Overrun Accidents

[PEI_3721]

Request for Accident Reports involving Runway Excursion - EASA area.

The recently published EASA Safety Review 2017 (https://www.easa.europa.eu/system/files/dfu/209735_EASA_ASR_MAIN_REPORT_2017.pdf) identifies runway excursion as the outcome of 13% of fatal accidents and 30% of non fatal accidents during the period 2007 - 2016.

A search for accident reports has failed to find any with significant information as to the cause or contributing factors.
If there any Ppruners who are able to identify accident reports relating to the EASA operational area, associated with runway excursion, side or overrun end, will they please publish (or PM) details, links, etc, to aid understanding of the EASA Safety data.

[safetypee]

Try JEDEC database?
ASTB published a comprehensive list of accidents worldwide, but no links to reports.
https://www.atsb.gov.au/media/27370/ar2008018_1.pdf

[PEI_3721]

Thanks, but few details in the docs.
JACDEC database references a Bulgarian report but translation required, and there is a Danish report of a -8, gear collapse in strong crosswind.
This is a puzzling situation, EASA promote evidenced based safety, evidence based regulation, evidence based training, - the current buzz’s, but where is the evidence for runway excursions in EASA land.
Overruns are a major safety issue world wide, but there is little data on the problem or nature of problems in Europe.

The EASA Review connects Runway Excursion with the majority of Operational factors and all categories of Human Factors, but which are the important issues?

[sierra_mike]

there is an article discussing lateral runway excursions in issue 20 of airbus' safety first magazin if that helps your cause

[PEI_3721]

Thanks SM, not quite what I was looking for, but it has triggered alternative thoughts.
The EASA Safety Review focuses on Europe but without evidence of European problems. I have been looking for this - accidents / incidents reports, but if we assumed that the characteristics and contributions in overrun accidents are similar worldwide then there are several review documents, FSF, IATA, and accident reports to consider.

Future safety activities are usually based on past evidence - managing yesterday's risks, but although the same hazards have to be managed, the outcome will be unknown because there will be no absolute value of risk (likelihood x severity).
Furthermore, it might not be sensible to assume worldwide commonality for future activities, particularly as the European approach to risk managing the threat of overrun could differ from other world areas, e.g. requirements for contaminated runway performance - AMC CS 25.1591 is unique to EASA.

[Owain Glyndwr]

Is this what you are looking for?

3-Jan-08 Atlas Blue 737-400 Deauville, France Landing BEA Rapport cn-x080103

15-Jan-08 Air France A300-600 Paris, France Landing BEA tf-w080115

22-Apr-08 Carpatair BAe 146 Bucharest, Romania Landing No report found

25-May-08 Kalitta Air 747-200 Brussels,BelgiumTakeoff Ref. AAIU-2008-13

9-Feb-09 Air Mediterranee A321 Paris,France Landing BEA Rapport on F-GYAJ (unnumbered)

13-Feb-09 BA CityFlyer RJ-100 London,United Kingdom Landing AAIB Bulletin: 2/2010 G-BXAR EW/C2009/02/03

1-Nov-11 LOT Polish Airlines 767 Warsaw, Poland Landing SCAAI-1400/2011-EPWA-SP-LPC (rev.1)

16-Oct-12 Brit Air CRJ 700 Lorient, France Landing www.bea.aero/docspa/2012/f-ze121016.en/pdf/f-ze121016.en.pdf
29-Mar-13 Air Méditerranée A321 Lyon, France Landing BEA Ref sx-s130329en.pdf

24-May-13 Air Via A320 Varna, Bulgaria Landing No report found

08-Jun-13 Wizz Air A320 Rome, Italy Landing No formal ANSV report found

29-April-14 Air Contractors (Ireland) Ltd 737-400 East Midlands UK Landing AAIB Bulletin: 4/2015 EI-STD EW/C2014/04/03

5-Aug-16 ASL Airlines Hungary 737-400 Bergamo, Italy Landing No report yet published

[DaveReidUK]

Some of those accidents I'm not familiar with, but neither of the UK events was a runway excursion, either lateral or longitudinal.

[kirkbymoorside]

Try Avherald

Database has a crude search which for excursion turns up quite a few events but the listing is worldwide so needs to be reviewed to locate those in EASAland.

