ATSB Media Release- B737-800 Darwin Runway Overshoot.

[lame]

ATSB MEDIA RELEASE

16 March 2004

Final 737-800 Darwin runway overshoot aircraft investigation report


The ATSB’s final investigation report has found that a Boeing 737 passenger aircraft that overran the runway in Darwin in June 2002 did so because of a high approach speed, an inaccurate and unstabilised approach, and poor crew resource management.

Significant safety action has been taken by the operator to address the problems found and to improve training and safety systems to seek to ensure it doesn’t happen again.

At about 1135pm on 11 June 2002, Boeing 737-800 registered VH-VOE touched down an estimated 1016 metres from the departure end of Runway 29 at Darwin, overran the runway and came to a stop about 44m into the 90m runway end safety area.

There were no injuries among the 92 passengers and 7 crew when the aircraft crossed the end of the runway at 35-40 knots groundspeed, and the aircraft was undamaged.

The investigation found that the pilot in command continued with an unstabilised approach and did not go around in accordance with company operating procedures. The copilot did not announce that the approach was unstable and call for a go around. A high approach speed led to a long landing and overrun situation.

Runway overruns and excursions are prominent in accidents and serious incidents involving passenger jets and typically involve long and/or fast landings.

Other factors in the Darwin incident included that the non-precision approach was flown at night in circumstances conducive to visual illusions; a displaced runway threshold limited the landing distance available; and that the relatively new operator had at the time an underdeveloped crew landing risk assessment and a safety management system that did not incorporate recommended flight data monitoring programs.

As part the operator’s maturation process, it has developed a number of measures that are being implemented over the short, medium and longer terms to improve the training of crews, and the capability of the operator’s safety management system.

The full investigation report is available on the ATSB website www.atsb.gov.au.

[The_Cutest_of_Borg]

Interesting read. A classic rushed approach of the sort that QF was experiencing not long ago.

QF instigated a new "stable/not stable" call at 500'. Called by the PNF, I believe it has gone a long way to reducing the number of these sorts of incidents in QF.

If this sort of approach has any sort of trend at DJ, it may be worthwhile to look at.

[Time Out]

You can go straight to the actual report here (http://www.atsb.gov.au/aviation/pdf/200202710.pdf)

[Disco Stu]

Lots of things for DJ to contemplate in this, though considering the incident was 20 months ago "the operator’s maturation process" would hopefully be allot further down the track now. I'm not sure the operator had a deliberate 'maturation process' (a bit like wine:D ) more likely lurching from one crisis to the next.

One of the more disturbing aspects highlighted in the report para1.1 History of the flight, page 5 and I quote
"ATC was unaware of the overrun until a safety officer, carrying out a runway inspection 3 hours later, noticed wheel tracks in the RESA."
We are being told here that the aircraft overan the runway and the crew did not report it. Terrific, why didn't they report it? What were they afraid of? What sort of 'culture' is being engendered by the Flight Op's Management specifically and the Airline Management in general.

Bell's, what bells

Disco Stu

[Next Generation]

Lots of things for DJ to contemplate in this, though considering the incident was 20 months ago "the operator’s maturation process" would hopefully be allot further down the track now.

At least it wasn't left parked on a golf course!

How's the maturation process going for one of the world's oldest airlines?

Short memory???????

[DoogieD]

Speaking of the maturation process...time to grow up NG?

Take a stroll through the forum way back when the QF incident occurred, and I'm sure you'll see that there was many a heated debate over the incident and particulars.

No, I wouldn't say it comes down to a short memory on DS's behalf; merely keeping to the topic the thread was designed for ;)

Regards

[fire wall]

N.G. , you would do well to reconsider your statement.
Personally I prefer those that inhabit foward of the flight deck door to display a bit more maturity that what your comment on this thread (and those of past threads) indicates.

[Keg]

Ah, so that's OK then. Because they didn't leave it parked in a golf course, they don't have to report it. That's the logic is it NG?

I'm pretty hard to get wound up on PPRUNE but Independant audits show you're a goose. You have nothing useful to contribute.

