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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

  • B739, Kathmandu Nepal, 2018 (On 19 April 2018, a Boeing 737-900 made a high speed rejected takeoff at Kathmandu in response to a configuration warning and overran the runway without serious consequences. The Investigation found that when a false Takeoff Configuration Warning caused by an out of adjustment switch had been annunciated just after V1, the Captain had decided to reject the takeoff because of concerns about the local terrain and locally adverse weather. It was noted that the aircraft operator did not provide criteria for rejecting takeoff up to or above the 80 knot crosscheck but that the Boeing reference QRH did so.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)

Overrun on Landing

Overrun on Landing.jpg

  • 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.)
  • 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.)
  • A343, Toronto Canada, 2005 (On 2 August 2005, an Air France Airbus A340 attempted a daylight landing at destination on a rain-soaked runway during an active thunderstorm and overran for 300 metres ending up in a ravine from where, despite its destruction by fire, all occupants escaped. The Investigation recommendations focussed mainly on crew decision making in adverse weather conditions and issues related to the consequences of such an overrun on survivability.)
  • 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.)
  • 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.)

Veer Off

Directional Control.jpg On landing...

  • BE20, Nadi Fiji, 2010 (On 25 April 2010, a Beech King Air touched down at Nadi with its landing gear in the transit position after flying a night approach during which a significant electrical system failure had occurred. The landing gear retracted and the aircraft left the runway to the side and came to a stop resting on its fuselage. The Investigation attributed the electrical failure, which directly affected the landing gear operating system and required two diodes to have both failed was likely to have meant that one would have failed on an earlier occasion with no apparent consequence.)
  • A343, Nairobi Kenya, 2008 (On 27 April 2008 an Airbus A340-300 crew lost previously-acquired visual reference in fog on a night auto ILS into Nairobi but continued to a touchdown which occurred with the aircraft heading towards the edge of the runway following an inappropriate rudder input. The left main gear departed the paved surface and a go around was initiated and a diversion made. The event was attributed to a delay in commencing the go around. No measured RVR from any source was passed by ATC although it was subsequently found to have been recorded as I excess of Cat 1 limits throughout.)
  • 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.)
  • 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.)
  • 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.)

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.)
  • 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.)
  • B735, Denver USA, 2008 (Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind Conditions.)
  • 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.)
  • B752, Mumbai India, 2010 (On 9 June 2010, a Boeing B757-200 being operated by Chennai-based Blue Dart Aviation on a scheduled cargo flight from Mumbai to Bangalore lined up and commenced a night take off in normal ground visibility aligned with the right hand runway edge lights of 45 metre wide runway 27. ATC were not advised of the error and corrective action and once airborne, the aircraft completed the intended flight without further event. A ground engineer at Bangalore then discovered damage to the right hand landing gear assembly including one of the brake units. After being alerted, the Mumbai Airport Authorities discovered a number of broken runway edge lights.)

Events by A&I Tag

Excessive Airspeed

  • 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.)
  • 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.)
  • 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.)
  • 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.)

RTO decision after V1

  • B739, Kathmandu Nepal, 2018 (On 19 April 2018, a Boeing 737-900 made a high speed rejected takeoff at Kathmandu in response to a configuration warning and overran the runway without serious consequences. The Investigation found that when a false Takeoff Configuration Warning caused by an out of adjustment switch had been annunciated just after V1, the Captain had decided to reject the takeoff because of concerns about the local terrain and locally adverse weather. It was noted that the aircraft operator did not provide criteria for rejecting takeoff up to or above the 80 knot crosscheck but that the Boeing reference QRH did so.)
  • 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.)
  • 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.)
  • B742, Brussels Belgium, 2008 (On 25 May 2008 a Kalitta Air B747-200F, which was departing Brussels on a cargo flight to Bahrain, overran Runway 20 at Brussels Airport, Belgium during a rejected take-off. The aircraft came to a stop 300m beyond the end of runway 20 and broke into three parts. The crew of four and one passenger safely evacuated from the aircraft and suffered only minor injuries.)
  • 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.)

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.)
  • B733, Birmingham UK, 2009 (On 6 February 2009, the crew of a Boeing 737-300 departing Birmingham successfully rejected take off from well above V1 when it became clear to the First Officer as handling pilot, that it was impossible to rotate. The Investigation found that cause of the rotation difficulty was that the crew had failed to set the stabiliser trim to the appropriate position for take off after delaying this action beyond the normal point in pre flight preparations because ground de icing was in progress and not subsequently noticing.)
  • 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.)
  • 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.)
  • 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.)

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.)
  • 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.)
  • 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.)
  • 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.)
  • A321, Sandefjord Norway, 2006 (A321 experienced minimal braking action during the daylight landing roll in wet snow conditions and normal visibility and an overrun occurred. The aircraft came to a stop positioned sideways in relation to the runway centreline with the right hand main landing gear 2 metres beyond the limit of the paved surface.)
  • 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.)
  • F100, Southampton UK, 1998 (On 24 November 1998, a KLM uk Fokker 100 overran runway 20 at Southampton after a late and fast daylight touchdown in rain was followed by poor braking. The Investigation found that the assessment of the runway as ‘wet’ passed by ATC prior the incident was correct but that sudden heavy rain shortly before the aircraft landed had caused a rapid deterioration to somewhere between ‘Wet’ and ‘Flooded’. Slow drainage of water from the runway was subsequently identified and the runway was grooved.)

