ATSB Media Release- B737-800 Darwin Runway Overshoot.
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ATSB Media Release- B737-800 Darwin Runway Overshoot.
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.
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.
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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.
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.
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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
) 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
) 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
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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.
How's the maturation process going for one of the world's oldest airlines?
Short memory???????
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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
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
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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.
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.
Nunc est bibendum
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!
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? 
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!
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?
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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.
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.
Last edited by TIMMEEEE; 18th Mar 2004 at 03:27.
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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.
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.
Nunc est bibendum
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!
'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!
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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
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
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CASA's eyes on Virgin
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.
==========================================
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.
==========================================
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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
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
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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 .
Knowingly hiding these defects has earned the Captain a permanent demotion to the Right Seat .
Last edited by DDG; 19th Mar 2004 at 05:25.
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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.
Anyone can make a mistake, well those of us that are Human, however you MUST report it.
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)
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)
