 October 2017, an Airbus A320 slightly overran the end of runway 22 at Surat during an early morning daylight landing. A temporarily displaced landing threshold meant the runway length was only 1,905 metres rather than the 2,905 metre full length. The aircraft remained on a paved surface and was undamaged. Its crew did not report the excursion which was only discovered when broken runway lighting was subsequently discovered. The Investigation found that the non-precision approach made was unstable and that a prolonged float in the subsequent flare meant that only 600 metres of runway remained ahead at touchdown.

On 30 September 2017, an Airbus A320 touched down late after an ILS approach to runway 32 at Sylt with a significant tailwind component being reported and failed to stop before overrunning the end of the runway and subsequently stopped on grass 80 metres beyond it. The Investigation noted that the calculated required landing distance was close to the landing distance available, the actual approach speed was 20 knots above the calculated one and that the aircraft had floated in the flare above a wet runway. It was concluded that the runway excursion was attributable to non-performance of a go-around.

On 12 September 2018, a Gulfstream G-IV overran the runway at Abuja after the air/ground status system failed to transition to ground on touchdown and the crew were slow to recognise that as a result neither spoilers nor thrust reversers had deployed. In the absence of recorded flight data, it was not possible to establish why the air/ground sensing system did not transition normally but no fault was found. The aircraft operator’s procedures in the event of such circumstances were found to be inadequate and regulatory oversight of the operator to have been comprehensively deficient over an extended period.

On 16 May 2019, an Ilyushin Il-76 overran the end of the landing runway at Yerevan after completing an ILS approach because the crew hadn’t realised until it was too late to stop that the available landing distance was reduced at the far end of the runway. The Investigation noted that it would have been possible to stop the aircraft in the distance available and attributed the lack of flight crew awareness to a combination of their own lack of professionalism and that exhibited by the Dispatcher and to the inadequacy and lack of clarity in the NOTAM communications advising the change.

On 17 July 2007, the commander of a TAM Airlines Airbus A320 being operated with one thrust reverser locked out was unable to stop the aircraft leaving the landing runway at Congonhas at speed and it hit buildings and was destroyed by the impact and fire which followed killing all on board and others on the ground. The investigation attributed the accident to pilot failure to realise that the thrust lever of the engine with the locked out reverser was above idle, which by design then prevented both the deployment of ground spoilers and the activation of the pre-selected autobrake.

Veer Off

On landing

On 28 July 2018, a right engine compressor stall on an ATR72-500 bound for Port Vila followed by smoke in the passenger cabin led to a MAYDAY declaration and shutdown of the malfunctioning engine. The subsequent single engine landing at destination ended in a veer-off and collision with two unoccupied parked aircraft. The Investigation noted the disorganised manner in which abnormal/emergency and normal checklists had been actioned and found that the Before Landing Checklist had not been run which resulted in the rudder limiter being left in high speed mode making single engine directional control on the ground effectively impossible.

On 7 January 2019, a Saab 340B made a late touchdown during light snowfall at night close to the edge of the runway at Savonlinna before veering off and eventually stopping. The Investigation attributed the excursion to flight crew misjudgements when landing but also noted the aircraft operator had a long history of similar investigated events in Scandinavia and had failed to follow its own documented Safety Management System. The Investigation also concluded that there was a significant risk that EU competition rules could indirectly compromise publicly-funded air service contract tendering by discounting the operational safety assessment of tendering organisations.

On 18 December 2017, an A320 crew found that only one thrust reverser deployed when the reversers were selected shortly after touchdown but were able to retain directional control. The Investigation found that the aircraft had been released to service in Adelaide with the affected engine reverser lockout pin in place. This error was found to have occurred in a context of multiple failures to follow required procedures during the line maintenance intervention involved for which no mitigating factors of any significance could be identified. A corrective action after a previous similar event at the same maintenance facility was also found not to have been fully implemented.

On 4 March 2019, a Boeing 767-300 crew lost directional control of their aircraft as speed reduced following their touchdown at Halifax and were unable to prevent it being rotated 180° on the icy surface before coming to a stop facing the runway landing threshold. The Investigation found that the management of the runway safety risk by the airport authority had been systemically inadequate and that the communication of what was known by ATC about the runway surface condition had been incomplete. A number of subsequent corrective actions taken by the airport authority were noted.

On 6 December 2016, a Boeing 737-800 approaching Darwin at night in the vicinity of thunderstorm activity suddenly encountered very heavy rain just before landing which degraded previously good visual reference. After drifting right of centreline just before and after touchdown, the right main gear left the runway for 400 metres before regaining. The landing and taxi-in was subsequently completed. The Investigation attributed the excursion to difficulty in discerning lateral drift during the landing flare to an abnormally wide runway with no centreline lighting in poor night visibility and noted similar previous outcomes had been consistently associated with this context.

On Take Off

On 9 February 2020, a Boeing 737-800 rejected its takeoff from East Midlands from a speed above V1 after encountering windshear in limiting weather conditions and was brought to a stop with 600 metres of runway remaining. The Investigation found that the Captain had assigned the takeoff to his First Officer but had taken control after deciding that a rejected takeoff was appropriate even though unequivocal QRH guidance that high speed rejected takeoffs should not be made due to windshear existed. Boeing analysis found that successful outcomes during takeoff windshear events have historically been more likely when takeoff is continued.

On 11 November 2017, a type-experienced Boeing 747-400ERF crew making a night rolling takeoff at Maastricht-Aachen lost aircraft directional control after an outer engine suddenly failed at low speed and a veer-off onto soft ground adjacent to the runway followed. The Investigation found that rather than immediately reject the takeoff when the engine failed, the crew had attempted to maintain directional control without thrust reduction to the point where an excursion became unavoidable. The effect of startle , the Captain s use of a noise cancelling headset and poor alerting to the engine failure by the First Officer were considered contributory.

On 23 January 2019, a Bombardier DHC8-100 failed to complete its intended night takeoff from Rouyn-Noranda after it had not been commenced on or correctly aligned parallel to the (obscured) centreline and the steadily increasing deviation had not been recognised until a runway excursion was imminent. The Investigation attributed this to the failure of the crew to pay sufficient attention to the external perspective provided by the clearly-visible runway edge lighting whilst also noting the Captain s likely underestimation of the consequences of a significant flight deck authority gradient and a failure to fully follow relevant applicable operating procedures.

On 28 October 2013 a BAe Jetstream 31 crew failed to release one of the propellers from its starting latch prior to setting take off power and the aircraft immediately veered sharply off the side of the runway without directional control until the power levers were returned to idle. The aircraft was then steered on the grass towards the nearby apron and stopped. The Investigation found that the pilots had habitually used multiple unofficial procedures to determine propeller status prior to take off and also noted that no attempt had been made to stop the aircraft using the brakes.

