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Accident and Serious Incident Reports: RE

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Category: Runway Excursion Runway Excursion
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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 Off, Overrun 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

Overrun on Take Off.jpg

  • DC86, Manston UK, 2010 (On 11 August 2010, a Douglas DC8-63F being operated by Afghanistan-based operator Kam Air on a non scheduled cargo flight from Manston UK to Sal, Cape Verde Islands failed to get airborne until after the end of departure runway 28 during a daylight take off in normal visibility. The aircraft eventually became airborne and climbed away normally and when ATC advised of the tail strike, the aircraft commander elected to continue the flight as planned and this was achieved without further event. Minor damage to the aircraft was found after flight and there was also damage to an approach light for the reciprocal runway direction.)
  • DHC6, Jomson Nepal, 2013 (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.)
  • A345, Melbourne Australia, 2009 (On 20 March 2009 an Airbus A340-500, operated by Emirates, commenced a take-off roll for a normal reduced-thrust take-off on runway 16 at Melbourne Airport. The attempt to get the aircraft airborne resulted in a tail strike and an overrun because insufficient thrust had been set based upon an incorrect flight crew data entry.)
  • MD83, Are/Ostersund Sweden, 2007 (On 9 September 2007, an MD83 being operated by Austrian Company MAP Jet, which was over the permitted weight for the runway and conditions, made a night take off from Are/Ostersund airport, Sweden, very near the end of the runway and collided with the approach lights for the opposite runway before climbing away.)
  • B738, Manchester UK, 2003 (On 16 July 2003, a Boeing 737-800, being operated by Excel Airlines on a passenger flight from Manchester to Kos began take off on Runway 06L without the flight crew being aware of work in progress at far end of the runway. The take off calculations, based on the full runway length resulted in the aircraft passing within 56 ft of a 14 ft high vehicle just after take off.)

Overrun on Landing

Overrun on Landing.jpg

  • B734, Timbuktu Mali, 2017 (On 5 May 2017, a Boeing 737-400 made a visual approach to Timbuktu and slightly overran the end of the 2,170 metre-long runway into soft ground causing one of the engines to ingest significant quantities of damaging debris. The Investigation found that the landing had been made with a significantly greater than permitted tailwind component but that nevertheless had the maximum braking briefed been used, the unfactored landing distance required would have been well within that available. The preceding approach was found to have been comprehensively unstable throughout with no call for or intent to make a go around.)
  • B737, Chicago Midway USA, 2005 (On 8 December 2005, a delay in deploying the thrust reversers after a Boeing 737-700 touchdown at night on the slippery surface of the 1176 metre-long runway at Chicago Midway with a significant tailwind component led to it running off the end, subsequently departing the airport perimeter and hitting a car before coming to a stop. The Investigation concluded that pilots’ lack of familiarity with the autobrake system on the new 737 variant had distracted them from promptly deploying the reversers and that inadequate pilot training provision and the ATC failure to provide adequate braking action information had contributed.)
  • AT45, Sienajoki Finland, 2006 (On 11 December 2006, a Finnish Commuter Airlines ATR 42-500 veered off the runway on landing at Seinäjoki, Finland.)
  • AT72, Mumbai India, 2009 (On 10 November 2010, a Kingfisher Airlines ATR 72-200 made an excessively steep and unstabilised tailwind approach in light rain to runway 27 at Mumbai in visual daylight conditions. After touching down late, the aircraft was steered off the side of the runway when it became obvious that an overrun would otherwise occur. The Investigation found that ATC had failed to advise of water patches on the runway and aquaplaning had occurred. It also found that without aquaplaning, the available distance from the actual touchdown point would have been sufficient to stop the aircraft in.)
  • A320, Varadero Cuba, 2010 (On 31 January 2010, an Airbus A320-200 being operated by the Canadian Airline Skyservice on a passenger flight from Toronto Canada to Varadero Cuba made a procedural night ILS approach to destination in heavy rain and, soon after touchdown on a flooded runway, drifted off the side and travelled parallel to it for a little over 500 metres before subsequently re-entering it at low speed. There were no injuries to the 186 occupants and the aircraft sustained only minor damage.)

Veer Off

Directional Control.jpg On landing...

