Air Europa Overrun: Final Report
By Simon Hradecky, created Wednesday, Feb 15th 2012 14:38Z, last updated Wednesday, Feb 15th 2012 14:40Z
Spain's Comision de Investigacion de Accidentes e Incidents de Aviacion Civil (CIAIAC) released their final report concluding the probable cause of the incident was:
a high-energy unstabilized approach followed by a landing with excessive speed, 1300 m past the threshold, with a wet runway. In addition, neither the autobrake nor the reversers was used efficiently.
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A contributing factor to the incident was a combination of deficiencies involving several aspects of CRM (Crew Resource Management).
The first officer (35, ATPL, 3,818 hours total, 806 hours on type) was pilot flying, the captain (41, ATPL, 14,330 hours, 8,388 hours on type) was pilot monitoring.
Approaching the Canary Islands the first officer checked ATIS, which broadcast runway 03 was in use in good weather conditions. During the descent the crew was instructed to follow the TERTO1P standard arrival route, the FMS was prepared for a landing on runway 03, and the first officer held a detailed briefing about the approach and landing on runway 03. The landing weight was estimated at 54,000 kg (118,940 lbs), the Vref was thus computed at 134 KIAS for a flap setting of 30 degrees.
When the aircraft was descending through FL210 the captain requested to inquire about the possibility of landing on runway 21, about 2 minutes later, the aircraft was descending through 14,600 feet about 30.5nm from the threshold of runway 21, the aircraft was cleared to proceed directly to the fix 11nm before runway 21.
The first officer began reprogramming the FMS but had difficulties for about 2 minutes to find the point they were cleared to. The captain in the meantime advised the first officer that they needed to descend faster, the captain however did not take control of the aircraft.
The aircraft reached 10,000 feet at 315 KIAS about 21nm before touchdown, the approach was continued.
Descending through 1000 feet AGL the enhanced ground proximity warning system (EGPWS) began to issue a series of warnings including "SINK RATE", "PULL UP" and "TOO LOW TERRAIN".
The final approach was continued, the aircraft crossed the runway threshold at 180 feet AGL at 175 KIAS (Vref+41), which caused the flaps to be relieved to 25 degrees. At that point the captain realized the landing would be long on a wet runway and decided to increase the autobrake setting from 2 to maximum. At about 07:15L (07:15Z) following a long flare the aircraft touched down at 157 KIAS (Vref+23) about half way down the runway (landing distance available 2400 meters/7870 feet), 1300 meters/4260 feet past the runway threshold, autobrakes engaged but were disengaged about 5 seconds later by manual braking. Thrust reversers were selected 13 seconds after touchdown, the engines were unable to reach sufficient thrust until the aircraft had come to a stop. The aircraft went past the runway end at a speed of 51 knots above ground, went past the runway stop area (60 meters) and came to a stop about one meter short of the jet blast fence alongside the airport's perimeter fence about 28 seconds after the main wheels touched down.
The control tower alerted emergency services which responded and quickly arrived at the aircraft, however their intervention was not needed.
The passengers disembarked via a mobile ladder at door L2. Nobody needed medical assistance.
The aircraft received damage to its tyres only, two approach lights on the threshold runway 03 were damaged.
The investigation did not find indication of any malfunction of any system prior to landing.
About 90 to 70 minutes prior to landing 7mm of rain (7 liters per square meter) had fallen, the rain stopped about 60 minutes prior to landing after some more negligible rain (less than 1mm). Statements of both crew members as well as ground personnel indicated that the runway surface had changed colour due to the water on the runway, a "cloud of pulverized water" appeared when the wheels contacted the runway.
In addition to being wet runway 21 has a negative gradient of 0.5 percent for the first 1850 meters and 0.01 percent during the last 550 meters. The Aeronautics Information Package clearly prefers runway 03 for all conditions with tailwinds less than 10 knots and braking action being good. Runway 03 offers a VOR/DME/ILS approach at a descent profile of 3 degrees, while runway 21 only offers a VOR approach at a descent profile of 3.71 degrees to ensure obstacle clearance requiring descent rates close to 1000 fpm.
The flight data recorder showed: "During the first 13 seconds of the landing run, while the airplane’s speed was still high, the braking efficiency varied between the low values typical of normal braking (0.2-0.4G) and values corresponding to smooth braking (up to 0.2G). It then increased, though it dropped during a 2 to 3 second period, reaching the highest values at the end of the run."
The CIAIAC reported that prior to beginning their flight schedule the captain had doubts about the legality of their work schedule of 10:30 hours that day, just below the maximum of 11 hours. The captain also considered that their entire scheduled activity would take place within the circadian rythm phase of lowest performance.