On 6 November 2014 a DHC8-400 sustained a burst right main gear tyre during take-off, probably after running over a hard object at high speed and diverted to Edmonton. Shortly after touching down at Edmonton with 'three greens' indicated, the right main gear leg collapsed causing wing and propeller damage and minor injuries to three occupants due to the later. The Investigation concluded that after a high rotational imbalance had been created by the tyre failure, gear collapse on touchdown had been initiated by a rotational speed of the failed tyre/wheel which was similar to one of the natural frequencies of the assembly.

Events by A&I Tag

Excessive Airspeed

On 4 October 2017, an Airbus A320 slightly overran the end of runway 22 at Surat during an early morning daylight landing. A temporarily displaced landing threshold meant the runway length was only 1,905 metres rather than the 2,905 metre full length. The aircraft remained on a paved surface and was undamaged. Its crew did not report the excursion which was only discovered when broken runway lighting was subsequently discovered. The Investigation found that the non-precision approach made was unstable and that a prolonged float in the subsequent flare meant that only 600 metres of runway remained ahead at touchdown.

On 30 September 2017, an Airbus A320 touched down late after an ILS approach to runway 32 at Sylt with a significant tailwind component being reported and failed to stop before overrunning the end of the runway and subsequently stopped on grass 80 metres beyond it. The Investigation noted that the calculated required landing distance was close to the landing distance available, the actual approach speed was 20 knots above the calculated one and that the aircraft had floated in the flare above a wet runway. It was concluded that the runway excursion was attributable to non-performance of a go-around.

On 13 September 2016, a Boeing 737-300 made an unstabilised approach to Wamena and shortly after an EGPWS ‘PULL UP’ warning due to the high rate of descent, a very hard landing resulted in collapse of the main landing gear, loss of directional control and a lateral runway excursion. The Investigation found that the approach had been carried out with both the cloudbase and visibility below the operator-specified minima and noted that the Captain had ignored a delayed go around suggestion from the First Officer because he was confident he could land safely as the two aircraft ahead had done.

On 22 December 2009, the flight crew of an American Airlines Boeing 737-800 made a long landing at Kingston at night in heavy rain and with a significant tailwind component and their aircraft overran the end of the runway at speed and was destroyed beyond repair. There was no post-crash fire and no fatalities, but serious injuries were sustained by 14 of the 154 occupants. The accident was attributed almost entirely to various actions and inactions of the crew. Damage to the aircraft after the overrun was exacerbated by the absence of a RESA.

On 9 January 2012, an Enerjet Boeing 737-700 overran the landing runway 03 at Fort Nelson by approximately 70 metres after the newly promoted Captain continued an unstabilised approach to a mis-managed late-touchdown landing. The subsequent Investigation attributed the accident to poor crew performance in the presence of a fatigued aircraft commander.

RTO decision after V1

On 9 February 2020, a Boeing 737-800 rejected its takeoff from East Midlands from a speed above V1 after encountering windshear in limiting weather conditions and was brought to a stop with 600 metres of runway remaining. The Investigation found that the Captain had assigned the takeoff to his First Officer but had taken control after deciding that a rejected takeoff was appropriate even though unequivocal QRH guidance that high speed rejected takeoffs should not be made due to windshear existed. Boeing analysis found that successful outcomes during takeoff windshear events have historically been more likely when takeoff is continued.

On 8 October 2019, a BAe Jetstream 32 departing Münster/Osnabrück couldn’t be rotated and after beginning rejected takeoff from well above V1, the aircraft departed the side of the runway passing close to another aircraft at high speed before regaining the runway for the remainder of its deceleration. The Investigation noted that the flight was the first supervised line training sector for the very inexperienced First Officer but attributed the whole event to the Training Captain’s poor performance which had, apart many from other matters, led indirectly to the inability to rotate and to the subsequent directional control problem.

On 19 April 2018, a Boeing 737-900 made a high speed rejected takeoff at Kathmandu in response to a configuration warning and overran the runway without serious consequences. The Investigation found that when a false Takeoff Configuration Warning caused by an out of adjustment switch had been annunciated just after V1, the Captain had decided to reject the takeoff because of concerns about the local terrain and locally adverse weather. It was noted that the aircraft operator did not provide criteria for rejecting takeoff up to or above the 80 knot crosscheck but that the Boeing reference QRH did so.

On 19 January 2010, PSA Airlines CRJ 200 began take off from Charleston with an incorrect flap setting. After late crew recognition, a rejected take off was commenced at V1+13KIAS and an overrun into the EMAS bed at approximately 50knots followed. It was noted that had the overrun occurred prior to installation of the EMAS bed, the aircraft would probably have run down the steep slope immediately after the then-available RESA. The flap setting error was attributed non-adherence to a sterile flight deck. The late reject decision to an  initial attempt to correct the flap error during the take off.

On 9 August 2012, a serviceable Cobham Leasing Fan Jet Falcon overran the 2291 metre long runway at Durham Tees Valley after beginning rejecting take off from above V1 because of a suspected bird strike. The crew believed there was a possibility of airframe damage from a single medium sized bird sighted ahead which might have been hit by the main landing gear. It was found that the overrun distance had been increased by low friction on the stopway and noted that the regulatory exemption issued for operation without FDR and CVR was no longer appropriate.

High Speed RTO (V above 80 but not above V1)

On 27 April 2020, an ATR 72-200 freighter crew attempted a night takeoff in good visibility aligned with the edge of runway 06 and did not begin rejecting it until within 20 knots of the applicable V1 despite hearing persistent regular noises which they did not recognise as edge light impacts and so completed the rejection on the same alignment. The Investigation noted both pilots’ familiarity with the airport and their regular work together and attributed their error to their low attention level and a minor distraction during the turnround after backtracking.

On 9 August 2019, a Bombardier CRJ-200LR about to depart Toronto which had read back and actioned a clearance to line up on the departure runway then began its takeoff without clearance and only commenced a high speed rejected takeoff when a Boeing 777-300 came into view crossing the runway ahead. A high speed rejected takeoff was completed from a maximum speed of around 100 knots. The Investigation concluded that an increased crew workload, an expectation that a takeoff clearance would be received without delay and misinterpretation of the line up instructions led to the premature initiation of a takeoff.

On 28 January 2019, a departing Embraer 170-200 narrowly avoided collision with part of a convoy of four snow clearance vehicles which failed to follow their clearance to enter a parallel taxiway and instead entered a Rapid Exit Taxiway and continued across the runway holding point before stopping just clear of the actual runway after multiple calls to do so. A high speed rejected takeoff led to the aircraft stopping just before the intersection where the incursion had occurred. The Investigation noted the prevailing adverse weather without attributing any specific cause to the vehicle convoy’s failure to proceed as cleared.

On 27 July 2018, Amsterdam ATC cleared a Boeing 737-800 to line up for departure from an intermediate taxiway but the 737 crew then heard the controller issue a takeoff clearance to an Embraer ERJ190 from the full length of the same runway. Having stopped past the holding point but clear of the actual runway and reported on the runway, they were then given a takeoff clearance, too, but held position. The 190 crew heard the 737 takeoff clearance and rejected their own takeoff, passing clear of the 737 at high speed. The Investigation suggested a review of intersection takeoffs.