Reports generally have links to the investigation report and translated extracts if not in English so quite useful.

Hope this helps...

[kirkbymoorside]

It really means there aren't many/enough European events to form any conclusions.

I have had a quick look at the AvHerald search I mentioned and without going through more than a couple of pages of the results have noted 15 events in EASAland or with an aircraft registered in an EU country.

There are about nine pages of results in total and even allowing for initial and duplicate reports likely to be a fair number of events in Europe.

[Owain Glyndwr]

OK it seems to have been confusing, so I have deleted the post . I was only trying to help!

[DaveReidUK]

Why not just ask EASA to run some numbers from their database? In my experience they're a friendly, approachable lot.

[PEI_3721]

Owain, your post was a help, please reinstate (or PM) so that I might sort through the refs.
So called irrelevant reports provide valuable information; how many of these event might be reported erroneously as an overrun, recorded in some database or other, then statistically applied to generate safety action.
An anecdotal view of European operations suggests that the rate of overruns (and excursions) is less than other world regions, but where's the data. Are there common factors in the few adverse events with the worldly views given in the big summary reports, if so then the European policy to follow world initiatives is justified.

If not, then what specific activities have provided a defence for our industry, what have operators been doing to achieve this success. With this knowledge Europe should continue their best practices, and only add those worldly threats judged relevant to European operations - operators / overseas locations, but not unnecessarily suffer imposed ‘worldwide’ safety activities.

A recent European conference on GAs challenged some of the ‘established’ ideas about stabilised approach. Emergent views of the US FSF sponsored ‘improve the rate of GAs’ suggested other ways of addressing the issue of unstable approaches; the alternative of improving the safety of all landings, focus on flying the approach, vice knowing when to GA, might be more profitable and have benefits elsewhere.

Thanks to other posters for their efforts, we need to identify ‘the evidence’.
“Absence of evidence is not evidence of absence".

Dave, the EASA Safety Review #1, reflects such a search. The introduction to the Review lists the sources of information, and according to these there were no overrun accidents in Europe 2016.
The relevant accident categorisation is the all-encompassing ‘Runway Excursion’ with corresponding extensive range of safety issues, which hinders the identification of specifics for overruns.

The Review presents a rosy view of European safety, yet appropriately identifies runway excursion as the key risk, but there is no detail or explanation as to how this was achieved; and that appears to start with what's in their database and how did it get there.

[Owain Glyndwr]

@ PEI

I can repeat the Boeing data with no problem as I have the reports stored. Sorry, the URL addresses were googled “on the fly”, and I don’t have the motivation to do it again. You should have no problem finding the reports using the date, airline and place though. Not all the reports are in English. The runway associated accidents from the Boeing data are:
3 January 2008 Atlas Blue 737-400 Deauville Landing Over-run
15 January 2008 Air France A300-600 Paris Landing lateral excursion
22 April 2008 Carpatair BAE 146 Bucharest Landing Runway turn off
25 May 2008 Kalitta Air 747-400 Brussels Take off abort after V1
9 February 2009 Air Mediterranee A321 Paris Overshot runway turn off
13 February 2009 BA City Flyer RJ 100 London Landing Nose gear collapse
1 November 2011 LOT B767 Warsaw Landing all gears retracted
18 October 2012 Brit Air CRJ 100 Lorient Landing Runway Over-run
29 March 2013 Air Mediterranee A321 Lyon Landing Runway Over-run
24 May 2013 Air Via A320 Varna Landing Runway Over-run
8 June 2013 Wizz Air A320 Rome Landing LH gear did not extend
29 April 2014 Air Contractors (Ireland) Ltd B737-400 East Midlands Landing LH gear collapsed
5 August 2016 ASL Airlines B737-400 Bergamo Landing Runway Over-run
There are of course many other accidents one could consider, but these are the only examples I could find that occurred in Europe proper.

PM me if you are interested in years outside 2007 to 2016

[DaveReidUK]

If you have a general interest in runway overruns (not specifically in Europe) a good source of data is the NTSB's accident database. It has the advantage that it's in the public domain, and runway overrun events are specifically coded as such enabling them to be readily extracted.

[john_tullamarine]

OG's earlier deleted post undeleted to pick up the odd URL.

