On 6 December 2018, a Boeing 737-700 overran the 1,770 metre-long landing runway at destination by 45 metres after entering the EMAS. Normal visibility prevailed but heavy rain was falling and a 10 knot tailwind component existed. The event was attributed to the pilots’ continuation bias in the face of deteriorating conditions and a late touchdown on the relatively short runway. A lack of guidance from the operator on the need for pilots to re-assess the validity of landing data routinely obtained at the top of descent was identified.

On 4 March 2019, an Embraer 145 attempting to land off an ILS approach at Presque Isle in procedure-minima weather conditions flew an unsuccessful first approach and a second in similar conditions which ended in a crash landing abeam the intended landing runway substantially damaging the aircraft. The accident was attributed to the crew decision to continue below the applicable minima without acquiring the required visual reference and noted that the ILS localiser had not been aligned with the runway extended centreline and that a recent crew report of this fault had not been promptly passed to the same Operator.

On 29 November 2017, a Boeing 737-900 on an ILS approach at Atlanta became unstable after the autothrottle and autopilot were both disconnected and was erroneously aligned with an occupied taxiway parallel to the intended landing runway. A go-around was not commenced until the aircraft was 50 feet above the ground after which it passed low over another aircraft on the taxiway. The Investigation found that the Captain had not called for a go around until well below the Decision Altitude and had then failed to promptly take control when the First Officer was slow to begin climbing the aircraft.

On 24 February 2016 a DHC6 (9N-AHH) on a VFR flight to Jomsom which had continued towards destination after encountering adverse weather impacted remote rocky terrain at an altitude of almost 11,000 feet approximately 15 minutes after takeoff after intentionally and repeatedly entering cloud in order to reach the destination. The aircraft was destroyed and all on board were killed. The Investigation attributed this to the crew’s repeated decision to fly in cloud and their deviation from the intended route after losing situational awareness. Spatial disorientation followed and they then failed to respond to repeated EGPWS cautions and warnings.

On 10 June 2018, a Boeing 737-800 departing Amsterdam with line training in progress and a safety pilot assisting only became airborne just before the runway end. The Investigation found that the wrong reduced thrust takeoff performance data had been used without any of the pilots noticing and without full thrust being selected as the end of the runway approached. The operator was found to have had several similar events, not all of which had been reported. The implied absence at the operator of a meaningful safety culture and its ineffective flight operations safety oversight process were also noted. 

On 12 September 2020, an Airbus A318 was seriously mismanaged during a largely autopilot-controlled ILS glideslope capture from above and despite being unstabilised after the crew had intentionally ignored required approach management procedures, the flight was continued without hesitation to a landing. The Investigation found that the operator’s oversight of operating standards relating to unstabilised approaches was systemically flawed and also insufficiently supportive of their ‘Evidence Based Training’ method used for pilot training. It was also noted that the Captain involved had stated to the Investigation that “he considered this flight as a non event”.

On 18 July 2018, an Airbus A330-300 failed to reject its night takeoff from Brisbane despite the absence of any airspeed indication for either pilot. A PAN call was made as a climb to FL110 continued. Once there, preparations for a somewhat challenging return were made and subsequently achieved. The Investigation noted multiple missed opportunities, including non-compliance with several procedural requirements, to detect that all pitot mast covers had remained in place and was extremely concerned that the takeoff had been continued rather than rejected. Flawed aircraft operator ground handling procedures and ineffective oversight of contractors were also deemed contributory.

On 18 September 2018, an Airbus A320 crewed by a Training Captain and a trainee Second Officer departing Sharjah was cleared for an intersection takeoff on runway 30 but turned onto the 12 direction and commenced takeoff with less than 1000 metres of runway ahead. On eventually recognising the error the Training Captain took control, set maximum thrust and the aircraft became airborne beyond the end of the runway and completed its international flight. The Investigation attributed the event to the pilots’ total absence of situational awareness noting that after issuing takeoff clearance, the controller did not monitor the aircraft.

On 11 September 2019, a Boeing 737-800 landed at night on Runway 13 at Malaga only 520 metres behind a departing Boeing 737-800 which was about to become airborne from the same runway. The Investigation noted the relatively low level of aircraft movements at the time, that both aircraft had complied with their respective clearances and that the landing aircraft crew had judged it safer to land than to commence a late go around. The conflict was attributed to non-compliance with the regulatory separation minima and deficient planning and decision making by the controller.

On 16 May 2013, a DHC6-300 on a domestic passenger flight made a tailwind touchdown at excessive speed in the opposite direction of the of 740 metre-long runway to the notified direction in use and, after departing the runway to one side during deceleration, re-entered the runway and attempted to take off. This failed and the aircraft breached the perimeter fence and fell into a river. The Investigation identified inappropriate actions of the aircraft commander in respect of both the initial landing and his response to the subsequent runway excursion and also cited the absence of effective CRM.

On 7 August 2020, a Boeing 737-800 making its second attempt to land at Calicut off a night ILS approach with a significant tailwind component became unstabilised and touched down approximately half way down the 2,700 metre-long wet table top runway and departed the end of it at 85 knots before continuing through the RESA and a fence and then dropping sharply onto a road. This caused the fuselage to separate into three pieces with 97 of the 190 occupants including both pilots being fatally or seriously injured and 34 others sustaining minor injuries. Significant fuel spillage occurred but there was no fire.

On 3 May 2019, a Boeing 737-800 significantly overran the wet landing runway at Jacksonville Naval Air Station at night when braking action was less than expected and ended up in shallow tidal water. The Investigation found that although the approach involved had been unstabilised and made with a significant tailwind and with only a single thrust reverser available, these factors had not been the cause of the overrun which was entirely attributable to attempting to complete a landing after touching down on a wet runway during heavy rain in conditions which then led to viscous aquaplaning.

On 7 November 2018, a Boeing 747-400F overran wet landing runway 14 at Halifax at night and was sufficiently damaged as a result of exceeding the available RESA to render it a hull loss. The Investigation attributed the overrun to a combination of factors including use of un-factored landing distance, momentary mishandling of the thrust levers just after touchdown, a pilot-caused lateral deviation diverting attention from deceleration, inadequate braking and late recognition of an approach tailwind component. Poor NOTAM presentation of runway availability also led the crew to believe that the longer and more suitable runway 25 was not available.

On 14 October 2019, a Sikorsky S92A manoeuvring below low cloud in poor daylight visibility in an unsuccessful attempt to locate the intended private landing site flew north towards rising ground approximately ¾ mile east of it, coming within a recorded 28 feet above terrain near to occupied houses before making an emergency climb and over-torqing the engines followed by an unstable but successful second approach. The Investigation found relevant operator procedures absent or ineffective, an intention by the management pilot in command to reach the landing site despite conditions and uncertainty about the applicable regulatory context for the flight. 

On 20 January 2020, a Bombardier DHC8-300 crew opted for a visual approach into Schefferville and after the First Officer significantly misjudged the approach, it was continued to a landing despite being well outside the operator’s stabilised approach criteria with the high rate of descent and excessive nose-up attitude resulting in structural damage to the aircraft. The Investigation noted the context for the event was inadequate operator procedures, pilot training and monitoring of procedural compliance in the presence of systemically ineffective regulatory oversight and observed that it appeared that unstabilised approaches at the operator may be occurring with unacceptable regularity.