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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

Overrun on Landing

Overrun on Landing.jpg

  • MD11, Riyadh Saudi Arabia, 2010 (On 27 July 2010, a Boeing MD11F being operated by Lufthansa Cargo on a scheduled flight from Frankfurt to Riyadh bounced twice prior to a third hard touchdown whilst attempting to land on 4205 metre-long Runway 33L at destination in normal day visibility. The fuselage was ruptured and, as the aircraft left the side of the runway, the nose landing gear collapsed and a fire began to take hold. A ‘MAYDAY’ call was made as the aircraft slid following the final touchdown. Once the aircraft had come to a stop, the two pilots evacuated before it was largely destroyed by fire. One pilot received minor injuries, the other injuries described as major.)
  • 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.)
  • 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.)
  • B463, Khark Island Iran, 2016 (On 19 June 2016, a BAe 146-300 landed long at Khark Island and overran the end of the runway at speed with the aircraft only stopping because the nose landing gear collapsed on encountering uneven ground. The Investigation attributed the accident - which caused enough structural damage for the aircraft to be declared a hull loss - entirely to the decisions and actions of the aircraft commander who failed to go around from an unstabilised approach, landed long and then did not ensure maximum deceleration was achieved. The monitoring role of the low experience First Officer was ineffective.)
  • CRJ2, Providence RI USA, 2007 (On 16 December 2007, a Bombardier CRJ-200 being operated by Air Wisconsin on a scheduled passenger flight from Philadelphia, PA to Providence RI made an ILS approach to Runway 05 at destination in IMC which became unstable but was continued to an extremely hard night touchdown which broke the left hand main landing gear and was followed by exit of the aircraft from the left hand side of the runway and a slide through a snow-covered grassy area before it came to a stop without impacting any obstructions. There were no injuries to the occupants, who left the aircraft using the integral air stairs at the main door but the aircraft suffered “substantial” damage.)

Veer Off

Directional Control.jpg On landing...

  • 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.)
  • AT75, Port Vila Vanuatu, 2018 (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.)
  • GLF4, Le Castellet France, 2012 (On 13 July 2012, a Gulfstream G-IV left the side of the runway at high speed during the landing roll at Le Castellet following a positioning flight after ineffective deceleration after the flight crew had forgotten to arm the ground spoilers. The Investigation found that pilot response to this situation had been followed by a loss of directional control, collision with obstructions and rapid onset of an intense fire. Contributory factors identified included poor procedural compliance by the pilots, their lack of training on a relevant new QRH procedure which Gulfstream had ineffectively communicated and ineffective FAA oversight of the operation.)
  • AT72, Helsinki Finland, 2012 (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.)
  • DHC6, Tiree UK, 2017 (On 7 March 2017, a DHC-6-300 left the side of the runway after touchdown in what the crew believed was a crosswind component within the Operator's crosswind limit. The Investigation concluded that the temporary loss of control of the aircraft was consistent with the occurrence with a sudden gust of wind above the applicable crosswind limits and noted the reliance of the crew on 'spot' winds provided by TWR during the final stages of the approach.)

Directional Control.jpg On take off..

  • B738, Sydney Australia, 2007 (On 14 July 2007, a Boeing 737-800 being operated by New Zealand airline Polynesian Blue on a scheduled passenger service from Sydney to Christchurch New Zealand commenced take off on Runway 16R with asymmetric thrust set and veered off the side of the runway reaching the intersecting runway 07 before rejected take off action initiated by the flight crew took effect and the aircraft came to a stop.)
  • DH8A, Rouyn-Noranda QC Canada, 2019 (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.)
  • 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.)
  • B744, Maastricht-Aachen Netherlands, 2017 (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.)
  • 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.)

Events by A&I Tag

Excessive Airspeed

  • B738, vicinity Skavsta Sweden, 2004 (On 2 July 2004, a Boeing 737-800 being operated by Irish operator Ryanair on a scheduled passenger flight from London Stansted to Skavsta Sweden, completed an extremely high speed and unstable approach in day VMC to destination during which relevant Operator SOPs were comprehensively ignored, EGPWS warnings were not actioned and AFM limits for trailing edge flap deployment were breached. Despite this, a landing at excessive speed was accommodated by just within the full length of the 2878 metre long dry runway.)
  • AN26, Kassel Germany, 2007 (On 4 October 2007, an Antonov An-26B cargo aircraft being operated for an unidentified Hungarian-registered carrier by a Ukrainian crew on an empty positioning flight from Stuttgart to Kassel overran the destination runway during a daylight landing in normal ground visibility. None of the six crew on board were injured. There was no damage to the aircraft but some damage to ground installations.)
  • 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.)
  • 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.)
  • B737, Fort Nelson BC Canada, 2012 (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

  • 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.)
  • 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.)
  • 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.)
  • D328, Isle of Man, 2005 (On 28 November 2005, a Dornier 328 departing from Isle of Man was unable to rotate at the speed calculated as applicable but the crew were able to complete a successful rejected take off. The Investigation found that the crew had failed to use the increased tale off speeds which were required for the aircraft type involved after the aircraft had been de/anti iced prior to taxiing for takeoff.)
  • DH8B, Nuuk Greenland, 2019 (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.)