  • CRJ1, Southampton UK, 2007 (On 17 January 2007, a Bombardier CRJ 100 being operated by French airline Brit Air on a scheduled night passenger flight from Paris CDG to Southampton could not be directionally controlled after touchdown on a dry surface in normal visibility and almost calm winds and departed the side of the runway during the landing roll. There were no injuries to any of the 36 occupants and there was no damage to the aircraft.)
  • DH8A, Nuuk Greenland, 2011 (On 4 March 2011, an aircraft left the runway during a mishandled landing at Nuuk, Greenland which resulted in the collapse of the right main landing gear due to excessive 'g' loading. The landing followed an unstabilised VMC approach in challenging weather conditions. The Investigation concluded that the crew had become focussed solely on landing and that task saturation had mentally blocked any decision to go around. The aircraft commander had less than 50 hours experience on the aircraft type and had only been released from supervised line training 6 days earlier.)
  • E145, Dayton OH USA, 2011 (On 31 January 2011, an Embraer 145LR being operated by Expressjet Airlines on a scheduled passenger flight from Cleveland OH to Dayton left landing runway 06R during a night landing in normal ground visibility and light winds and ended up on intersecting active runway 36. None of the 32 occupants were injured and only minor damage was caused to ground installations and the aircraft. No conflict with other aircraft resulted from the incursion onto runway 36 and after establishing that there was no major damage to the aircraft and after the taxiway route had been ‘sanded’ the aircraft was taxied in to the gate for passenger disembarkation.)
  • B737, Chicago Midway USA, 2005 (On 8 December 2005, a delay in deploying the thrust reversers after a Boeing 737-700 touchdown at night on the slippery surface of the 1176 metre-long runway at Chicago Midway with a significant tailwind component led to it running off the end, subsequently departing the airport perimeter and hitting a car before coming to a stop. The Investigation concluded that pilots’ lack of familiarity with the autobrake system on the new 737 variant had distracted them from promptly deploying the reversers and that inadequate pilot training provision and the ATC failure to provide adequate braking action information had contributed.)
  • B744, Montreal Canada, 2008 (During the landing roll in normal the aircraft veered to the right and stopped with the nose landing gear off the side of the runway.)

Directional Control.jpg On take off..

  • B738, Lyon France, 2009 (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.)
  • DH8D, Edmonton AB Canada, 2014 (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.)
  • B738, Nuremburg Germany, 2010 (On 8 January 2010, an Air Berlin Boeing 737-800 attempted to commence a rolling take off at Nuremburg on a runway pre-advised as having only ‘medium’ braking action. Whilst attempting to position the aircraft on the runway centreline, directional control was lost and the aircraft exited the paved surface onto soft ground at low speed before the flight crew were able to stop it. The event was attributed to the inappropriately high taxi speed onto the runway and subsequent attempt to conduct a rolling take off. Relevant Company standard operating procedures were found to be deficient.)
  • SF34, Stornoway UK, 2015 (On 2 January 2015, the commander of a Saab 340 suddenly lost directional control during a within-limits crosswind take off and the aircraft left the runway onto grass at approximately 80 knots. No call to reject the take off was made and no action was taken to shut down the engines until the aircraft had come to a stop in the soft ground with a collapsed nose gear and substantial damage to the propellers and lower forward fuselage. The Investigation concluded that the most likely explanation for the excursion was the absence of any rudder input as the aircraft accelerated.)
  • A320, Harstad/Narvik Norway 2004 (On 25 November 2004, a MyTravel Airways Airbus A320 departed the side of the runway at Harstad, Norway at a low speed after loss of directional control when thrust was applied for a night take off on a runway with below normal surface friction characteristics. It was found that the crew had failed to follow an SOP designed to ensure that any accumulated fan ice was shed prior to take off and also failed to apply take off thrust as prescribed, thus delaying their appreciation of the uneven thrust produced.)