On 6 November 2017, an Embraer E190 cleared for a normal visibility night takeoff at Nice began it on a parallel taxiway without ATC awareness until it had exceeded 80 knots when ATC noticed and a rejected takeoff was instructed and accomplished without any consequences. The Investigation found that although both pilots were familiar with Nice, their position monitoring relative to taxi clearance was inadequate and both had demonstrated a crucial lack of awareness of the colour difference between taxiway and runway lighting. Use of non-standard communications phraseology by both controllers and flight crew was also found to be contributory.

Unable to rotate at VR

On 8 October 2019, a BAe Jetstream 32 departing Münster/Osnabrück couldn’t be rotated and after beginning rejected takeoff from well above V1, the aircraft departed the side of the runway passing close to another aircraft at high speed before regaining the runway for the remainder of its deceleration. The Investigation noted that the flight was the first supervised line training sector for the very inexperienced First Officer but attributed the whole event to the Training Captain’s poor performance which had, apart many from other matters, led indirectly to the inability to rotate and to the subsequent directional control problem.

On 24 November 2019, as an Airbus A321 taking off from the 2665 metre-long runway 05 at Glasgow approached the calculated V1 with the flex thrust they had set, the aircraft was not accelerating as expected and they applied TOGA thrust. This resulted in the aircraft becoming airborne with less than 400 metres of runway remaining. The Investigation confirmed what the crew had subsequently discovered for themselves - that they had both made an identical error in their independent EFB performance calculations which the subsequent standard procedures and checks had not detected. The operator is reviewing its related checking procedures.

On 19 January 2010, PSA Airlines CRJ 200 began take off from Charleston with an incorrect flap setting. After late crew recognition, a rejected take off was commenced at V1+13KIAS and an overrun into the EMAS bed at approximately 50knots followed. It was noted that had the overrun occurred prior to installation of the EMAS bed, the aircraft would probably have run down the steep slope immediately after the then-available RESA. The flap setting error was attributed non-adherence to a sterile flight deck. The late reject decision to an  initial attempt to correct the flap error during the take off.

On 30 May 2019, a DHC8-200 departing from Nuuk could not be rotated at the calculated speed even using full aft back pressure and the takeoff was rejected with the aircraft coming to a stop with 50 metres of the 950 metre long dry runway remaining. The initial Investigation focus was on a potential airworthiness cause associated with the flight control system but it was eventually found that the actual weights of both passengers and cabin baggage exceeded standard weight assumptions with the excess also resulting in the aircraft centre of gravity being outside the range certified for safe flight.

On 8 March 2017, a Boeing MD83 departing Ypsilanti could not be rotated and the takeoff had to be rejected from above V1. The high speed overrun which followed substantially damaged the aircraft but evacuation was successful. The Investigation found that the right elevator had been locked in a trailing-edge-down position as a result of damage caused to the aircraft by high winds whilst it was parked unoccupied for two days prior to the takeoff. It was noted that on an aircraft with control tab initiated elevator movement, this condition was undetectable during prevailing pre flight system inspection or checks.

Collision Avoidance Action

On 17 September 2017, a Boeing 737-300 requested and was approved for a visual approach to Aqaba which involved a significant tailwind component and, after approaching at excessive speed, it touched down late and overran the 3000 metre runway onto sandy ground. The Investigation found that despite EGPWS Alerts relating to both the high rate of descent and late configuration, the Captain had instructed the First Officer to continue what was clearly an unstabilised approach and when touchdown had still not occurred with around 1000 metres of runway left, the Captain took over but was unable to prevent an overrun.

On 4 August 2014, a Boeing 737-300 making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown by the crew of a DHC8-400 which was taxiing along the same taxiway in the opposite direction. This resulted in a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.

On 7 December 2009, an South African Airlink Embraer 135 overran the recently refurbished wet landing runway at George after braking was ineffective and exited the aerodrome perimeter to end up on a public road. There was no fire and all occupants were able to evacuate the aircraft. The subsequent investigation attributed the overrun principally to inadequate wet runway friction following the surface maintenance activities and noted various significant non-compliances with ICAO Annex 14.

Parallel Approach Operations

none on SKYbrary

Late Touchdown

On 4 October 2017, an Airbus A320 slightly overran the end of runway 22 at Surat during an early morning daylight landing. A temporarily displaced landing threshold meant the runway length was only 1,905 metres rather than the 2,905 metre full length. The aircraft remained on a paved surface and was undamaged. Its crew did not report the excursion which was only discovered when broken runway lighting was subsequently discovered. The Investigation found that the non-precision approach made was unstable and that a prolonged float in the subsequent flare meant that only 600 metres of runway remained ahead at touchdown.

On 16 November 2012, an Air Contractors Airbus A300 departed the left the side of the landing runway at Bratislava after an abnormal response to directional control inputs. Investigation found that incorrect and undetected re-assembly of the nose gear torque links had led to the excursion and that absence of clear instructions in maintenance manuals, since rectified, had facilitated this. It was also considered that the absence of any regulation requiring equipment in the vicinity of the runway to be designed to minimise potential damage to aircraft departing the paved surface had contributed to the damage caused by the accident.

On 22 December 2009, the flight crew of an American Airlines Boeing 737-800 made a long landing at Kingston at night in heavy rain and with a significant tailwind component and their aircraft overran the end of the runway at speed and was destroyed beyond repair. There was no post-crash fire and no fatalities, but serious injuries were sustained by 14 of the 154 occupants. The accident was attributed almost entirely to various actions and inactions of the crew. Damage to the aircraft after the overrun was exacerbated by the absence of a RESA.

On 9 January 2012, an Enerjet Boeing 737-700 overran the landing runway 03 at Fort Nelson by approximately 70 metres after the newly promoted Captain continued an unstabilised approach to a mis-managed late-touchdown landing. The subsequent Investigation attributed the accident to poor crew performance in the presence of a fatigued aircraft commander.

On 17 October 2011, the pilot of a Merpati DHC6 attempting to land at Dabra on a scheduled passenger flight lost control of the aircraft when several bounces were followed by the aircraft leaving the runway and hitting some banana trees before re entering the runway whereupon a ground loop was made near the end of the runway to prevent an overrun onto unfavourable terrain. The aircraft was damaged but none of the occupants were injured. The mis-managed landing was attributed to an unstabilised approach.

Significant Tailwind Component

On 30 September 2017, an Airbus A320 touched down late after an ILS approach to runway 32 at Sylt with a significant tailwind component being reported and failed to stop before overrunning the end of the runway and subsequently stopped on grass 80 metres beyond it. The Investigation noted that the calculated required landing distance was close to the landing distance available, the actual approach speed was 20 knots above the calculated one and that the aircraft had floated in the flare above a wet runway. It was concluded that the runway excursion was attributable to non-performance of a go-around.

On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.