The good thing though is that you just keep sticking your head out of the trench! :rolleyes: :p Have you made a post in the last month or so since your grand standing b/s one about the independant audits that HASN'T been roundly derided as worthless? :E

[TIMMEEEE]

Like it or not, the act of overunning a runway and then disguising it by taxying back without advising ATC reaks of a total lack of airmanship, common sense and discipline.
To condone this action is reckless to say the least.

If you stuff up then hey - you stuff up.
Overruns have happened before for whatever reason and will happen again.
There but for the grace of god go I!!
Nobody is perfect.

And wasn't a Metro Captain from a former commuter airline actually sacked for doing the same thing?

In this case the Metro ran off to the side of the runway in Cudal NSW and left bloody great track marks in the grass where this mishap occurred.
The witness in this case was no less than the company CEO and owner!
Rumour has it that when questioned, said pilot denied the occurence vehemently and tried to cover their actions up.

The result was the sack.

[The_Cutest_of_Borg]

NG, that post sums you up.

I now know where the NG comes from, you have the maturity of a 11 year old.

Your attitude has no place on a professional flight deck.

[Cactus Jack]

Don't suppose we will here from you again in the near future, NG.

Your post is a disgrace my friend, and you are an embarassment to all of your very professional collegues.

[Sperm Bank]

NG defending the company is honourable but you may want to re-consider your input next time. Deriding QF is not in the spirit and has nothing to do with one of our a/c running off the rwy in DN.

The incident was a mess.. end of story...Procedures were not followed and a blatant lack of procedural compliance displayed. The Captain is now a career F/O as a result.

I can assure readers of this forum there are no "cultural" issues with this type of behaviour. Most pilot's do as required and follow SOP's (as they do in most Western airlines). I do not want to cast aspertions or vilify the individuals involved. I will not however defend the indefensible. We have to take this one on the chin and get on with it.

[Cactus Jack]

Good on you, SB. Well said. We at QF have (IMHO) done the same with our incident, so readily brought to light by NG....

But the less said about maturation the better.....

[Keg]

Obviously not a fan of Human Factors and CRM issues then Menen!?!?!

'Pilot Error' as a 'cause' for accidents went out a LONG time ago. What gripes me worse though is that the media love it and crawl all over terms like that. Sure, the pilots tend to be the people to make the LAST bad call but that doesn't mean that in the absence of making that call that everything is otherwise hunky dory. EG: QF1 showed Qantas (and it's drivers) that even if the prang had been adverted and the aircraft had gone around that there were still some significant 'other' issues at play. Read the investigation for the full break down.

The over run was an event that probably occurred at the end of a long error chain. The decision to not report it is something that concerns me more!?!?! One is things that can be fixed by looking at software, hardware, systems, and all the other good guts stuff that Reason and SCHELL looks at; the other is a flagrant breach. If the crew has been disciplined over that misjudgement then nothing more need be said! ;)

Spermie, it's great to see members standing up against members from their own airline and 'calling' them for irresponsible/poor behaviour. It isn't pleasant but it beats having nongs constantly 'drag down' a reputation that some people work hard to build up! :ok:

[Sheep Guts]

I suppose they could back track atleast. But this a pure example, that could happen anywhere. There are alot o DJ knockers HERE, but it could happen in any Airline. Thats why a rigorous check and training system is valuable.

Those DJ knockers we have here, do you remmember the QF74 in Thailand about 5 years back. They couldnt backtrack after that. And Multi-Crew CRM rules were in dissaray there moreso.

We have to learn from these incidents and not blow them off, training and education helps PILOTS be more vigilant

Sheep

[Wirraway]

Fri "The Australian"

CASA's eyes on Virgin
By Steve Creedy
March 19, 2004

THE Civil Aviation Safety Authority says it has its finger on the pulse of Virgin Blue, despite another indication this week that past practices were not up to scratch.

The comment came after Australian Transport Safety Bureau investigators found that a Virgin jet which ran off the end of a runway in Darwin landed too fast after an inaccurate and unstable approach by pilots involving "several safety issues".

"Virgin Blue has worked constantly to upgrade a range of their safety systems," a CASA spokesman said.

"That work's being oversighted by CASA and is continuing successfully."