Events by A&I Tag

Excessive Airspeed

  • B736, Montréal QC Canada, 2015 (On 5 June 2015, a Boeing 737-600 landed long on a wet runway at Montréal and the crew then misjudged their intentionally-delayed deceleration because of an instruction to clear the relatively long runway at its far end and were then unable to avoid an overrun. The Investigation concluded that use of available deceleration devices had been inappropriate and that deceleration as quickly as possible to normal taxi speed before maintaining this to the intended runway exit was a universally preferable strategy. It was concluded that viscous hydroplaning had probably reduced the effectiveness of maximum braking as the runway end approached.)
  • B722, Moncton Canada, 2010 (On 24 March 2010, a Boeing 727-200 being operated by Canadian company Cargojet AW on a scheduled cargo flight from Hamilton Ontario to Moncton New Brunswick failed to stop after a night landing on 1875 metre long runway 06 at destination in normal ground visibility and eventually stopped in deep mud approximately 100 metres beyond the runway end and approximately 40 metres past the end of the paved runway end strip. The three operating flight crew, who were the only occupants, were uninjured and the aircraft received only minor damage.)
  • E55P, Blackbushe UK, 2015 (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.)
  • BE9L, Zurich Switzerland, 2007 (On 27 September 2007, a Beech 90 King Air being operated single pilot by a small UK air taxi operator on a day cargo flight from Southend UK to Zurich left the runway after unintentionally touching down at destination without the landing gear extended following an approach in day VMC. The pilot, the only occupant, was uninjured but the aircraft was declared a hull loss because of substantial damage.)
  • JS32, Torsby Sweden, 2014 (On 31 January 2014, an Estonian-operated BAE Jetstream 32 being used under wet lease to fulfil a government-funded Swedish domestic air service requirement landed long at night and overran the end of the runway. The Investigation concluded that an unstabilised approach had been followed by a late touchdown at excessive speed and that the systemic context for the occurrence had been a complete failure of the aircraft operator to address operational safety at anything like the level appropriate to a commercial operation. Failure of the responsible State Safety Regulator to detect and act on this situation was also noted.)

RTO decision after V1

  • B703, Sydney Australia, 1969 (On 1 December 1969, a Boeing 707-320 being operated by Pan Am and making a daylight take off from Sydney, Australia ran into a flock of gulls just after V1 and prior to rotation and after a compressor stall and observed partial loss of thrust on engine 2 (only), the aircraft commander elected to reject the take off. Despite rapid action to initiate maximum braking and the achievement of full reverse thrust on all engines including No 2, this resulted in an overrun of the end of the runway by 170m and substantial aircraft damage. A full emergency evacuation was carried out with no injuries to any of the occupants. There was no fire.)
  • LJ60, Columbia SC USA, 2008 (On September 19 2008, a Learjet 60 departing Columbia SC USA on a non scheduled passenger overran after attempting a rejected take off from above V1 and then hit obstructions which led to its destruction by fire and the death or serious injury of all six occupants. The subsequent investigation found that the tyre failure which led to the rejected take off decision had been due to under inflation and had damaged a sensor which caused the thrust reversers to return to their stowed position after deployment with the unintended forward thrust contributing to the severity of the overrun.)
  • B732, Pekanbaru Indonesia, 2002 (On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.)
  • B738, Eindhoven Netherlands, 2010 (On 4 June 2010, a Boeing 737-800 being operated by Ryanair and departing on a scheduled passenger flight from Eindhoven to Faro, Portugal carried out a daytime rejected take off on runway 04 from above V1 in normal visibility because the handling pilot perceived that the aircraft status was abnormal. The aircraft was stopped 500m before the end of the 3000m runway, none of the occupants were injured and the aircraft suffered only hot brakes.)
  • GLF4, Bedford MA USA, 2014 (On 31 May 2014, a Gulfstream IV attempted to take off with the flight control gust locks engaged and, when unable to rotate, delayed initiating the inevitable rejected take off to a point where an overrun at high speed was inevitable. The aircraft was destroyed by a combination of impact forces and fire and all seven occupants died. The Investigation attributed the accident to the way the crew were found to have habitually operated but noted that type certification had been granted despite the aircraft not having met requirements which would have generated an earlier gust lock status warning.)

High Speed RTO (V above 80 but no above V1)

Unable to rotate at VR

  • AT43, Madang Papua New Guinea, 2013 (On 19 October 2013, an ATR42 freighter departing Madang had to reject its takeoff when it was impossible to rotate and it ended up semi-submerged in a shallow creek beyond the airfield perimeter. The Investigation found that loading had been contrary to instructions and the aircraft had a centre of gravity outside the permitted range and was overweight. This was attributed to the aircraft operator’s lack of adequate procedures for acceptance and loading of cargo. A lack of appreciation by all parties of the need to effectively mitigate runway overrun risk in the absence of a RESA was also highlighted.)
  • ATP, Helsinki Finland, 2010 (On 11 January 2010, a British Aerospace ATP crew attempting to take off from Helsinki after a two-step airframe de/anti icing treatment (Type 2 and Type 4 fluids) were unable to rotate and the take off was successfully rejected from above V1. The Investigation found that thickened de/anti ice fluid residues had frozen in the gap between the leading edge of the elevator and the horizontal stabiliser and that there had been many other similarly-caused occurrences to aircraft without powered flying controls. There was concern that use of such thickened de/anti ice fluids was not directly covered by safety regulation.)
  • B732, Pekanbaru Indonesia, 2002 (On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.)
  • CL60, Teterboro USA, 2005 (On 2 February 2005, a Challenger, belonging to Platinum Jet Management, crashed after taking off from Teterboro, New Jersey, USA. The aircraft's center of gravity was well forward of the forward takeoff limit.)
  • CRJ2, Charleston WV USA, 2010 (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.)