On 22 December 2009, the flight crew of an American Airlines Boeing 737-800 made a long landing at Kingston at night in heavy rain and with a significant tailwind component and their aircraft overran the end of the runway at speed and was destroyed beyond repair. There was no post-crash fire and no fatalities, but serious injuries were sustained by 14 of the 154 occupants. The accident was attributed almost entirely to various actions and inactions of the crew. Damage to the aircraft after the overrun was exacerbated by the absence of a RESA.

On 31 July 2008, the crew of an HS125-800 attempted to reject a landing at Owatonna MN after a prior deployment of the lift dumping system but their aircraft overran the runway then briefly became airborne before crashing. The aircraft was destroyed and all 8 occupants were killed. The Investigation attributed the accident to poor crew judgement and general cockpit indiscipline in the presence of some fatigue and also considered that it was partly consequent upon the absence of any regulatory requirement for either pilot CRM training or operator SOP specification for the type of small aircraft operation being undertaken.

On 14 February 2011, a Lion Air Boeing 737-900 making a night landing at Pekanbaru overran the end of the 2240 metre long runway onto the stopway after initially normal deceleration largely attributable to the thrust reversers was followed by a poor response to applied maximum braking in the final 300 metres. Whilst performance calculations showed that a stop on the runway should have been possible, it was concluded that a combination of water patches with heavy rubber contamination had reduced the friction properties of the surface towards the end of the runway and hence the effectiveness of brake application.

Significant Crosswind Component

On 22 May 2020, a BAe ATP made a go around after the First Officer mishandled the landing flare at Birmingham and when the Captain took over for a second approach, his own mishandling of the touchdown led to a lateral runway excursion. The Investigation found that although the prevailing surface wind was well within the limiting crosswind component, that component was still beyond both their handling skill levels. It also found that they were both generally inexperienced on type, had not previously encountered more than modest crosswind landings and that their type training in this respect had been inadequate.

On 9 February 2020, a Boeing 737-800 rejected its takeoff from East Midlands from a speed above V1 after encountering windshear in limiting weather conditions and was brought to a stop with 600 metres of runway remaining. The Investigation found that the Captain had assigned the takeoff to his First Officer but had taken control after deciding that a rejected takeoff was appropriate even though unequivocal QRH guidance that high speed rejected takeoffs should not be made due to windshear existed. Boeing analysis found that successful outcomes during takeoff windshear events have historically been more likely when takeoff is continued.

On 16 October 2012, a Brit Air Bombardier CRJ 700 landed long on a wet runway at Lorient and overran the runway. The aircraft sustained significant damage but none of the occupants were injured. The Investigation attributed the accident to poor decision making by the crew whilst showing signs of complacency and fatigue and failing to maintain a sterile flight deck or go around when the approach became unstable. A context of deficiencies at the airport and at the Operator was also detailed and it was concluded that aquaplaning had occurred.

On 17 July 2011, an Aer Arann ATR 72-200 made a bounced daylight landing at Shannon in gusty crosswind conditions aggravated by the known effects of a nearby large building. The nose landing gear struck the runway at 2.3g and collapsed with subsequent loss of directional control and departure from the runway. The aircraft was rendered a hull loss but there was no injury to the 25 occupants. The accident was attributed to an excessive approach speed and inadequate control of aircraft pitch during landing. Crew inexperience and incorrect power handling technique whilst landing were also found to have contributed.

On 1 September 2018, a Boeing 737-800, making its second night approach to Sochi beneath a large convective storm with low level windshear reported, floated almost halfway along the wet runway before overrunning it by approximately 400 metres and breaching the perimeter fence before stopping. A small fire did not prevent all occupants from safely evacuating. The Investigation attributed the accident to crew disregard of a number of windshear warnings and a subsequent encounter with horizontal windshear resulting in a late touchdown and noted that the first approach had meant that the crew had been poorly prepared for the second.

Thrust Reversers not fitted

On 10 October 2006, a BAE Systems 146-200 being operated by Danish airline Atlantic Airways on a passenger flight from Sola to Stord overran the end of runway 33 at destination at a slow speed in normal visibility at dawn (but just prior to the accepted definition of daylight) before plunging down a steep slope sustaining severe damage and catching fire immediately it had come to rest. The rapid spread of the fire and difficulties in evacuation resulted in the death of four of the 16 occupants and serious injury to six others. The aircraft was completely destroyed.

On 7 December 2009, an South African Airlink Embraer 135 overran the recently refurbished wet landing runway at George after braking was ineffective and exited the aerodrome perimeter to end up on a public road. There was no fire and all occupants were able to evacuate the aircraft. The subsequent investigation attributed the overrun principally to inadequate wet runway friction following the surface maintenance activities and noted various significant non-compliances with ICAO Annex 14.

On 14 August 2005, a British Regional Airlines Embraer 145 overran Runway 27L at Hannover by 160 metes after flying a stable approach in daylight but then making a soft and late touchdown on a water covered runway. Dynamic aquaplaning began and this was followed by reverted rubber aquaplaning towards the end of the paved surface when the emergency brake was applied. The aircraft suffered only minor damage and only one of the 49 occupants was slightly injured.

Landing Performance Assessment

On 16 October 2012, a Brit Air Bombardier CRJ 700 landed long on a wet runway at Lorient and overran the runway. The aircraft sustained significant damage but none of the occupants were injured. The Investigation attributed the accident to poor decision making by the crew whilst showing signs of complacency and fatigue and failing to maintain a sterile flight deck or go around when the approach became unstable. A context of deficiencies at the airport and at the Operator was also detailed and it was concluded that aquaplaning had occurred.

On 31 July 2008, the crew of an HS125-800 attempted to reject a landing at Owatonna MN after a prior deployment of the lift dumping system but their aircraft overran the runway then briefly became airborne before crashing. The aircraft was destroyed and all 8 occupants were killed. The Investigation attributed the accident to poor crew judgement and general cockpit indiscipline in the presence of some fatigue and also considered that it was partly consequent upon the absence of any regulatory requirement for either pilot CRM training or operator SOP specification for the type of small aircraft operation being undertaken.

On 14 February 2011, a Lion Air Boeing 737-900 making a night landing at Pekanbaru overran the end of the 2240 metre long runway onto the stopway after initially normal deceleration largely attributable to the thrust reversers was followed by a poor response to applied maximum braking in the final 300 metres. Whilst performance calculations showed that a stop on the runway should have been possible, it was concluded that a combination of water patches with heavy rubber contamination had reduced the friction properties of the surface towards the end of the runway and hence the effectiveness of brake application.

On 10 June 2008, a Sudan Airways Airbus A310 made a late night touchdown at Khartoum and the actions of the experienced crew were subsequently unable to stop the aircraft, which was in service with one thrust reverser inoperative and locked out, on the wet runway. The aircraft stopped essentially intact some 215 metres beyond the runway end after overrunning on smooth ground but a fuel-fed fire then took hold which impeded evacuation and eventually destroyed the aircraft.