The Brisbane-Darwin flight carrying 92 passengers and seven crew stopped 44m into a 90m asphalt safety area after crossing the end of the runway at more than 65kmh.

No one was injured in the landing on June 11, 2002, and the aircraft was undamaged but the incident led to the captain being demoted.

Part of the runway was closed on the night of the incident and the instrument landing system was not available, but investigators determined there was enough room to land.

They found the plane's captain continued with an unstable approach and landed too far down the runway when he should have aborted the landing in accordance with company procedures.

His co-pilot also did not announce that the approach was unstable, or call for a go-around.

"Overall, there was a number of safety issues identified during the course of the investigation," the report said.

Those issues included the shortened runway, a lack of communication between the crew, and poor assessment of the risks of landing.

But the report noted the airline, which was launched in 2000, was relatively new at the time of the incident.

It said the airline had since moved to implement a number of measures to address crew training and Virgin's safety management system.

Virgin Blue spokesman David Huttner said the airline had viewed the incident seriously when it occurred two years ago.

The airline had since received two positive Boeing safety system reviews and had changed its crew training to encourage assertiveness.

==========================================

[tightcannon]

Hey guys I am going to attempt to explain an important attribute of this incident, so as to help us all, if I dont explain it well please forgive me here goes.

I think one of the big traps in all of this was the kind of unstable approach it was. Yes they were fast however when you see the charts the a/c was on slope. So they were sort of stabilised. I think we all think of being unstabilised as some sort of pitch unstable ie going up and down to regain the slope, in this case they were on slope but the speed was up the creek. which means that the crew were trying to judge speed decay (decelleration) so as to land, this is one of the reasons that the FO may not have said anything, when we are all learning we all know that getting the speed back is hard and most of the times you think the Captain hasnt got a chance he magically gets it all together and is stable at 500, now imagine a FO that is tired (as well as Captain) and he falls for the same trap.
I guess what I am trying to say is that beware of a approach that is stable (ie in a deccelarting) state as it is the worst kind of approach as all of the traditional indicators are not there. i know my self that I have landed not spooled up by 500' have you.
If anyone else can explain this better have a go

[DDG]

What NG and the ATSB report failed to mention was the fact that the operating crew failed to check the aircraft for damage on arrival on the gate and advise Virgin of any defects.Damage was found by Airport safety Officer .Rescue mission had to be done ex-BNE to change both nose wheels(damaged by runway lights) .
Knowingly hiding these defects has earned the Captain a permanent demotion to the Right Seat .

[lame]

Well IF that is true, it makes a diiference.

Anyone can make a mistake, well those of us that are Human, however you MUST report it. :uhoh:

[ftrplt]

Isnt a permanent visit to the right seat just a little kind??

Sounds like the sack would be more appropriate - how is he going to be in the right seat as a demoted captain??


(bad night, low on fuel, newly promoted captain, demoted captain in right seat - doesnt sound great)

[404 Titan]

tightcannon
I think one of the big traps in all of this was the kind of unstable approach it was. Yes they were fast however when you see the charts the a/c was on slope. So they were sort of stabilised.
Hate to put holes in your story but a stable approach “DOESN’T” mean just on slope. It means on slope in the landing config at Vapp or Vref as the case may be. Now if DJ’s SOP’s state that the approach must be stable by 500 ft then they should have gone around, period. There are no excuses and I’m glad they realize this and have taken appropriate action to remedy this problem.

[O410e]

DDG sure you are citing the right incident there. Not getting a little confused with the QF incident in DRW some months later are you? ATSB reports no damage to aircraft.

[DDG]

O410e,
I can assure you both nose wheels had to be replaced prior to further flight due to both outer wheel hubs suffering impact damage.Damage to the nose wheelswas not reported by flight crew contrary to VB OPS Manual .
The engine ingestion was QF,sorry got me facts mixed up,previous post edited for accuracy.

[Cactus Jack]

Let me prefix this with the fact that I'm certain this is an isolated and rare incident which was unfortunately with VB. The Virgin guys that I have met are thoroughly professional, and good blokes to boot. But...

Failing to report the incident is tantamount to lying. Had the Captain reported the incident and said "hey guys, I stuffed up", I'm certain he would still be in the left hand seat.