Collision Avoidance Action

  • B733 / DH8D, Fort McMurray Canada, 2014 (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.)
  • E135, George South Africa, 2009 (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

Late Touchdown

  • LJ25, Northolt London UK,1996 (On 13 August 1996, a Bombardier Learjet 25B being operated by a Spanish Air Taxi Operator on a private charter flight from Palma de Mallorca Spain to Northolt made a high speed overrun of the end of the landing runway after an approach in day VMC and collided with traffic on a busy main road after exiting the airport perimeter. All three occupants - the two pilots and one passenger - suffered minor injuries as did the driver of a vehicle hit by the aircraft. The aircraft was destroyed by impact forces but there was no fire.)
  • D328, Mannheim Germany, 2008 (On 19 March 2008, a Cirrus AL Dornier 328 overran runway 27 at Mannheim after a late touchdown, change of controlling pilot in the flare and continued failure to control the aircraft so as to safely complete a landing. The Investigation attributed the late touchdown and subsequent overrun to an initial failure to reject the landing when the TDZ was overflown and the subsequent failure to control the engines properly. The extent of damage to the aircraft was attributed to the inadequate RESA and extensive contextual safety deficiencies were identified in respect of both the aircraft and airport operators.)
  • B734, Timbuktu Mali, 2017 (On 5 May 2017, a Boeing 737-400 made a visual approach to Timbuktu and slightly overran the end of the 2,170 metre-long runway into soft ground causing one of the engines to ingest significant quantities of damaging debris. The Investigation found that the landing had been made with a significantly greater than permitted tailwind component but that nevertheless had the maximum braking briefed been used, the unfactored landing distance required would have been well within that available. The preceding approach was found to have been comprehensively unstable throughout with no call for or intent to make a go around.)
  • E55P, St Gallen-Altenrhein Switzerland, 2012 (On 6 August 2012 an Embraer Phenom 300 initiated a late go-around from an unstabilised ILS/DME approach at St. Gallen-Altenrhein. A second approach was immediately flown with a flap fault which had occurred during the first one and was also unstabilised with touchdown on a wet runway occurring at excessive speed. The aircraft could not be stopped before an overrun occurred during which a collision with a bus on the public road beyond the aerodrome perimeter was narrowly avoided. The aircraft was badly damaged but the occupants were uninjured. The outcome was attributed to the actions and inactions of the crew.)
  • A320, Toronto ON Canada, 2017 (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.)

Significant Tailwind Component

  • CRJ7, Kanpur India, 2011 (On 20 July 2011, an Alliance Air CRJ 700 touched down over half way along the 9000 ft long runway at Kanpur after a stable ILS approach but with an unexpected limiting tailwind component and failed to stop before the end of the paved surface. Although an emergency evacuation was not necessary and there were no injuries, the aircraft was slightly damaged by impact with an obstruction. The subsequent investigation attributed the event to the commanders continued attempt at a landing when a late touchdown became increasingly likely.)
  • B739, Pekanbaru Indonesia, 2011 (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.)
  • E135, Norwich UK, 2003 (On 30 January 2003, an Embraer 135 being operated by Swedish company City Airline on a scheduled night passenger flight from Aberdeen to Norwich overran the slush-covered landing runway following a late touchdown in normal visibility. There were no injuries to any of the 25 occupants and with no signs of fire, the passengers subsequently disembarked via the aircraft integral airstairs. There was only minor damage to the aircraft landing gear which required wheel replacement.)
  • H25B, vicinity Owatonna MN USA, 2008 (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.)
  • B738, Limoges France, 2008 (On 21 March 2008, a Boeing 737-800 being operated by Ryanair on a scheduled passenger flight from Charleroi, Belgium to Limoges carried out a daylight approach at destination followed by a landing in normal ground visibility but during heavy rain and with a strong crosswind which ended with a 50 metre overrun into mud. None of the 181 occupants were injured but both engines were damaged by ingestion of debris.)