On 7 September 2006, a DHL Boeing 727-200 overran the runway at Lagos by 400 metres after the First Officer was permitted to attempt a landing in challenging weather conditions on a wet runway off an unstable ILS approach. Following a long and fast touchdown at maximum landing weight, a go around was then called after prior selection of thrust reversers but was not actioned and a 400 metre overrun onto soft wet ground followed. The accident was attributed to poor tactical decision making by the aircraft commander.

Off side of Runway

On 22 May 2020, a BAe ATP made a go around after the First Officer mishandled the landing flare at Birmingham and when the Captain took over for a second approach, his own mishandling of the touchdown led to a lateral runway excursion. The Investigation found that although the prevailing surface wind was well within the limiting crosswind component, that component was still beyond both their handling skill levels. It also found that they were both generally inexperienced on type, had not previously encountered more than modest crosswind landings and that their type training in this respect had been inadequate.

On 13 September 2016, a Boeing 737-300 made an unstabilised approach to Wamena and shortly after an EGPWS ‘PULL UP’ warning due to the high rate of descent, a very hard landing resulted in collapse of the main landing gear, loss of directional control and a lateral runway excursion. The Investigation found that the approach had been carried out with both the cloudbase and visibility below the operator-specified minima and noted that the Captain had ignored a delayed go around suggestion from the First Officer because he was confident he could land safely as the two aircraft ahead had done.

On 27 December 2016, the crew of a Boeing 737-800 taking off from Goa at night lost control shortly after setting takeoff thrust following which the aircraft almost immediately began to drift right and off the runway. It then continued at speed over rough ground for almost 300 metres before eventually stopping after which a MAYDAY call was followed by an emergency evacuation. The Investigation found that the Captain had increased thrust to takeoff without first ensuring that both engines were stabilised and then attempted to correct the drift by left rudder and brake rather than rejecting the takeoff.

On 11 December 2019, a Bombardier BD700 Global 6000 making a night landing at Liverpool suffered a nose wheel steering failure shortly after touchdown. The crew were unable to prevent the aircraft departing the side of the runway into a grassed area where it stopped, undamaged, in mud. The Investigation found that the crew response was contrary to that needed for continued directional control but also that no pilot training or QRH procedure covered such a failure occurring at high speed nor was adequate guidance available on mitigating the risk of inadvertent opposite brake application during significant rudder deflection.

On 8 October 2019, a BAe Jetstream 32 departing Münster/Osnabrück couldn’t be rotated and after beginning rejected takeoff from well above V1, the aircraft departed the side of the runway passing close to another aircraft at high speed before regaining the runway for the remainder of its deceleration. The Investigation noted that the flight was the first supervised line training sector for the very inexperienced First Officer but attributed the whole event to the Training Captain’s poor performance which had, apart many from other matters, led indirectly to the inability to rotate and to the subsequent directional control problem.

Taxiway Take Off/Landing

On 2 October 2008, a Boeing 737-400 being used for flight crew command upgrade line training unintentionally landed off a non precision approach at Palembang in daylight on a taxiway parallel to the landing runway. Neither pilot realised their error until the aircraft was already on the ground when they saw a barrier ahead and were able to brake hard to stop only 700 metres from touchdown. It was found that the taxiway involved had served as a temporary runway five years earlier and that previously obliterated markings from that use had become visible.

On 24 September 2015, a Boeing 737-400 cleared for a night take-off from Sharjah took off from the parallel taxiway. The controller decided that since the taxiway was sterile and the aircraft speed was unknown, the safest option was to allow the take-off to continue. The Investigation noted that the taxiway used had until a year previously been the runway, becoming a parallel taxiway only when a new runway had been opened alongside it. It was noted that the controller had lost visual watch on the aircraft and regained it only once the aircraft was already at speed.

On 12 July 2015, a Japanese-operated Boeing 767-300 deviated from its acknowledged clearance and lit-centreline taxi routing and began take-off from a parallel taxiway in good night visibility, crossing a lit red stop bar in the process. When ATC observed this, the aircraft was instructed to stop which was achieved without further event. A subsequent take-off was uneventful. The crew did not report the event to their airline or their State authorities because the Captain determined that this case did not need to be reported and these organisations only became aware when subsequently contacted by the Investigating Agency.

On 4 August 2014, a Boeing 737-300 making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown by the crew of a DHC8-400 which was taxiing along the same taxiway in the opposite direction. This resulted in a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.

On 27 November 2010, a Finnair Airbus A340-300 unintentionally attempted a night take off from Hong Kong in good visibility from the taxiway parallel to the runway for which take off clearance had been given. ATC observed the error and instructed the crew to abandon the take off, which they then did. The Investigation attributed the crew error partly to distraction. It was considered that the crew had become distracted and that supporting procedures and process at the Operator were inadequate.

Runway Length Temporarily Reduced

On 4 October 2017, an Airbus A320 slightly overran the end of runway 22 at Surat during an early morning daylight landing. A temporarily displaced landing threshold meant the runway length was only 1,905 metres rather than the 2,905 metre full length. The aircraft remained on a paved surface and was undamaged. Its crew did not report the excursion which was only discovered when broken runway lighting was subsequently discovered. The Investigation found that the non-precision approach made was unstable and that a prolonged float in the subsequent flare meant that only 600 metres of runway remained ahead at touchdown.

On 16 May 2019, an Ilyushin Il-76 overran the end of the landing runway at Yerevan after completing an ILS approach because the crew hadn’t realised until it was too late to stop that the available landing distance was reduced at the far end of the runway. The Investigation noted that it would have been possible to stop the aircraft in the distance available and attributed the lack of flight crew awareness to a combination of their own lack of professionalism and that exhibited by the Dispatcher and to the inadequacy and lack of clarity in the NOTAM communications advising the change.

On 24 April 2005, an Airbus A340-200 landed short of the temporarily displaced runway threshold at Perth in good daylight visibility despite their prior awareness that there was such a displacement. The Investigation concluded that the crew had failed to correctly identify the applicable threshold markings because the markings provided were insufficiently clear to them and probably also because of the inappropriately low intensity setting of the temporary PAPI. No other Serious Incidents were reported during the same period of runway works.

On 16 August 2008, an AMC Airlines Boeing 737-800 inadvertently began a night take off from an intersection on runway 27L at Paris CDG which left insufficient take off distance available before the end of the temporarily restricted runway length. It collided with and damaged obstructions related to construction works in progress on the closed section of the runway but sustained only minor damage and completed the intended flight to Luxor. The context for the flight crew error was identified as inadequate support from the Operator and inadequate airport risk assessment for operations with a reduced runway length.

On 9 May 2008, a Boeing 737-800 made a low go around at Perth in good daylight visibility after not approaching with regard to the temporarily displaced runway threshold. A second approach was similarly flown and, having observed a likely landing on the closed runway section, ATC instructed a go around. However, instead, the aircraft flew level at a low height over the closed runway section before eventually touching down just beyond the displaced threshold. The Investigation found that runway closure markings required in Australia were contrary to ICAO Recommendations and not conducive to easy recognition when on final approach.