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

Unable to rotate at VR

  • MD83, Ypsilanti MI USA, 2017 (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.)
  • 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.)
  • 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.)
  • A321, Glasgow UK, 2019 (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.)
  • 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.)

Collision Avoidance Action

  • B733, Aqaba Jordan, 2017 (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.)
  • 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

  • B733, Yogyakarta Indonesia, 2011 (On 20 December 2011, the experienced Captain of a Sriwijaya Air Boeing 737-300 flew an unstabilised non-precision approach to a touchdown at Yogyakarta at excessive speed whilst accompanied by a very inexperienced First Officer. The aircraft overran the end of the 2200 metre-long wet runway by 75 metres . During the approach, the Captain 'noticed' several GPWS PULL UP Warnings but no action was taken. The Investigation attributed the accident entirely to the actions of the flight crew and found that there had been no alert calls from the First Officer in respect of the way the approach was flown.)
  • B734, Amsterdam Netherlands, 2010 (2) (On 2 October 2010 a Boeing 737-400 being operated by Turkish operator Corendon Airlines on a passenger flight from Dalaman to Amsterdam made a late touchdown on landing runway 22 at destination in normal daylight visibility conditions and failed to stop before the end of the runway. The overrun occurred at low speed and there were no injuries to the 173 occupants and only minor damage to the aircraft.)
  • 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.)
  • DHC6, Dabra Indonesia, 2011 (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.)
  • B737, New York La Guardia USA, 2013 (On 22 July 2013 the Captain of a Boeing 737-700 failed to go around when the aircraft was not stabilised on final approach at La Guardia and then took control from the First Officer three seconds before touchdown and made a very hard nose first touchdown which substantially damaged the aircraft. The Investigation concluded that the accident had been a consequence of the continued approach and the attempt to recover with a very late transfer of control instead of a go around as prescribed by the Operator. The aircraft was "substantially damaged".)

Significant Tailwind Component

  • 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.)
  • SB20, Unalaska AK USA, 2019 (On 17 October 2019, a Saab 2000 overran the landing runway at Unalaska and after exiting the airport perimeter finally came to rest on shoreline rocks. One passenger was killed, one was seriously injured and three others sustained minor injuries. The Investigation has so far established that the overrun occurred after completion of a second approach following a go around from the first after it became unstabilised and that touchdown was made with a tailwind component in excess of 10 knots.)
  • A318/B738, Nantes France, 2010 (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.)
  • B737, New York La Guardia USA, 2016 (On 27 October 2016, a Boeing 737-700 crew made a late touchdown on the runway at La Guardia and did not then stop before reaching the end of the runway and entered - and exited the side of - the EMAS before stopping. The Investigation concluded that the overrun was the consequence of a failure to go around when this was clearly necessary after a mishandled touchdown and that the Captain's lack of command authority and a lack of appropriate crew training provided by the Operator to support flight crew decision making had contributed to the failure to go around.)
  • 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.)

Significant Crosswind Component

  • F50, Isle of Man, 2009 (On 15 January 2009 a VLM Fokker 50 left the side of the runway at the Isle of Man during the daylight landing roll. It was concluded that directional control had been lost on the wet runway because the crew had attempted rudder steering whilst also applying reverse pitch, an action which was contrary to SOPSs.)
  • MD11, Dublin Ireland, 2002 (On 3 February 2002, a Delta Airlines MD-11 encountered a sudden exceptional wind gust (43 kts) during the landing roll at Dublin, Ireland. The pilot was unable to maintain the directional control of the aircraft and a runway excursion to the side subsequently occurred.)
  • 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.)
  • 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.)
  • D328, Sumburgh Shetland Islands UK, 2017 (On 26 January 2017, an EASA Test Pilot carrying out certification test flying to extend the Dornier 328's maximum demonstrated crosswind was unable to retain control during an intended full stop landing on runway 09 at Sumburgh and it departed the side of the runway onto soft ground and stopped abruptly. The Investigation noted the Test Pilot's total type experience was the three circuits immediately prior to the excursion and attributed it to inappropriate flight control inputs and power lever movements. Intervention on the power levers by the aircraft commander had not been enough to prevent the excursion.)