Significant Crosswind Component

  • B735, Denver USA, 2008 (Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind Conditions.)
  • SF34, Izumo Japan, 2007 (On 10 December, 2007 a SAAB 340B being operated by Japan Air Commuter on a scheduled passenger flight left the runway at Izumo Airport during the daylight landing roll in normal visibility and continued further while veering to the right before coming to a stop on the airport apron.)
  • AT72, Shannon Ireland, 2011 (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.)
  • AT45, Sienajoki Finland, 2006 (On 11 December 2006, a Finnish Commuter Airlines ATR 42-500 veered off the runway on landing at Seinäjoki, Finland.)
  • GLF4, Teterboro NJ USA, 2010 (On 1 October 2010, a Gulfstream G-IV being operated by General Aviation Flying Service as ‘Meridian Air Charter’ on a corporate flight from Toronto International to Teterboro made a deep landing on 1833m-long runway 06 at destination in normal day visibility and overran the end of the runway at a speed of 40 to 50 knots before coming to a stop 30m into a 122m long EMAS installation.)

Thrust Reversers not fitted

  • E145, Hannover Germany, 2005 (On 14 August 2005, a British Airways Regional 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.)
  • B462, Stord Norway, 2006 (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.)
  • E135, George South Africa, 2009 (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.)

Landing Performance Assessment

  • BE9L, Zurich Switzerland, 2007 (On 27 September 2007, a Beech 90 King Air being operated single pilot by a small UK air taxi operator on a day cargo flight from Southend UK to Zurich left the runway after unintentionally touching down at destination without the landing gear extended following an approach in day VMC. The pilot, the only occupant, was uninjured but the aircraft was declared a hull loss because of substantial damage.)
  • SW4, Sanikiluaq Nunavut Canada, 2012 (On 22 December 2012, the crew of a Swearingen SA227 attempting a landing, following an unstabilised non-precision approach at Sanikiluaq at night with questionable alternate availability in marginal weather conditions, ignored GPWS PULL UP Warnings, then failed in their attempt to transition into a low go around and the aircraft crashed into terrain beyond the runway. One occupant – an unrestrained infant – was killed and the aircraft was destroyed. The Investigation faulted crew performance, the operator and the regulator and reiterated that lap-held infants were vulnerable in crash impacts.)
  • MD88, New York La Guardia USA, 2015 (On 5 March 2015 a Boeing MD88 veered off a snow-contaminated runway 13 at New York La Guardia soon after touchdown after the experienced flight crew applied excessive reverse thrust and thus compromised directional control due to rudder blanking, a known phenomenon affecting the aircraft type. The aircraft stopped partly outside the airport perimeter with the forward fuselage over water. In addition to identifying the main cause of the accident, the Investigation found that exposure to rudder blanking risks was still widespread. It also noted that the delayed evacuation was partly attributable to inadequate crew performance and related Company procedures.)
  • B739, Yogyakarta Indonesia, 2015 (On 6 November 2015, a Boeing 737-900 overran the 2,200 metre-long landing runway at Yogyakarta after a tailwind approach with airspeed significantly above the applicable Vref followed by a long landing on a wet runway without optimum use of deceleration devices. The flight crew management of the situation once the aircraft had come to a stop was contrary to procedures in a number of important respects. The aircraft operator took extensive action to improve crew performance following the event. The Investigation found significant fault with the airport operator's awareness of runway surface condition and an absence of related significant risk management.)
  • DHC6, Jomson Nepal, 2013 (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.)

Off side of Runway

  • A332, Jakarta Indonesia, 2013 (On 13 December 2013, an Airbus A330 encountered very heavy rain below 100 feet agl just after the autopilot had been disconnected for landing off an ILS approach at Jakarta. The aircraft Commander, as pilot flying, lost visual reference but the monitoring First Officer did not. A go around was neither called nor flown and after drifting in the flare, the aircraft touched down with the right main landing gear on the grass and continued like this for 500 metres before regaining the runway. The Investigation noted that prevailing SOPs clearly required that a go around should have been flown.)
  • A320, Toronto ON Canada, 2017 (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.)
  • ATP, Vilhelmina Sweden, 2016 (On 6 April 2016, a BAe ATP partly left the side of the runway soon after touchdown, regaining it after 155 metres before completing its landing roll. It sustained damage rendering it unfit to continue flying but this was not noticed until five further flights had been made. Investigation attributed the excursion to lack of pilot response to unexpected beta range power and the continued flying to the aircraft Captain's failure to ensure proper event recording, accurate operator notification or a post-excursion engineering inspection of the aircraft. Systemic inadequacy in safety management and culture at the operator was identified.)
  • DHC6, Jomson Nepal, 2013 (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.)
  • B737, Chicago Midway IL, USA 2011 (On 26 April 2011 a Southwest Boeing 737-700 was assessed as likely not to stop before the end of landing runway 13C at alternate Chicago Midway in daylight and was intentionally steered to the grass to the left of the runway near the end, despite the presence of a EMAS. The subsequent investigation determined that the poor deceleration was a direct consequence of a delay in the deployment of both speed brakes and thrust reverser. It was noted that the crew had failed to execute the ‘Before Landing’ Checklist which includes verification of speed brake arming.)