Intentional Premature Rotation

On 30 August 2016, a Boeing 777-300 crew began takeoff from London Heathrow at an intersection one third of the way along the runway using the reduced thrust calculated for a full-length take off instead of the rated thrust calculated for the intersection takeoff. As a result, the aircraft was only just airborne as it crossed the airport boundary and an adjacent public road. The Investigation attributed the data input error to crew failure to respond appropriately on finding that they had provisionally computed performance data based on different assumptions and concluded that the relevant Operator procedures were insufficiently robust.

On 13 December 2008, a Thomsonfly Boeing 767-300 departing from Manchester for Montego Bay Jamaica was considered to be accelerating at an abnormally slow rate during the take off roll on Runway 23L. The aircraft commander, who was the pilot not flying, consequently delayed the V1 call by about 10 - 15 because he thought the aircraft might be heavier than had been calculated. During the rotation the TAILSKID message illuminated momentarily, indicating that the aircraft had suffered a tail strike during the takeoff. The commander applied full power and shortly afterwards the stick shaker activated briefly. The aircraft continued to climb away and accelerate before the flaps were retracted and the after-takeoff check list completed. The appropriate drills in the Quick Reference Handbook (QRH) were subsequently actioned, fuel was dumped and the aircraft returned to Manchester for an overweight landing without further incident.

On 17 June 2003, a crew of a Boeing MD-88, belonging to Onur Air, executed a high speed rejected take-off at a late stage which resulted in overrun of the runway and serious damage to the aircraft.

Incorrect Aircraft Configuration

On 29 August 2019, an Airbus A319 crew used more runway than expected during a reduced thrust takeoff from Nice, although not enough to justify increasing thrust. It was subsequently found that an identical error made by both pilots when independently calculating takeoff performance data for the most limiting runway intersection had resulted in use of data for a less limiting intersection than the one eventually used. The Investigation concluded that the only guaranteed way to avoid such an error would be an automatic cross check, a system upgrade which was not possible on the particular aircraft involved.

On 28 July 2018, a right engine compressor stall on an ATR72-500 bound for Port Vila followed by smoke in the passenger cabin led to a MAYDAY declaration and shutdown of the malfunctioning engine. The subsequent single engine landing at destination ended in a veer-off and collision with two unoccupied parked aircraft. The Investigation noted the disorganised manner in which abnormal/emergency and normal checklists had been actioned and found that the Before Landing Checklist had not been run which resulted in the rudder limiter being left in high speed mode making single engine directional control on the ground effectively impossible.

On 15 July 2018, an Airbus 220-300 crew were slow to recognise that the maximum de-rate thrust required for their takeoff from Porto had not been reached but after increasing it were able to get safely airborne prior to the end of the runway. The Investigation found that applicable SOPs had not been followed and that the function of both the spoiler and autothrottle systems was inadequately documented and understood and in the case of the former an arguably flawed design had been certified. Five similar events had been recorded by the aircraft operator involved in less than six months.

On 17 September 2017, a Boeing 737-300 requested and was approved for a visual approach to Aqaba which involved a significant tailwind component and, after approaching at excessive speed, it touched down late and overran the 3000 metre runway onto sandy ground. The Investigation found that despite EGPWS Alerts relating to both the high rate of descent and late configuration, the Captain had instructed the First Officer to continue what was clearly an unstabilised approach and when touchdown had still not occurred with around 1000 metres of runway left, the Captain took over but was unable to prevent an overrun.

On 24 July 2018, a Boeing 777-200 making its second attempt to land at Dhaka in moderate to heavy rain partly left the runway during its landing roll and its right main landing gear sustained serious impact damage before the whole aircraft returned to the runway with its damaged gear assembly then causing runway damage. The Investigation attributed the excursion to the flight crew s inadequate coordination during manual handling of the aircraft and noted both the immediate further approach in unchanged weather conditions and the decision to continue to a landing despite poor visibility instead of going around again.

Reduced Thrust Take Off

On 29 August 2019, an Airbus A319 crew used more runway than expected during a reduced thrust takeoff from Nice, although not enough to justify increasing thrust. It was subsequently found that an identical error made by both pilots when independently calculating takeoff performance data for the most limiting runway intersection had resulted in use of data for a less limiting intersection than the one eventually used. The Investigation concluded that the only guaranteed way to avoid such an error would be an automatic cross check, a system upgrade which was not possible on the particular aircraft involved.

On 16 September 2019, an Airbus A320 departing Lisbon only became airborne 110 metres before the end of runway 21 and had a high speed rejected takeoff been required, it was likely to have overrun the runway. The Investigation found that both pilots had inadvertently calculated reduced thrust takeoff performance using the full 3705 metre runway length and then failed to identify their error before FMS entry. They also did not increase the thrust to TOGA on realising that the runway end was fast approaching. This was the operator’s third almost identical event at Lisbon in less than five months.

On 24 November 2019, as an Airbus A321 taking off from the 2665 metre-long runway 05 at Glasgow approached the calculated V1 with the flex thrust they had set, the aircraft was not accelerating as expected and they applied TOGA thrust. This resulted in the aircraft becoming airborne with less than 400 metres of runway remaining. The Investigation confirmed what the crew had subsequently discovered for themselves - that they had both made an identical error in their independent EFB performance calculations which the subsequent standard procedures and checks had not detected. The operator is reviewing its related checking procedures.

On 15 July 2017, a Boeing 747-8F close to its maximum takeoff weight only became airborne just before the end of the 2,500 metre-long north runway at Narita after the reduced thrust applicable to the much longer south runway was used for the takeoff and the aircraft cleared the upwind runway threshold by only 16 feet. The Investigation found that the very experienced Captain and the very inexperienced First Officer had both failed to follow elements of the applicable takeoff performance change procedures after the departure runway anticipated during pre-start flight preparations prior to ATC clearance delivery had changed.

On 21 July 2017, a Boeing 737-800 taking off from Belfast was only airborne near the runway end of the runway and then only climbed at a very shallow angle until additional thrust was eventually added. The Investigation found that the thrust set had been based on an incorrectly input surface temperature of -52°C, the expected top of climb temperature, instead of the actual surface temperature. Although inadequate acceleration had been detected before V1, the crew did not intervene. It was noted that neither the installed FMC software nor the EFBs in use were conducive to detection of the data input error.

Fixed Obstructions in Runway Strip

On 16 November 2012, an Air Contractors Airbus A300 departed the left the side of the landing runway at Bratislava after an abnormal response to directional control inputs. Investigation found that incorrect and undetected re-assembly of the nose gear torque links had led to the excursion and that absence of clear instructions in maintenance manuals, since rectified, had facilitated this. It was also considered that the absence of any regulation requiring equipment in the vicinity of the runway to be designed to minimise potential damage to aircraft departing the paved surface had contributed to the damage caused by the accident.