Thrust Reversers not fitted

  • 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.)
  • 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.)
  • 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.)

Landing Performance Assessment

  • 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.)
  • 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.)
  • CRJ9, Turku Finland, 2017 (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.)
  • CRJ7, Lorient France, 2012 (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.)
  • 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.)

Off side of Runway

  • 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.)
  • B773, Munich Germany, 2011 (On 3 November 2011, a Boeing 777-300ER crew lost directional control of their aircraft soon after touchdown and after veering off one side of runway 08R, it then crossed to the other side of it before stopping. The Investigation found that during the final stages of an intended autoland in CAT 1 conditions, an ILS LLZ signal disturbance caused by a departing aircraft had led a flight path deviation just before touchdown and, after delaying a pre-briefed automatic go-around until this was inhibited by main gear runway contact, the crew failed to either set thrust manually or disconnect the autopilot.)
  • A320, Jaipur India, 2014 (On 5 January 2014, an Airbus A320 was unable to land at Delhi due to visibility below crew minima and during subsequent diversion to Jaipur, visibility there began to deteriorate rapidly. A Cat I ILS approach was continued below minima without any visual reference because there were no other alternates within the then-prevailing fuel endurance. The landing which followed was made in almost zero visibility and the aircraft sustained substantial damage after touching down to the left of the runway. The Investigation found that the other possible alternate on departure from Delhi had materially better weather but had been ignored.)
  • MD83, Port Harcourt Nigeria, 2018 (On 20 February 2018, a Boeing MD-83 attempting a night landing at Port Harcourt during a thunderstorm and heavy rain touched down well beyond the touchdown zone and departed the side of the runway near its end before continuing 300 metres beyond it. The Investigation found that a soft touchdown had occurred with 80% of the runway behind the aircraft and a communications failure on short final meant a wind velocity change just before landing leading to a tailwind component of almost 20 knots was unknown to the crew who had not recognised the need for a go around.)
  • AT72, Trollhättan Sweden, 2018 (On 9 October 2018, an ATR 72-200 left the runway during a night landing at Trollhättan before regaining it undamaged and taxiing in normally. The excursion was not reported or observed except by the flight crew. The subsequent discovery of tyre mark evidence led to an Investigation which concluded that the cause of the excursion had been failure of the left seat pilot to adequately deflect the ailerons into wind on routinely taking over control from the other pilot after landing because there was no steering tiller on the right. The non-reporting was considered indicative of the operator’s dysfunctional SMS.)

Taxiway Take Off/Landing

  • A343, Hong Kong China, 2010 (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.)
  • 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.)
  • 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).)
  • 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.)

Runway Length Temporarily Reduced

  • B738, Paris CDG France, 2008 (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.)
  • 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.)
  • IL76, Yerevan Armenia, 2019 (On 16 May 2019, an Ilyushin Il76 A320 overran the end of the landing runway at Yerevan after completing an ILS approach because the crew hadn’t realised that the available landing distance was reduced at the far end until it was too late to stop. 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.)
  • 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.)
  • A343, London Heathrow, UK 2012 (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.)

Intentional Premature Rotation

  • B773, London Heathrow UK, 2016 (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.)
  • 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.)
  • 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.)

Incorrect Aircraft Configuration

  • 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.)
  • 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.)
  • B733, Aqaba Jordan, 2017 (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.)
  • 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.)
  • 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

  • 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.)
  • A319, Nice France, 2019 (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.)
  • A321, Glasgow UK, 2019 (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.)
  • A332, Montego Bay Jamaica, 2008 (On 28 October 2008, an Airbus A330-200 could not be rotated for liftoff whist making a night takeoff from Montego Bay until the Captain had increased the reduced thrust set to TOGA, after which the aircraft became airborne prior to the end of the runway and climbed away normally. The Investigation found that the takeoff performance data used had been calculated for the flight by Company Despatch and the fact that it had been based on a takeoff weight which was 90 tonnes below the actual take off weight had not been noticed by any of the flight crew.)
  • B738, Belfast International UK, 2017 (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

  • B738, Manila Philippines, 2018 (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.)
  • 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.)
  • 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.)
  • 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