The CIAIAC analysed: "Fatigue could have been a contributing factor to the performance of both pilots. By the time of the incident they had logged 10 hours and 30 minutes of flight time, all of it in the minimum performance phase of the circadian rhythm."
The CIAIAC analysed that the visual approach was not stabilized, which would have required the pilot monitoring (the captain) to call out at 500 feet AGL: "FIVE HUNDRED, NOT STABILIZED, GO AROUND".
The company procedures required the crew to go around immediately upon an EGPWS call "PULL UP" while "SINK RATE" and "TOO LOW TERRAIN" warnings required the crew to correct their flight path or configuration.
With the decision to land on runway 21 about 70nm from touchdown the captain reduced the distance tho descend by 23nm, which meant instead of maintaining a descent rate of about 330 feet per nm they now needed a descent rate of about 450 feet per nm. Radar data showed, that the descent rate continuously increased from that point until it reached an "impractical extreme" about 30 seconds prior to touch down with 2000 feet per nautical mile or above 1800 fpm (descending through 200 feet AGL).
The CIAIAC heavily criticized the captain highlighting his (lack of) leadership stating for example: "The captain undoubtedly noticed that the FO could not adapt properly to the circumstances and that the situation was worsening, and yet he decided to maintain his role and not take control of the airplane himself. The captain made every decision. At no time did he ask the FO his opinion. He decided to request the runway change, he decided to have the FO continue flying and he decided to continue the approach in spite of the presence of a multitude of indications that suggested or required that the maneuver be stopped. He eventually decided to land, increasing the autobrake setting to MAX instead of ordering a go around when he saw they were landing too fast in the middle of a wet runway."
However, also the first officer was criticized: "The FO’s long and meticulous briefing for runway 03 is evidence of his preoccupation over the detailed preparation of the operation, as confirmed by his custom of arriving early to prepare the flight. When the captain decided to request the change in runway, the FO did not exhibit the necessary assertiveness to tell him that he needed time to prepare for this new approach." The CIAIAC continued: "His lack of assertiveness to tell the captain that he did not agree with what he was being forced to do is undoubtedly a contributing factor to the genesis of the incident."
The investigation released 4 safety recommendations.
Deceleration Graph (Graphics: CIAIAC):
By Simon Hradecky, created Wednesday, Feb 11th 2009 14:15Z, last updated Wednesday, Feb 11th 2009 14:15Z
The CIAIAC (Spanish Accident Investigation) wrote in their preliminary report, that the airplane was on an ILS approach to runway 03. ATC had reported variable winds at 3 knots and a few clouds at 1800 feet. The copilot was pilot flying and the captain pilot monitoring.
The crew requested a visual circuit to runway 21 (the CIAIAC actually wrote runway 22) during the approach and was cleared for the circling. Following the circling approach the aircraft touched down 1300 meters past the runway threshold at a speed of 23knots above computed and briefed landing speed Vref. The airplane overran the runway end at a speed of 51 knots, passed the overrun area and came to a stop just before a perimeter fence without causing injuries or noteworthy damages.
By Simon Hradecky, created Friday, Oct 31st 2008 08:58Z, last updated Friday, Oct 31st 2008 14:00Z
EC-HJQ at Lanzarote (Photo: Reuters/Stringer Spain)
An Air Europa Lineas Aereas Boeing 737-800, registration EC-HJQ performing flight UX196 from Glasgow,SC (UK) to Lanzarote,CI (Spain) with 74 passengers and 6 crew, ran off the end of runway 21 at Lanzarote during the landing roll and came to a stop on soft ground in the beach area almost perpendicular to the runway around 07:30 local time (07:30Z). No injuries have been reported, the damage is reported minor. The passengers disembarked via stairs.
Canary Island Authorities reported, that the airplane may have suffered a broken axle. Emergency services helped the passengers off the airplane and brought them to the terminal.
The airport was closed for about 4 hours.
Metars:
GCRR 310930Z 26016KT 9999 SCT030 22/15 Q1014
GCRR 310830Z 27009KT 9999 FEW025 SCT070 19/15 Q1014
GCRR 310800Z 27009KT 9999 FEW025 BKN075 19/15 Q1014
GCRR 310730Z 24004KT 210V280 9999 FEW025 SCT100 18/14 Q1014
GCRR 310700Z VRB02KT 9999 FEW025 SCT100 18/14 Q1014
GCRR 310630Z 29004KT 270V330 9999 FEW018 BKN090 18/14 Q1014
GCRR 310600Z 28011KT 250V310 9999 -RA FEW010 BKN022 18/15 Q1014
EC-HJQ at Lanzarote (Photo: Reuters/Stringer Spain)