THERE IS NO PLACE IN AVIATION FOR DISHONESTY!

I would not enjoy travelling VB knowing that this guy is still out there, albeit in the RHS. Virgin's actions have sent a message to their crew that if you screw up and don't report it, then all tyhat will happen is a demotion. You still have a place in our airline.

BAD message VB.

[tightcannon]

404 Titan

Hey mate I know what stabilised means but I was trying to point out the traps of an on slope approach with the speed way to high, and rate of speed decay unaceptable. They were just doing what you do every day at the upper levels and that is attempting to judge a deceleration rate, I do not condone thier behavior and you are right 500' (VFR) is the call. I guess my attempt to explain the situation went to the dogs.

[TAY 611]

Approach window:
maintaining on slope
IVSI maintaining within sensible limits
Correct flap configuration
IAS at VREF + addidtives (if any)
Engines spooled to a known setting

[rescue 1]

TAY, think that you should visit Flight Safety Foundation and have a read of their criterion for stabilised approaches.

[proplever]

That quote used to be very funny until you used it, Tay. Quite inappropriate, mate.

The problem with the parameters you provided, Tay, are that they are negotiable depending upon individual perception. Now, that may have been OK quite a few years ago, but in todays environment operators must give their pilots something "to hang their hat on". That's for everyone's benefit.

For example, you may believe that 1500 fpm ROD is "within sensible limits". Others may not. I'm not for a minute saying that we should legislate for every possibility, because it's just not possible. But the parameters you provide are a recipe for disaster.

[amos2]

I think Tightcannon and others of you should think seriously of what constitutes a stable approach!

Once you have done that apply it in the future for all our sakes!! :cool:

[Capt Basil Brush]

404,

Your bagging old Tightcannon about Stable Approaches, and stating what you think a Stable Approach is - but you missed out about 4 extra things that are part of a Stabilised Approach that are equally important.

I am not going to tell you what they are - you tell us if your such an accademic on the subject.

[404 Titan]

Capt Basil Brush

My intension was never to bag Tightcannon. Different companies have different requirements for a stabilize approach. I only mentioned a few that are generally common to all. To clarify it from our operational point of view I will quote our requirements.

In order to comply with Company approach requirements, the following shall be achieved at or
before the altitudes stated:

• Landing configuration by 1,500 feet AAL.
• Stabilized on Glide Slope/Final Approach Path by 1,500 feet AAL.
• Stabilized at VAPP with thrust above idle and landing checklist complete by 1,000 feet AAL.

[news]

A question for the professional jet guys and girls on this topic. How difficult would it be to hit your desired touchdown zone at the appropriate speed if from 3000 agl to 1000 agl you were to encounter a 40-50 knot tailwind. The ATIS indicated little wind on runway. Would it not be an issue or would it come down to knowing when the tailwind would cease?

[topend3]

DDG,

What NG and the ATSB report failed to mention was the fact that the operating crew failed to check the aircraft for damage on arrival on the gate and advise Virgin of any defects.Damage was found by Airport safety Officer .Rescue mission had to be done ex-BNE to change both nose wheels(damaged by runway lights) .

your information is incorrect, there was no damage to aircraft, and there were no engineering staff employed to service Virgin in Darwin at that time. No nosewheels were changed on the aircraft. I should know, I was there. I was working on the ground in Darwin for Virgin at the time. check your facts buddy. there were only two ex-bne rescue missions during my time in drw, and both were birdstrike incidents involving -700 series aircraft, vh-vbm and vh-vbo.

[proplever]

Tay, I have figured it out.

You really aren'y very clever, but you think that you are. You have just spent all that time explaining my very own position, all because you clearly did not understand my post.

Read the post again, mate, and this time try to understand it, hmmm?

I did not say 1500fpm was acceptable. What I said was the requirements for a stable approach must be clearly defined. In YOUR definition, there are no clearly defined limits, and thus it is open to interpretation.