Significant Tailwind Component

  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • C550, Southampton UK, 1993 (On 26 May 1993, a Cessna Citation II being operated by a UK Air Taxi Company on a positioning flight from Oxford to Southampton to collect passengers with just the flight crew on board overran the ‘very wet’ landing runway at the destination in normal daylight visibility and ended up on an adjacent motorway where it collided with traffic, caught fire and was destroyed. The aircraft occupants and three people in cars received minor injuries.)

Significant Crosswind Component

  • 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.)
  • 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.)
  • 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.)
  • B735, Denver USA, 2008 (Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind 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.)

Thrust Reversers not fitted

  • 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.)
  • 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

  • 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".)
  • 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.)
  • 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.)
  • 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.)
  • B742, Montreal Canada, 2000 (On 23 July 2000, a Boeing 747-200 being operated by Royal Air Maroc on a scheduled passenger flight from New York to Montreal overran the temporarily restricted available landing runway length after the aircraft failed to decelerate sufficiently during a daylight landing with normal on-ground visibility. It struck barriers at the displaced runway end before stopping 215 metres further on. Shortly before it stopped, ATC observed flames coming out of the No. 2 engine and advised the flight crew and alerted the RFFS. However, no sustained fire developed and the aircraft was undamaged except for internal damage to the No 2 engine. No emergency evacuation was deemed necessary by the aircraft commander and there were no occupant or other injuries)

Off side of Runway

  • B734, Barcelona Spain, 2004 (On 28 November 2004, a KLM B737-400 departed laterally from the runway on landing at Barcelona due to the effects on the nosewheel steering of a bird strike which had occured as the aircraft took off from Amsterdam.)
  • 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".)
  • 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, Brunei, 2014 (On 7 July 2014, an Airbus A320 landing at Brunei departed the side of the runway almost immediately after touchdown and continued to gradually diverge from the runway axis until stopping after a ground run of approximately 1,050 metres. The Investigation concluded that the aircraft commander, having taken over control from the First Officer when the latter lost their previously-acquired prescribed visual reference below Decision Altitude due to a sudden-onset intense rain shower ahead, had then continued the approach without recognising that the only lights still visible to him were those at the right hand edge of the runway.)
  • SU95, Moscow Sheremetyevo Russia, 2019 (On 5 May 2019, a Sukhoi RRJ-95B making a manually-flown return to Moscow Sheremetyevo after a lightning strike caused a major electrical systems failure soon after departure made a mismanaged landing which featured a sequence of three hard bounces of increasing severity. The third of these occurred with the landing gear already collapsed and structural damage and a consequential fuel-fed fire followed as the aircraft veered off the runway at speed. The subsequent evacuation was only partly successful and 41 of the 73 occupants died and 3 sustained serious injury. An Interim Report has been published.)

Taxiway Take Off/Landing

  • 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.)
  • 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.)
  • A320, Oslo Norway, 2010 (On 25 February 2010, an Aeroflot Airbus A320-200 unintentionally made a daylight take off from Oslo 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 identified contributory factors attributable to the airline, the airport and the ANSP.)
  • 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).)

Runway Length Temporarily Reduced

  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)

Intentional Premature Rotation

  • 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.)
  • 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.)
  • 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

  • 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.)
  • 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.)
  • 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.)
  • BCS3, Porto Portugal, 2018 (On 15 July 2018, an Airbus 220-300 crew were slow to recognise that the maximum de-rate thrust required for their takeoff from Porto had not been reached but after increasing it were able to get safely airborne prior to the end of the runway. The Investigation found that applicable SOPs had not been followed and that the function of both the spoiler and autothrottle systems was inadequately documented and understood and in the case of the former an arguably flawed design had been certified. Five similar events had been recorded by the aircraft operator involved in less than six months.)
  • 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.)

Reduced Thrust Take Off

  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)

Fixed Obstructions in Runway Strip

  • 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.)
  • 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.)
  • 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.)

Ineffective Use of Retardation Methods

  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • IL76, Yerevan Armenia, 2019 (On 16 May 2019, an Ilyushin Il-76 overran the end of the landing runway at Yerevan after completing an ILS approach because the crew hadn’t realised until it was too late to stop that the available landing distance was reduced at the far end of the runway. The Investigation noted that it would have been possible to stop the aircraft in the distance available and attributed the lack of flight crew awareness to a combination of their own lack of professionalism and that exhibited by the Dispatcher and to the inadequacy and lack of clarity in the NOTAM communications advising the change.)

Continued Take Off

  • A343, Bogota Colombia, 2017 (On 11 March 2017, contrary to crew expectations based on their pre-flight takeoff performance calculation, an Airbus 340-300 taking off from the 3,800 metre-long at Bogata only became airborne just before the end of the runway. The Investigation found that the immediate reason for this was the inadequate rate of rotation achieved by the Training Captain performing the takeoff. However, it was also found that the operator’s average A340-300 rotation rate was less than would be achieved using handling recommendations which themselves would not achieve the expected performance produced by the Airbus takeoff performance software that reflected type certification findings.)
  • DH8D, Saarbrucken Germany, 2015 (On 30 September 2015, the First Officer on an in-service airline-operated Bombardier DHC-8 400 selected the gear up without warning as the Captain was in the process of rotating the aircraft for take-off. The aircraft settled back on the runway wheels up and eventually stopped near the end of the 1,990 metre-long runway having sustained severe damage. The Investigation noted that a factor contributing to the First Officer's unintended action may have been her "reduced concentration level" but also highlighted the fact that the landing gear control design logic allowed retraction with the nose landing gear airborne.)
  • 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.)
  • 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.)
  • 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.)

Continued Landing Roll

  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)

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.)
  • 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.)

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

  • 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.)
  • 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.)
  • 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.)

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