  • B463, Khark Island Iran, 2016 (On 19 June 2016, a BAe 146-300 landed long at Khark Island and overran the end of the runway at speed with the aircraft only stopping because the nose landing gear collapsed on encountering uneven ground. The Investigation attributed the accident - which caused enough structural damage for the aircraft to be declared a hull loss - entirely to the decisions and actions of the aircraft commander who failed to go around from an unstabilised approach, landed long and then did not ensure maximum deceleration was achieved. The monitoring role of the low experience First Officer was ineffective.)
  • F28, Gällivare Sweden, 2016 (On 6 April 2016, a Romanian-operated Fokker F28 overran the runway at Gällivare after a bounced night landing. There were no occupant injuries and only slight aircraft damage. The Investigation concluded that after a stabilised approach, the handling of the aircraft just prior and after touchdown, which included late and inappropriate deployment of the thrust reversers, was not compatible with a safe landing in the prevailing conditions, that the crew briefing for the landing had been inadequate and that the reported runway friction coefficients were "probably unreliable". Safety Recommendations were made for a generic 'Safe Landing' concept to be developed.)
  • 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.)
  • GLF4, Le Castellet France, 2012 (On 13 July 2012, a Gulfstream G-IV left the side of the runway at high speed during the landing roll at Le Castellet following a positioning flight after ineffective deceleration after the flight crew had forgotten to arm the ground spoilers. The Investigation found that pilot response to this situation had been followed by a loss of directional control, collision with obstructions and rapid onset of an intense fire. Contributory factors identified included poor procedural compliance by the pilots, their lack of training on a relevant new QRH procedure which Gulfstream had ineffectively communicated and ineffective FAA oversight of the operation.)
  • 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.)

Continued Take Off

  • 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.)
  • B738, Paris CDG France, 2008 (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.)
  • 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.)
  • A320, Basel-Mulhouse-Freiburg France, 2014 (On 6 October 2014, an A320 crew requested, accepted and commenced an intersection takeoff at Basel using reduced thrust performance data based on the originally anticipated full length takeoff which would have given 65% more TODA. Recognition of the error and application of TOGA allowed the aircraft to get airborne just before the runway end but the Investigation found that a rejected take off from high speed would have resulted in an overrun and noted that despite changes to crew procedures after a similar event involving the same operator a year earlier, the relevant procedures were still conducive to error.)
  • 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.)

Continued Landing Roll

  • F28, Gällivare Sweden, 2016 (On 6 April 2016, a Romanian-operated Fokker F28 overran the runway at Gällivare after a bounced night landing. There were no occupant injuries and only slight aircraft damage. The Investigation concluded that after a stabilised approach, the handling of the aircraft just prior and after touchdown, which included late and inappropriate deployment of the thrust reversers, was not compatible with a safe landing in the prevailing conditions, that the crew briefing for the landing had been inadequate and that the reported runway friction coefficients were "probably unreliable". Safety Recommendations were made for a generic 'Safe Landing' concept to be developed.)
  • 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.)
  • AT72, Copenhagen Denmark, 2013 (On 14 January 2013, selection of the power levers to ground idle after an ATR 72-200 touchdown at Copenhagen produced only one of the two expected low pitch indications. As the First Officer called 'one low pitch' in accordance with SOP, the Captain selected both engines into reverse. He was unable to prevent the resultant veer off the runway. After travelling approximately 350 metres on grass alongside the runway as groundspeed reduced, the runway was regained. A propeller control fault which would have prevented low pitch transition on the right engine was recorded but could not subsequently be replicated.)
  • 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.)
  • B738, Georgetown Guyana, 2011 (On 30 July 2011, a Boeing 737-800 overran the wet landing runway at Georgetown after a night non-precision approach, exited the airport perimeter and descended down an earth embankment. There were no fatalities but the aircraft sustained substantial damage and was subsequently declared a hull loss. The Investigation attributed the overrun to a touchdown almost two thirds of the way down the runway and failure to utilise the aircraft’s full deceleration capability. Loss of situational awareness and indecision as to the advisability of a go-around after a late touchdown became inevitable was also cited as contributory to the outcome.)

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

  • B763, Halifax NS Canada, 2019 (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.)
  • 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

  • B738, Mumbai India, 2018 (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

  • AN72, Sao Tome, Sao Tome & Principe, 2017 (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.)
  • 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

  • DH8A, Rouyn-Noranda QC Canada, 2019 (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.)
  • 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.)
  • E120, Amsterdam Netherlands, 2016 (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.)

Runway Condition not as reported

  • B738, Sochi Russia, 2018 (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.)
  • B763, Halifax NS Canada, 2019 (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.)
  • CRJ9, Turku Finland, 2017 (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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