Approach window:
maintaining on slope
IVSI maintaining within sensible limits
Correct flap configuration
IAS at VREF + addidtives (if any)
Engines spooled to a known setting

OK, there's your definition. To someone else this may mean:

3 degree glide slope
VSI 2000fpm
flaps15
IAS VRef + 110kts (accounting for the high ROD)
35% N1 (A known setting)

Obviously a very poor profile. But it loosly fits YOUR definition of stable.

Understand what I'm saying now, hmmmm?

And don't use the holy grail again, I used to like that movie until you came along.

[Next Generation]

You really aren'y very clever, but you think that you are.

The figures you have shown in your demonstation are a very poor attempt to cover your lack of intelligence.

Tay is quite correct in what he says.

2000 fpm or even 1500 fpm rate of descent would not be regarded by any pilot as "within sensible limits" for the final stages of an approach, and to try and cover that with the "110 kts additive to Vref" just shows that you know nothing about SOP's combined with a poor amount of technical proficiency.

Your argument is a waste of space (as usual).

[Cactus Jack]

NG, I think you might need to read props post again there, fella. I don't think that he was telling you that 1500 or 2000 fpm is acceptable. He say's "obviously a very poor profile" there, doesn't he?

I think you've just made a fool of yourself NG, yet again. Or do we need another independent audit?

IMHO, as an operator, your pilots need to be given clear guidelines as to what is a stable approach, otherwise you won't be able to hang the guys when they screw up.

[TAY 611]

Hi there Prop lever answers in CAPITALS:

3 degree glide slope -SOUNDS NORMAL
VSI 2000fpm -SOUNDS HIGH FOR MOST CAT C/D TYPES
flaps15 -I GUESS SOME TYPES USE FLAP 15 FOR LANDING
IAS VRef + 110kts (accounting for the high ROD) -WAY TOO FAST (WHATS YOUR POINT)
35% N1 (A known setting) -ON THE TYPES I AM FAMILIAR WITH (BAe 146 & GIV) IT WOULD BE TOO LOW HOWEVER ON YOUR AEROPLANE... WELL YOU SHOULD KNOW


Just a question there Proppie why all the AGRO when all I did was post a generic window that I and others use (It varies from type to type hence why I quoted no numbers) along with a bit of humour? :confused:

Just so that you can remain a MP fan I have removed the offending statement.


Cactus, I am left with the impression that this forum is here for rumours and exchange of information. If everytime someone says anything that you don't agree with and you call them a fool (or "Stupid" there Proplever), I suspect that they will take their opinions elsewhere and you will not learn anything (unless you allready know it all).

[Cactus Jack]

Fair call Tay and I'll let the old proppy answer for himself, but along with NG, I don't think you get his point either.

My reading of his post is that those conditions are obviously not a stable approach. Thats quite clear, and he has said that. But those conditions DO fit into your definition. I think he's saying that your definition won't work.

Love the quote though. Why'd you remove it?

[Next Generation]

I stand by what I said.

His "example" is a poor attempt to deviate from TAY 611's concept of a stable approach.

NOBODY believes that 1500 to 2000 fpm is within "SENSIBLE" limits during the final stages of an approach, and to then say that to compensate for that, he will carry an extra 110 kts above Vref just shows that he has no idea.

Again, NOBODY would believe that these are "SENSIBLE" limits, except maybe old Proppy!

TAY 611 is quite correct, and accurate.

[proplever]

Thanks Cactus. But I don't think that NG can read. Go back and try to read it again NG you fool.

I did not say that 1500 to 2000 feet per minute was a stable approach. I said the exact opposite in order to highlight the problem with Tay's definition.

For the last time, you cannot just say "IVSI within sensible limits". You must define what "sensible limits" are. Same for the remainder of the parameters. They must be defined or someone who can't read, like NG will misinterpret them.

Has my point been made now? Feel like a fool having reread everything NG? Independent audits have concluded that you are f :mad: ing stupid. Dear oh dear.

No agro Tay. You have a nice day.

[Next Generation]

Again, I say that I stand behind what I said earlier.

Generally, there is a maximum limit as to what amount of additive may be carried on top of Vref (usually around 20kts). This will be DEFINED in your aircraft or company operations manual.

Thus, to achieve a 3 degree glideslope, carrying your maximum allowable Vref additive, you will never come close to the tripe that you espouse as proof that TAY 611's definition is flawed.