Taxiway Take Off/Landing

  • B738, Oslo Gardermoen Norway, 2005 (On a 23 October, 2005 a Boeing 737-800 operated by Pegasus Airlines, during night time, commenced a take-off roll on a parallel taxiway at Oslo Airport Gardermoen. The aircraft was observed by ATC and stop instruction was issued resulting in moderate speed rejected take-off (RTO).)
  • B763, Singapore, 2015 (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.)
  • B733, Amsterdam Netherlands, 2010 (On 10 February 2010 a KLM Boeing 737-300 unintentionally made a night take off from Amsterdam in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation noted the familiarity of the crew with the airport and identified apparent complacency.)
  • B734, Palembang Indonesia, 2008 (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.)
  • B734, Sharjah UAE, 2015 (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.)

Runway Length Temporarily Reduced

  • A342, Perth Australia, 2005 (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.)
  • A306, Yerevan Armenia, 2015 (On 17 May 2015, an Airbus A300-600 crew descended their aircraft below the correct vertical profile on a visual daytime approach at Yerevan and then landed on a closed section of the runway near the displaced runway threshold. The Investigation found that the crew had failed to review relevant AIS information prior to departing from Tehran and had not been expecting anything but a normal approach and landing. The performance of the Dispatcher in respect of briefing and the First Officer in respect of failure to adequately monitor the Captain's flawed conduct of the approach was highlighted.)
  • A343, London Heathrow, UK 2012 (On 5 February 2012, a SriLankan Airlines Airbus A340-300 started its takeoff from an intermediate point on the runway for which no regulated takeoff weight information was available on board the aircraft and was observed by ATC and others to become airborne much nearer to the end of the runway than usual. The subsequent investigation found that the flight crew had relied on data for a different runway which did not consider obstacles relevant to the runway used and determined that the regulatory position in respect of this was deficient, leading to corresponding safety recommendations being made)
  • B773, Auckland Airport New Zealand, 2007 (On 22 March 2007, an Emirates Boeing 777-300ER, started its take-off on runway 05 Right at Auckland International Airport bound for Sydney. The pilots misunderstood that the runway length had been reduced during a period of runway works and started their take-off with less engine thrust and flap than were required. During the take-off they saw work vehicles in the distance on the runway and, realising something was amiss, immediately applied full engine thrust and got airborne within the available runway length and cleared the work vehicles by about 28 metres.)
  • B738, Perth Australia, 2008 (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

  • MD88, Groningen Netherlands, 2003 (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.)
  • B763, Manchester UK, 2008 (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.)

