B738, vicinity Skavsta Sweden, 2004
From SKYbrary Wiki
|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.|
|Actual or Potential
|Human Factors, Runway Excursion|
|Type of Flight||Public Transport (Passenger)|
|Take off Commenced||Yes|
|Location - Airport|
|Tag(s)||Approach not stabilised|
Procedural non compliance
|Safety Net Mitigations|
|Malfunction of Relevant Safety Net||No|
|TAWS||Available but ineffective|
|Damage or injury||No|
|Aircraft damage||None"None" is not in the list (Minor, Major, Hull loss) of allowed values for the "Aircraft damage" property.|
|Injuries||None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Injuries" property.|
|Fatalities||None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Fatalities" property. ()|
|Causal Factor Group(s)|
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 Visual Meteorological Conditions (VMC) to destination during which relevant Operator SOPs were comprehensively ignored, Terrain Avoidance and Warning System (TAWS) 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.
The Irish AAIU initially opened an investigation into the event on 30 July 2004 after notification from the Operator. On 2 September 2004, the Swedish Accident Investigation Board (AIB) was formally notified of this serious incident by the Irish AAIU and it was “agreed that the AAIU would undertake the investigation.”
It was established that the aircraft commander, who was on his last working day for the Operator prior to a planned return to his native country, had been PF. Descent was commenced late for no apparent reason and this was not challenged by the PNF. The approach checks were reportedly completed at or before Flight Level (FL) 100 but by this time, the PNF had become concerned about the visually-evident proximity of the destination landing runway and the PF accepted that the aircraft ”was high above the standard profile “at this time. The Autopilot was already disconnected.
A determined attempt to descend to reach the Visual Approach Slope Indicator Systems-indicated vertical profile occurred during which it was found that nose down pitch had reached 12.3° and, with the use of side slip, contributed to rates of descent of up to 6,200 fpm. Flap extension was attempted as soon as limiting speeds were achieved but these speeds were then exceeded with the flaps deployed. Up to 270 KIAS was reached with Flap 5 deployed. All attempts by the PNF to influence the aircraft commander’s behaviour were to no avail and the latter subsequently admitted that he continued thinking that he would be able to “rescue the approach”. Despite the approach, touchdown was achieved in the TDZ of the dry landing runway at a speed of approximately 180 knots and the aircraft stopped at the end of the 2,878 metre long runway using manual braking and normal reverse thrust.
The aircraft subsequently flew the return leg to London Stansted without any record of the flap exceedance being recorded in the aircraft Technical Log or the required maintenance inspection being carried out. In addition, neither pilot initially made any verbal or written report to the Operator about the event and it was discovered only through routine flight data monitoring.
The Investigation noted that the aircraft commander accepted that, with the benefit of hindsight, he had been mentally unfit fly on the incident day because of personal concerns with which he was (understandably) preoccupied. The Investigation noted that:
“(his) first mistake was in not calling in sick on the morning of the flight, or, indeed, earlier in his monthly roster. However…..this can be a difficult thing to do, a matter of ‘not letting the side down’ and, even more so, when it is for a very personal matter. This derives from the fact that, in aviation safety matters, heavy reliance is placed on pilots to be judge of their own day to day fitness to fly. However, this attitude can have significant consequences in ‘life event’ induced circumstances where personal judgement calls may not be sufficient to rectify a given situation. Clearly, such a situation is a difficult call to make and one that is not restricted to the pilots’ profession only.”
It was concluded on the available evidence that:
“the behaviour of the PF on the descent to Skavsta Airport was irrational, contrary to all his Flight and Crew Resource Management training and inexplicable, even to himself at the time.” But noted also that “as the subsequent return flight to Stansted showed, he quickly recovered his professionalism and safely carried out his last flight for the Operator.” The formal statement of cause was:
“This serious incident was precipitated by the temporary aberrant behaviour of the PF in disregarding the Operator’s SOP’s/CRM requirements and compounded by the inability of the PNF to counteract this behaviour in the unusual circumstances of the approach to Skavsta”.
The 'Final Report of the Investigation was published on 19 September 2005 and may be seen in full at SKYbrary bookshelf: AAIU Synoptic Report No: 2005-018
Four Safety Recommendations were made in the Report and are reproduced below in full:
- The Operator develop a CRM training module, emphasising the insidious nature of stress as it affects the performance of a pilot’s flying capabilities. This should also include the recognition of pilot subtle incapacitation and intervention, to highlight the necessary level of assertiveness required, particularly on the part of first officers when the captain is the pilot flying. (SR No. 014 of 2005)
- The Operator reinforces to aircrew the necessity of a comprehensive briefing for all approaches, including visual approaches. (SR No. 015 of 2005)
- The Operator reinforces to aircrew the requirement to re-brief where the type of approach is changed, e.g. from ILS to Visual Approach, or other.
(SR No. 016 of 2005)
- The Operator reinforces to aircrew the necessity of reporting possible structural limit exceedances to ensure the continued airworthiness of an aircraft, regardless of how the exceedances may have occurred. (SR No. 017 of 2005)