On 16 August 2018, a Boeing 737-800 made a stabilised approach to Manila during a thunderstorm with intermittent heavy rain but the crew lost adequate visual reference as they arrived over the runway. After a drift sideways across the 60 metre-wide landing runway, a veer off occurred and was immediately followed by a damaging collision with obstructions not compliant with prevailing airport safety standards. The Investigation found that the Captain had ignored go around calls from the First Officer and determined that the corresponding aircraft operator procedures were inadequate as well as faulting significant omissions in the Captain s approach brief.

On 8 March 2015, directional control of a Bombardier DHC 8-400 which had just completed a normal approach and landing was lost and the aircraft departed the side of the runway following the collapse of both the left main and nose landing gear assemblies. The Investigation found that after being allowed to drift to the side of the runway without corrective action, the previously airworthy aircraft had hit a non-frangible edge light and the left main gear and then the nose landing gear had collapsed with a complete loss of directional control. The aircraft had then exited the side of the runway sustaining further damage.

On 31 July 2015 a Saudi-operated Embraer Phenom on a private flight continued an unstabilised day visual approach to Blackbushe in benign weather conditions. The aircraft touched down with excess speed with almost 70% of the available landing distance behind the aircraft. It overran and was destroyed by impact damage and fire and all occupants died. The Investigation concluded that the combination of factors which created a very high workload for the pilot may have saturated his mental capacity, impeding his ability to handle new information and adapt his mental model leading to his continuation of a highly unstable approach.

Ineffective Use of Retardation Methods

On 27 December 2016, the crew of a Boeing 737-800 taking off from Goa at night lost control shortly after setting takeoff thrust following which the aircraft almost immediately began to drift right and off the runway. It then continued at speed over rough ground for almost 300 metres before eventually stopping after which a MAYDAY call was followed by an emergency evacuation. The Investigation found that the Captain had increased thrust to takeoff without first ensuring that both engines were stabilised and then attempted to correct the drift by left rudder and brake rather than rejecting the takeoff.

On 11 December 2019, a Bombardier BD700 Global 6000 making a night landing at Liverpool suffered a nose wheel steering failure shortly after touchdown. The crew were unable to prevent the aircraft departing the side of the runway into a grassed area where it stopped, undamaged, in mud. The Investigation found that the crew response was contrary to that needed for continued directional control but also that no pilot training or QRH procedure covered such a failure occurring at high speed nor was adequate guidance available on mitigating the risk of inadvertent opposite brake application during significant rudder deflection.

On 12 September 2018, a Gulfstream G-IV overran the runway at Abuja after the air/ground status system failed to transition to ground on touchdown and the crew were slow to recognise that as a result neither spoilers nor thrust reversers had deployed. In the absence of recorded flight data, it was not possible to establish why the air/ground sensing system did not transition normally but no fault was found. The aircraft operator’s procedures in the event of such circumstances were found to be inadequate and regulatory oversight of the operator to have been comprehensively deficient over an extended period.

On 19 April 2018, a Boeing 737-900 made a high speed rejected takeoff at Kathmandu in response to a configuration warning and overran the runway without serious consequences. The Investigation found that when a false Takeoff Configuration Warning caused by an out of adjustment switch had been annunciated just after V1, the Captain had decided to reject the takeoff because of concerns about the local terrain and locally adverse weather. It was noted that the aircraft operator did not provide criteria for rejecting takeoff up to or above the 80 knot crosscheck but that the Boeing reference QRH did so.

On 16 May 2019, an Ilyushin Il-76 overran the end of the landing runway at Yerevan after completing an ILS approach because the crew hadn’t realised until it was too late to stop that the available landing distance was reduced at the far end of the runway. The Investigation noted that it would have been possible to stop the aircraft in the distance available and attributed the lack of flight crew awareness to a combination of their own lack of professionalism and that exhibited by the Dispatcher and to the inadequacy and lack of clarity in the NOTAM communications advising the change.

Continued Take Off

On 27 December 2016, the crew of a Boeing 737-800 taking off from Goa at night lost control shortly after setting takeoff thrust following which the aircraft almost immediately began to drift right and off the runway. It then continued at speed over rough ground for almost 300 metres before eventually stopping after which a MAYDAY call was followed by an emergency evacuation. The Investigation found that the Captain had increased thrust to takeoff without first ensuring that both engines were stabilised and then attempted to correct the drift by left rudder and brake rather than rejecting the takeoff.

On 16 August 2008, an AMC Airlines Boeing 737-800 inadvertently began a night take off from an intersection on runway 27L at Paris CDG which left insufficient take off distance available before the end of the temporarily restricted runway length. It collided with and damaged obstructions related to construction works in progress on the closed section of the runway but sustained only minor damage and completed the intended flight to Luxor. The context for the flight crew error was identified as inadequate support from the Operator and inadequate airport risk assessment for operations with a reduced runway length.

On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.

On 29 August 2009, an Air Algérie Boeing B737-800 departed the side of the runway during take off but then regained the paved surface after sustaining damage from obstructions, completed the take off without further event and continued to destination. Damage to one of the engines, to tyres and to two lights was discovered at the destination. ATC remained unaware of the excursion until the Operator asked its representative at Lyon to ask the airport to carry out a runway inspection.

On 11 March 2017, contrary to crew expectations based on their pre-flight takeoff performance calculation, an Airbus 340-300 taking off from the 3,800 metre-long at Bogata only became airborne just before the end of the runway. The Investigation found that the immediate reason for this was the inadequate rate of rotation achieved by the Training Captain performing the takeoff. However, it was also found that the operator’s average A340-300 rotation rate was less than would be achieved using handling recommendations which themselves would not achieve the expected performance produced by the Airbus takeoff performance software that reflected type certification findings.

Continued Landing Roll

On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.

On 17 July 2007, the commander of a TAM Airlines Airbus A320 being operated with one thrust reverser locked out was unable to stop the aircraft leaving the landing runway at Congonhas at speed and it hit buildings and was destroyed by the impact and fire which followed killing all on board and others on the ground. The investigation attributed the accident to pilot failure to realise that the thrust lever of the engine with the locked out reverser was above idle, which by design then prevented both the deployment of ground spoilers and the activation of the pre-selected autobrake.

On 19 August 2012, the crew of a Flybe Finland ATR 72-200 approaching Helsinki failed to respond appropriately to a fault which limited rudder travel and were then unable to maintain directional control after touchdown with a veer off the runway then following. It was concluded that as well as prioritising a continued approach over properly dealing with the annunciated caution, crew technical knowledge in respect of the fault encountered had been poor and related training inadequate. Deficiencies found in relevant aircraft manufacturer operating documentation were considered to have been a significant factor and Safety Recommendations were made accordingly.

On 17 September 2017, a Boeing 737-300 requested and was approved for a visual approach to Aqaba which involved a significant tailwind component and, after approaching at excessive speed, it touched down late and overran the 3000 metre runway onto sandy ground. The Investigation found that despite EGPWS Alerts relating to both the high rate of descent and late configuration, the Captain had instructed the First Officer to continue what was clearly an unstabilised approach and when touchdown had still not occurred with around 1000 metres of runway left, the Captain took over but was unable to prevent an overrun.