Incorrect Aircraft Configuration

  • SF34, Marsh Harbour Bahamas, 2013 (On 13 June 2013, a rushed and unstable visual approach to Marsh Harbour by a Saab 340B was followed by a mishandled landing and a runway excursion. The Investigation concluded that the way the aircraft had been operated had been contrary to expectations in almost every respect. This had set the scene for the continuation of a visual approach to an attempted landing in circumstances where there had been multiple indications that there was no option but to break off the approach, including a total loss of forward visibility in very heavy rain as the runway neared.)
  • E145, Bristol UK, 2017 (On 22 December 2017, an Embraer 145 departed the side of the runway shortly after touching down at Bristol and finally stopped 120 metres from the runway edge. The Investigation found that the aircraft had landed after the emergency/parking brake had been inadvertently selected on during the approach when the intention had been to deploy the speed brakes. It was noted that the Captain designated as Pilot Flying had been new to both the aircraft type and the Operator and had been flying under supervision as part of the associated type conversion requirement for line training.)
  • B738, Pardubice Czech Republic, 2013 (On 25 August 2013, the type-experienced crew of a Boeing 737-800 operating with one thrust reverser locked out made a late touchdown with a significant but allowable tail wind component present and overran the end of the runway at Pardubice onto grass at 51 knots. No damage was caused to the aircraft and no emergency evacuation was performed. The Investigation concluded that the aircraft had been configured so that even for a touchdown within the TDZ, there would have been insufficient landing distance available. The flight crew were found not to have followed a number of applicable operating procedures.)
  • E190, Kupang Indonesia, 2015 (On 21 December 2015, an Embraer 195 crew continued a significantly unstable approach which included prolonged repetition of 'High Speed' and a series of EGPWS Alerts which were both ignored and which culminated in a high speed late touchdown which ended in a 200 metre overrun. The Investigation attributed the event to poor flight management and noted the systemic lack of any effective oversight of pilot operating standards compounded in the investigated event by the effects of a steep flight deck authority gradient and the failure to detect anomalies in the normal operating behaviour of both the pilots involved.)
  • JS41, Rhodes Greece, 2015 (On 2 February 2015, a Jetstream 41 made a hard and extremely fast touchdown at Rhodes and the left main gear leg collapsed almost immediately. The crew were able to prevent the consequent veer left from leading to a lateral runway excursion. The Investigation found that the approach had been significantly unstable throughout with touchdown at around 50 knots above what it should have been and that a whole range of relevant procedures had been violated by the management pilot who had flown the approach in wind shear conditions in which approaches to Rhodes were explicitly not recommended.)

Reduced Thrust Take Off

  • A320, Basel-Mulhouse-Freiburg France, 2014 (On 6 October 2014, an A320 crew requested, accepted and continued with an intersection take off but failed to correct the takeoff performance data previously entered for a full length take off which would have given 65% more TODA. Recognition of the error and application of TOGA enabled completion of the take-off but the Investigation concluded that a rejected take off from high speed would have resulted in an overrun. It also concluded that despite change after a similar event involving the same operator a year earlier, relevant crew procedures were conducive to error.)
  • A332, Montego Bay Jamaica, 2008 (Prior to the departure of a Thomas Cook Airlines Airbus A330-200 from Montego Bay Jamaica during the hours of darkness and in normal visibility on 28 October 2008, incorrect takeoff speeds had been input to the FMS by the flight crew without this being recognised. When rotation during take off was, as a consequence, initiated too early, the aircraft failed to become airborne as expected. The aircraft commander, acting as PF, quickly selected TOGA power and the aircraft became airborne before the end of the available runway had been reached and climbed away safely.)
  • H25B, vicinity Owatonna MN USA, 2008 (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.)
  • B742, Halifax Canada, 2004 (On 14 October 2004, a B742 crashed on take off from Halifax International Airport, Canada, and was destroyed by impact forces and a post-crash fire. The crew had calculated incorrect V speeds and thrust setting using an EFB.)
  • B773, Auckland Airport New Zealand, 2007 (On 22 March 2007, an Emirates Boeing 777-300ER, started its take-off on runway 05 Right at Auckland International Airport bound for Sydney. The pilots misunderstood that the runway length had been reduced during a period of runway works and started their take-off with less engine thrust and flap than were required. During the take-off they saw work vehicles in the distance on the runway and, realising something was amiss, immediately applied full engine thrust and got airborne within the available runway length and cleared the work vehicles by about 28 metres.)

Fixed Obstructions in Runway Strip

  • E55P, Blackbushe UK, 2015 (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.)
  • DH8D, Hubli India, 2015 (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.)
  • A30B, Bratislava Slovakia, 2012 (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.)