[PEI_3721]

Thanks Dave. I have a general interest, but as discussed above the issues appear more about how events are categorised before they are put into a database.
ICAO provides broad categorisations, but these lack detail for analysis, particularly relating to human behaviour - decision to land, etc.
A reported event may be biased by the style of investigation and that investigators struggle with investigating and reporting the issues underlying HF.
In addition with local or self reporting - operator and individual, the report is often compiled by those affected, with associated bias.

:ok:

[error_401]

Unfortunately there is no consolidated database AFAIK. The entries are sometimes too generic to be properly identified.

Had to compile a couple of examples for runway excursions on contaminated runways. It ended with specific searches on most of the Nordic countries national accident investigation branches websites.

Another approach to find such accidents and incidents is via the press - search in the renown press archives and then try to find the respective reports.

Also a possible source is to search for studies on aquaplaning, contaminated runways, stopping distance, arresting gear and engineered surfaces. Many studies feature a list of incidents and accidents.

Depending on what the particular aim of the research is this can be helpful. I found about a dozen incidents and accidents which matched my requirements.

[B737C525]

29 April 2014 Air Contractors (Ireland) Ltd B737-400 East Midlands Landing LH gear collapsed

The aircraft definitely did not leave the runway, nor come close to doing so. The gear collapsed during the landing roll because of a defect, and the aircraft came to a halt entirely on the runway surface.

I haven't checked the veracity of the others cases quoted.

[PEI_3721]

error 401, spot on; but this lack of availability should not be the situation with the promotion of open reporting and safety analysis.
If we in this forum struggle with the availability of data, then what of the regulator, but they still publish ‘safety’ statistics. What confidence might the industry have in their conclusions; where is the justification for change, additional training, regulation, etc.
It's one thing to publish reports for public consumption - illustrating to the upper management and governing bodies the state of play, but what about the actual, practical safety activities; we have some, but based on what.

[Owain Glyndwr]

The aircraft definitely did not leave the runway

Neither did I say it did, merely that the gear collapsed, but in his post#5 PEI said he was looking for accident/incident reports, and if you are trying to build up a total picture then near misses can be as relevant as full accidents. That is why I included gear failure incidents.

[pattern_is_full]

How about this database: https://aviation-safety.net/database/

Unfortunately a cross-referenced search cannot be run from the internet, so at some point the Mk. 1 human eyeball/brain has to be used to additionally filter for location (specific country, not EASA area).

Does provide thumbnail "reports" - and links to complete official reports if available.

Running the online filters for:

Contributory/cause > Result > Runway excursion

....produces a worldwide 15-page list dating to 1935. The last four pages cover 2006-present day. Mk. 1 eyeball can filter that down for EASA locations by city/airport (or national flag icon).

If it were me, I'd probably also filter for and skim through some side-related "cause" categories, just to make sure I'd caught all the excursions. Such as:

Cause > Airplane - Engines - reverse thrust/prop ground
Cause > Airplane - Flight control surface - rudder
Cause > Airplane - Undercarriage - brakes
Cause > Airplane - Undercarriage - gear collapse
Cause > Airplane - Undercarriage - tire failure
Cause > Cargo Occurences - Overloaded/cargo shift
Cause > External factors - FOD/Wake vortex/wind/hail
Cause > Landing/TO > Landing - bounced/fast/heavy/late/unstabilized
Cause > Landing/TO > TO - aborted/failed to become airborne/locked controls/wrong runway/wrong config
Cause > Weather - crosswind/windshear

....or any others you find "suggestive" of risking or resulting in an excursion.

You could also try contacting them (Aviation Safety Network) directly to see if there is a way for industry professionals to get access to the whole database to run their own filter set (location PLUS outcome).

https://aviation-safety.net/about/contact.php

[B737C525]

Neither did I say it did, merely that the gear collapsed, but in his post#5 PEI said he was looking for accident/incident reports, and if you are trying to build up a total picture then near misses can be as relevant as full accidents. That is why I included gear failure incidents.

Respectfully: The case in point isn't a 'near miss' in respect of overruns. The whole aircraft, wingtip to wingtip, nose to tail, remained on the runway.