On 25 February 2017, an Airbus A320 left the side of the landing runway at Toronto when, for undetermined reasons, the Captain, as Pilot Flying, set up a drift to the right just before touchdown. This was then followed by a lateral runway excursion into wet grass in rain-reduced visibility which continued for 1,650 metres before the aircraft regained the runway and stopped. The Investigation noted that both the absence of runway centreline lighting and the aircraft operator’s policy of not activating the aircraft rain repellent system or applying the alternative hydrophobic windshield coating may have increased the excursion risk.

Excessive Exit to Taxiway Speed

Frozen Deposits on Runway

On 4 March 2019, a Boeing 767-300 crew lost directional control of their aircraft as speed reduced following their touchdown at Halifax and were unable to prevent it being rotated 180° on the icy surface before coming to a stop facing the runway landing threshold. The Investigation found that the management of the runway safety risk by the airport authority had been systemically inadequate and that the communication of what was known by ATC about the runway surface condition had been incomplete. A number of subsequent corrective actions taken by the airport authority were noted.

On 1 February 2015, a Bombardier CRJ 1000 departed from Pamplona with slush likely to have been in excess of the regulatory maximum depth on the runway. On landing at Madrid, the normal operation of the brake units was compromised by ice and one tyre burst damaging surrounding components and leaving debris on the runway, and the other tyre was slow to spin up and sustained a serious flat spot. The Investigation concluded that the Pamplona apron, taxiway and runway had not been properly cleared of frozen deposits and that the flight crew had not followed procedures appropriate for the prevailing conditions.

Excessive Water Depth

On 30 September 2017, an Airbus A320 touched down late after an ILS approach to runway 32 at Sylt with a significant tailwind component being reported and failed to stop before overrunning the end of the runway and subsequently stopped on grass 80 metres beyond it. The Investigation noted that the calculated required landing distance was close to the landing distance available, the actual approach speed was 20 knots above the calculated one and that the aircraft had floated in the flare above a wet runway. It was concluded that the runway excursion was attributable to non-performance of a go-around.

On 10 July 2018, a Boeing 737-800 marginally overran the wet landing runway at Mumbai after the no 1 engine thrust reverser failed to deploy when full reverse was selected after a late touchdown following a stabilised ILS approach. The Investigation found that the overrun was the result of touchdown with almost 40% of the runway behind the aircraft followed by the failure of normal thrust reverser deployment when attempted due to a failed actuator in one of the reversers. The prevailing moderate rain and the likelihood that dynamic aquaplaning had occurred were identified as contributory.

Intentional Veer Off Runway

On 29 July 2017, an Antonov AN-74 crew sighted several previously unseen large eagles rising from the long grass next to the runway as they accelerated for takeoff at Sao Tome and, concerned about the risk of ingestion, made a high speed rejected takeoff but were unable to stop on the runway and entered a deep ravine just beyond it which destroyed the aircraft. The Investigation found that the reject had been unnecessarily delayed until above V1, that the crew forgot to deploy the spoilers which would have significantly increased the stopping distance and that relevant crew training was inadequate.

On 11 February 2017, a Cessna 402 failed to stop on the runway when landing at Virgin Gorda and was extensively damaged. The Investigation noted that the landing distance required was very close to that available with no safety margin so that although touchdown was normal, when the brakes failed to function properly, there was no possibility of safely rejecting the landing or stopping normally on the runway. Debris in the brake fluid was identified as causing brake system failure. The context was considered as the Operator s inadequate maintenance practices and a likely similar deficiency in operational procedures and processes.

Misaligned take off

On 27 April 2020, an ATR 72-200 freighter crew attempted a night takeoff in good visibility aligned with the edge of runway 06 and did not begin rejecting it until within 20 knots of the applicable V1 despite hearing persistent regular noises which they did not recognise as edge light impacts and so completed the rejection on the same alignment. The Investigation noted both pilots’ familiarity with the airport and their regular work together and attributed their error to their low attention level and a minor distraction during the turnround after backtracking.

On 23 January 2019, a Bombardier DHC8-100 failed to complete its intended night takeoff from Rouyn-Noranda after it had not been commenced on or correctly aligned parallel to the (obscured) centreline and the steadily increasing deviation had not been recognised until a runway excursion was imminent. The Investigation attributed this to the failure of the crew to pay sufficient attention to the external perspective provided by the clearly-visible runway edge lighting whilst also noting the Captain s likely underestimation of the consequences of a significant flight deck authority gradient and a failure to fully follow relevant applicable operating procedures.

On 18 January 2016, an Embraer 120 crew made a night takeoff from Amsterdam Runway 24 unaware that the aircraft was aligned with the right side runway edge lights. After completion of an uneventful flight, holes in the right side fuselage and damage to the right side propeller blades, the latter including wire embedded in a blade leading edge, were found. The Investigation concluded that poor visual cues guiding aircraft onto the runway at the intersection concerned were conducive to pilot error and noted that despite ATS awareness of intersection takeoff risks, no corresponding risk mitigation had been undertaken.

On 25 January 2016, an ATR 72-200 crew departing from and very familiar with Karup aligned their aircraft with the runway edge lights instead of the lit runway centreline and began take-off, only realising their error when they collided with part of the arrester wire installation at the side of the runway after which the take-off was rejected. The Investigation attributed the error primarily to the failure of the pilots to give sufficient priority to ensuring adequate positional awareness and given the familiarity of both pilots with the aerodrome noted that complacency had probably been a contributor factor.

Runway Condition not as reported

On 1 September 2018, a Boeing 737-800, making its second night approach to Sochi beneath a large convective storm with low level windshear reported, floated almost halfway along the wet runway before overrunning it by approximately 400 metres and breaching the perimeter fence before stopping. A small fire did not prevent all occupants from safely evacuating. The Investigation attributed the accident to crew disregard of a number of windshear warnings and a subsequent encounter with horizontal windshear resulting in a late touchdown and noted that the first approach had meant that the crew had been poorly prepared for the second.

On 4 March 2019, a Boeing 767-300 crew lost directional control of their aircraft as speed reduced following their touchdown at Halifax and were unable to prevent it being rotated 180° on the icy surface before coming to a stop facing the runway landing threshold. The Investigation found that the management of the runway safety risk by the airport authority had been systemically inadequate and that the communication of what was known by ATC about the runway surface condition had been incomplete. A number of subsequent corrective actions taken by the airport authority were noted.

On 25 October 2017, a Bombardier CRJ-900 crew lost directional control after touchdown at Turku in the presence of a tailwind component on a contaminated runway at night whilst heavy snow was falling. After entering a skid the aircraft completed a 180° turn before finally stopping 160 metres from the end of the 2500 metre-long runway. The Investigation found that skidding began immediately after touchdown with the aircraft significantly above the aquaplaning threshold and that the crew did not follow the thrust reverser reset procedure after premature deployment or use brake applications and aileron inputs appropriate to the challenging conditions.

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