Therefore, "SENSIBLE" limits is not open to interpretation, but rather it is logically linked to achieving the correct glideslope at the specified approach speed.

Also, although you probably know this already because you are such a genius, the additive is to compensate for wind conditions, not your rate of descent.

Therefore, in your "example", assuming that a 110 kt correction was required due to some kind of cyclonic wind conditions, your ground speed would still be relatively slow, which would mean that the resultant Rate of Descent would still not be anywhere near 1500 to 2000 fpm.

I look forward to your reply.

NG

[proplever]

You just don't get it, do you? Need an independent audit? You couldn't even wrap your mind around that argument, let alone this one.

In each of your posts thus far you have shown an ignorance beyond comprehension. You refuse to go back and READ what has been stated.

You cannot read, or understand, or comprehend, anything, so therefore I'm not going to bother any further.

Good day, NG.

[Suffering Sucataash]

NG

Never say never or nobody

NOBODY believes that 1500 to 2000 fpm is within "SENSIBLE" limits during the final stages of an approach

I wonder what profile the US Space Shuttle uses?

Landing config & on speed with power stable at 500' is all I think we should be getting excited about. You should know by 30, 20 or 10 nm if you are going to make it.

In the p**sing contest of conservatism equals safety, some are moving this gate further and further up the profile, I believe the A330 has to be stable at 2000'. What a joke, even the conservative manufacturer uses 1000'. Friends in HK ask why we fly sooo slowly - I wonder when this rot will end?:\

[cunninglinguist]

Any company worth 2 bob and with a current AOC would outline all the requirements for a stabilized approach, including into unique airports like LCY.
Our SOPs are ( VMC ) one dot high or low vasis, not greater than Vapp +10, and ROD below 1000 AGL less than 1000' per minute, no engine limits due to very quick spool up of our type.
Obviously Vapp + 50, 2000'ROD and high on slope at 1200' would not be accepatable and a bit of coomon sense would need to be applied, unfortunately for some, the C&T dept. can't have procedures for every comprehendible situation, thats why they pay us good money.
There, bluddy simple is'nt it ??
If this is not achieved by 500 agl it is to be called ( although ROD obviously called below 1000 ) and if it's still not achieved by 200'......around you go, it's not brain surgery !

In closing, sorry if I offend anyone but I am not a believer in " there but for the grace of god go I " ( mentioned earlier ) , an unstabilized approach, yes, we could and probably have, all made that mistake, continuing with such a bad one and overunning the runway is not forgiveable, bluddy stupid, and if any of you think it could happen to you....let me know who you fly for, I don't wanna fly with ya !!!!!

[TAY 611]

Cunning, I agree with your comments however a "known" or "expected" power setting at the approach window is important for reasons other than slow engine spool up (even the turboprop types).
If on slope, configured correctly, vertical speed within limits and IAS (along with groundspeed) are normal and yet you are still at flight idle or perhaps finding that you are using a lot more power than normal (love the way those auto throttles work). This is an indication that you are experiencing performance enhancing or degrading windshear which can be a precurser to microburst activity. As a final note to Proplever when we have a procedure or SOP such as a stable approach procedure (which I am sure we all have) it is the technique, which involves the training department, that leads us to good practise. In other words it is the training and understanding of how the procedure is built that has the practise (what we do or the end result) matching the written SOP. What I origionally posted was a technique (from a training manual) and not a SOP.
The bottom line know your SOP's and know what your aeroplane is telling you.

[cunninglinguist]

Yes, point taken Tay.
We do have an N1 value that is recognised as part of a stabilized approach but it is not actually a requirement.
As you quite rightly mentioned, know what the A/C is telling you, or in a word....Airmanship.

As previously mentioned, C & T can't write procedures for every conceivable scenario ( well, they could, but you'd need a freighter to carry it ), at the end of the day, we are expected to stick to SOPs and also use a little nouse.

[amos2]

This thread is a lot like teaching your grandmother to suck eggs, don't you think? :rolleyes:

[cunninglinguist]

You're right Amos.
The VB pilots f**cked up, simple.