If we are discussing overruns, as I believe we are, it is not of relevance. That is why I made the point. If you're seeking to build a 'total picture' of everything that goes wrong during landing, it would be relevant, but it was an extraordinarily benign event in terms of risk to life, and the insurance market takes care of the rest.

Finally, the global, industry, viewpoint is that near misses are not as relevant. The two classes of events are given completely different treatment.

[slast]

Hi PEI,

This may not be a lot of use to you but I have been compiling data on approach and landing accidents and incidents for my website at picma.info . Where I have been able to provide a commentary (which is on a different aspect than you are looking at) I have provided a link to the original reports. There MAY be a few in there which you are not already familiar with. List accessed at Accident & Incident Reports Analysed | PicMA (http://picma.info/?q=content/accident-incident-reports-analysed)

[PEI_3721]

Steve thanks for the link, I am familiar with the principles in your site (we have corresponded), but was unaware of the event data.
The analysis appears to be more towards what I have been looking for, however the problem of validity remains.
Acknowledging your expert interpretations, these are still founded on the originating data from investigation reports or a range of public data bases often no better to first hand reports.

I believe that some form of speculative analysis will help, particularly when made by those with relevant experience and balanced thought on the subject, unfortunately I have yet to find any regulatory authority to heed such analysis.

[PEI_3721]

I started this thread under the wide umbrella of safety statistics and their relation to safety activity. The lack of overruns data stands out in the EASA report, but the principles apply to most, if not all, safety issues.
The shortage of investigative data would be an asset if the number of incidents were few, yet for overruns it is the opposite which is of concern; many hull loss events, fortunately few fatalities, but this does not equate to being safe, nor managing the risk of a fatality from any overrun.

There is a chronic shortage of data suitable for meaningful analysis to justifying safety activity.
An increasingly popular view is that the industry needs to look at what goes right opposed to measuring what goes wrong. So far this thread would support the need for a wider view, ‘what happens every day’, because most of this is ‘right’, but will this data (even if collectible) enable adequate meaning.

The point about ‘near miss’ triggers thoughts about what is a near miss; the gear collapse above is a ‘negative’ event, it's just not put into the box labelled overrun. Thus the choice and definition of safety boxes biases data and thoughts.
Thus what should a definition of ’near miss’ include.

All landings should be based on having a safety margin in the landing distance, but how often are these margins compromised, is this a near miss. One view is that only when the safety of a landing is assured then the remaining runway can be used for roll out; but this is a judgement - proactive.
Daily operations might suggest otherwise, that pilots only use what is perceived to be required to stop in the full length; then change the action as the landing develops - another but different judgement - reactive, requiring expertise. Note several accidents involving decreasing friction on wet rubber deposits towards the end of a runway.

So should our safety statistics include all occasions where the safety margin was compromised - not listing a human error of judgement, but to identify the circumstances where a judgement could be compromised.

One possibility is to use FDR and assess the deceleration achieved vs expected capability; distance is more difficult to capture.
But even if this collects relevant data are they shared for general safety activities within the industry.

No? Which might be one of the many problems with safety data collection; and perhaps understanding this is what I am looking for.

[slast]

Doesn't help move you forward but even when I have through multi stage searches managed to find a report, the quality of analysis is often pretty abysmal. But I'll alert you if I find anything that will help.

[DaveReidUK]

The lack of overruns data stands out in the EASA report, but the principles apply to most, if not all, safety issues.
The shortage of investigative data would be an asset if the number of incidents were few, yet for overruns it is the opposite which is of concern

I don't think it's reasonable to conclude, simply on the basis of what is and isn't included in an annual summary, that data is lacking.

The report shows just under 250 2007-2016 commercial air transport accidents, of which around 70 were runway excursions, and identifies safety issues relating to each category. Clearly there isn't enough space to list the causal factors identified for individual occurrences, but that doesn't mean the data doesn't exist.

[PEI_3721]

Dave, perhaps not a conclusion that data does not exist, but an observation that without a clear reference to EASAs data we don’t know how accurate it might be, nor if everything has been accessed. Also, without supporting analysis for the categorisation it is impossible to understand the relevance of each contributor.
It's easy to tick a box based on a probable cause / contribution; e.g. human factors can affect everything, tick, similar for organisation, tick, but how does this contribute to a safety programme?