Ineffective Use of Retardation Methods

  • JS31, Kärdla Estonia, 2013 (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.)
  • B739, Yogyakarta Indonesia, 2015 (On 6 November 2015, a Boeing 737-900 overran the 2,200 metre-long landing runway at Yogyakarta after a tailwind approach with airspeed significantly above the applicable Vref followed by a long landing on a wet runway without optimum use of deceleration devices. The flight crew management of the situation once the aircraft had come to a stop was contrary to procedures in a number of important respects. The aircraft operator took extensive action to improve crew performance following the event. The Investigation found significant fault with the airport operator's awareness of runway surface condition and an absence of related significant risk management.)
  • MD88, New York La Guardia USA, 2015 (On 5 March 2015 a Boeing MD88 veered off a snow-contaminated runway 13 at New York La Guardia soon after touchdown after the experienced flight crew applied excessive reverse thrust and thus compromised directional control due to rudder blanking, a known phenomenon affecting the aircraft type. The aircraft stopped partly outside the airport perimeter with the forward fuselage over water. In addition to identifying the main cause of the accident, the Investigation found that exposure to rudder blanking risks was still widespread. It also noted that the delayed evacuation was partly attributable to inadequate crew performance and related Company procedures.)
  • ATP, Vilhelmina Sweden, 2016 (On 6 April 2016, a BAe ATP partly left the side of the runway soon after touchdown, regaining it after 155 metres before completing its landing roll. It sustained damage rendering it unfit to continue flying but this was not noticed until five further flights had been made. Investigation attributed the excursion to lack of pilot response to unexpected beta range power and the continued flying to the aircraft Captain's failure to ensure proper event recording, accurate operator notification or a post-excursion engineering inspection of the aircraft. Systemic inadequacy in safety management and culture at the operator was identified.)
  • E190, Kupang Indonesia, 2015 (On 21 December 2015, an Embraer 195 crew continued a significantly unstable approach which included prolonged repetition of 'High Speed' and a series of EGPWS Alerts which were both ignored and which culminated in a high speed late touchdown which ended in a 200 metre overrun. The Investigation attributed the event to poor flight management and noted the systemic lack of any effective oversight of pilot operating standards compounded in the investigated event by the effects of a steep flight deck authority gradient and the failure to detect anomalies in the normal operating behaviour of both the pilots involved.)

Continued Take Off

  • DHC6, Jomson Nepal, 2013 (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.)
  • B737, Southend UK, 2010 (On 21 Nov 2010, a Boeing 737-700 being operated by Arik Air on a non revenue positioning flight from Southend to Lagos with only the two pilots on board carried out a successful take off in daylight and normal ground visibility from runway 06 but became airborne only just before the end of the runway.)
  • B738, Lyon France, 2009 (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.)
  • H25B, vicinity Owatonna MN USA, 2008 (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.)
  • A343, Auckland New Zealand, 2013 (On 18 May 2013 an Airbus A340 with the Captain acting as 'Pilot Flying' commenced its night take off from Auckland in good visibility on a fully lit runway without the crew recognising that it was lined up with the runway edge. After continuing ahead for approximately 1400 metres, the aircraft track was corrected and the take off completed. The incident was not reported to ATC and debris on the runway from broken edge lights was not discovered until a routine inspection almost three hours later. The Investigation concluded that following flights were put at risk by the failure to report.)

Continued Landing Roll

  • A320, Toronto ON Canada, 2017 (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.)
  • E55P, Blackbushe UK, 2015 (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.)
  • A320, São Paulo Congonhas Brazil, 2007 (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.)
  • E190, Kupang Indonesia, 2015 (On 21 December 2015, an Embraer 195 crew continued a significantly unstable approach which included prolonged repetition of 'High Speed' and a series of EGPWS Alerts which were both ignored and which culminated in a high speed late touchdown which ended in a 200 metre overrun. The Investigation attributed the event to poor flight management and noted the systemic lack of any effective oversight of pilot operating standards compounded in the investigated event by the effects of a steep flight deck authority gradient and the failure to detect anomalies in the normal operating behaviour of both the pilots involved.)
  • B737, Chicago Midway USA, 2005 (On 8 December 2005, a delay in deploying the thrust reversers after a Boeing 737-700 touchdown at night on the slippery surface of the 1176 metre-long runway at Chicago Midway with a significant tailwind component led to it running off the end, subsequently departing the airport perimeter and hitting a car before coming to a stop. The Investigation concluded that pilots’ lack of familiarity with the autobrake system on the new 737 variant had distracted them from promptly deploying the reversers and that inadequate pilot training provision and the ATC failure to provide adequate braking action information had contributed.)

Excessive Exit to Taxiway Speed

  • JS32, Torsby Sweden, 2014 (On 31 January 2014, an Estonian-operated BAE Jetstream 32 being used under wet lease to fulfil a government-funded Swedish domestic air service requirement landed long at night and overran the end of the runway. The Investigation concluded that an unstabilised approach had been followed by a late touchdown at excessive speed and that the systemic context for the occurrence had been a complete failure of the aircraft operator to address operational safety at anything like the level appropriate to a commercial operation. Failure of the responsible State Safety Regulator to detect and act on this situation was also noted.)

Frozen Deposits on Runway

  • CRJX, Madrid Spain, 2015 (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

Intentional Veer Off Runway

  • C402, Virgin Gorda British Virgin Islands, 2017 (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

  • AT72, Karup Denmark, 2016 (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

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