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Air Europa Overrun: Final Report

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Air Europa Overrun: Final Report

Old 15th Feb 2012, 17:26
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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.
C
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)
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Old 15th Feb 2012, 18:03
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An overbearing Captain lacking competence but overcome with arrogance? Where have we seen this before? For one, why would anyone request RW21 at ACE when above the descent profile for that runway? ( RW21 has too many considerations to make in a short time frame which in themselves negate any advantage to landing on the runway straight in). Secondly, continuing a landing with flap blowback and PULL UP from the GPWS due to a high energy approach stinks of negligence really. if the aircraft had been any heavier (54 tonnes is a pretty light landing weight for a 738) then the consequences could have been more severe. Yes the FO didn't advocate, however the Captain sounds like a CRM is obviously something kept for two checks a year then.
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Old 15th Feb 2012, 18:39
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In answer to your 2nd Q Er. . . ? Skavsta ? Fortunately with no injury except to the (end of anyhow? ) career, if I remember correctly.



Nonetheless, agree wholeheartedly with your assessment, pretty damn gash.

0730, after Glasgow & back from the Canaries, is not the best time to save 5 min by overloading your colleague , as you say, gash.

Anyone could have done it, but hopefully most of us would have swallowed our pride & thrown it away @ 500', or at latest crossing the threshold @ 180' at VREF +41.
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Old 15th Feb 2012, 19:05
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10,000 feet at 315 KIAS about 21nm before touchdown was not looking good already...
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Old 15th Feb 2012, 22:52
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So, what was the hurry?
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Old 16th Feb 2012, 12:46
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They were lucky:

- 315kts @ FL100 21NM in ACE RWY21??? A ******* offset approach with high minima and steep final descend due to a little vulcanic hill and 2400LDA wet.

- "SINK RATE", "PULL UP" and "TOO LOW TERRAIN"... and LAND!!!!

- the aircraft crossed the runway threshold at 180 feet AGL at 175 KIAS (Vref+41)...

- Flaps autoretraction... and continue???

- Unstabilized approach

- Bad CRM? Sorry, but NO CRM

They were really lucky!!!
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Old 16th Feb 2012, 23:50
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Can't be true, I don't believe this incident happened! Some misinformation or disinformation maybe?
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Old 17th Feb 2012, 01:56
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It's all in the report. Did you even read the opening posting in this thread?
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Old 17th Feb 2012, 09:58
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Can't Be True

Incident: Air Europa B738 at Lanzarote on Oct 31st 2008, departed runway on landing

This is the link to the report.
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Old 17th Feb 2012, 12:08
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Originally Posted by CIAIAC
The day before the incident, the crew had started its duty period in the evening in Lanzarote at 20:40 to fly the ACE-GLA-ACE (Lanzarote-Glasgow-Lanzarote) route. they had taken off at 22:01, a few minutes after the scheduled departure time.

(...)

07:14:34

RA 115 ft, IAS 173 kt, v/s 1500 ft/min, over runway

"SINK RATE" , "TOO LOW TERRAIN" , "TOO LOW TERRAIN" cautions sounded.

(...)

Regulation 859/2008 (EU-OPS) was published on August 2008. Subpart Q of said statute regulates crew duty and rest periods differently from the regulation that had been in effect until then, namely Operating circular 16B of Spain's Directorate General for Civil Aviation (DGAC). When the crew met at the airport, the captain had doubts concerning the legality of scheduled activity in the light of the new regulation, as a result of which he inquired with the airline, which confirmed that the activity was scheduled to last 10 hours and 30 minutes, below the maximum authorized of 11 hours and considering that the entirety of the activity would take place within the circadian rhythm phase of lowest performance.
I suppose that wording regarding the WoCL is a bit imprecise: not all of the flight(s) would be within the WoCL but planned duty would stretch through all of the WoCL, as well as before and after it.

For those of you finding the incident unbelievable, I'm sorry but my sense of deja vu prevents me from joining the shocked & the surprised brigade: Too long at the wheel, FSF Aviation Safety World's take on JetX landing excursion at Keflavik. Want more? Fatal persistence, this one is about Air India Express disaster at Mangalore.

That's "debilitating effect of fatigue" for you.

Subtly incapacitated pilots might, and far more often than not do, get away with with the routine operation. Change the ballgame and pilots who would have otherwise made an uneventful landing quickly drop behind the aeroplane without realizing it.

Bear in mind that while fatigue does reduce pilots to dunces, it is not the only thing derails the thought process on the flightdeck and also that not just "bad pilots" are affected by it.

Thirtysomething years ago and eightysomething miles west of Lanzarote, there was certain, very experienced, Dutch, gentleman aviator who was so obsessed with taking off ASAP that he took off without take-off clearance. In hindsight, we know it wasn't the smartest thing to do, yet one thing we can be mighty sure of: in his mind there was no doubt he was doing the right thing.

Take care.
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Old 17th Feb 2012, 13:48
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Whilst fatigue may have affected their "strategic" thinking processes, it should not have blocked their response to the safety net provided by the EGPWS alarms.

Without being at all judgemental, asking for the short-cut to runway 21 probably seemed like a completely reasonable request at the time. They were tired, it was a long day, and saving 5 minutes would be good news all round. The contribution of fatigue need only be a small error in the mental arithmetic that we do all the time - when ATC asks "can you make it from there" and you do a quick time/altitude/speed calculation in your head and say "yes".

However, as time passed and the evidence started to appear that the quick time/altitude/speed calculation had gone wrong, they pressed on. Even that poor judgement wouldn't be the end of the world. But, as soon as the aircraft starts saying "whoop, whoop, Pull Up!!", swiftly followed by most of the other announcements in its vocabluary, that is meant to tell you that this is never going to work.

You don't need to exercise any judgement at that point, and it doesn't matter how fatigued you are, because the Ops Manual (and all the training you ever had in the simulator) tells you that what happens next is not discretionary. You add power and pull up.

The breakdown in this incident wasn't the poor decision making that led them to try for the short cut. That was just a bit of a mistake. The error was the point where all the alarm bells went off - and they decided to keep going.
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Old 17th Feb 2012, 14:45
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The error was the point where all the alarm bells went off - and they decided to keep going.
CJ, stabilized approach criteria and non adherence to EGPWS have already been
mentioned. The error(s) had probably already been made , these are safety nets that failed, question is why?

.... asking for the short-cut to runway 21 probably seemed like a completely reasonable request at the time. They were tired.....
Reasonable? Quite the opposite!
Asking for a shortcut when tired, that's more like the error to me.
At the very least it is a threat that one should be aware of.
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Old 17th Feb 2012, 21:09
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Sorry to come across (as I assuredly will) as a cocky "been there done that" old [email protected], but most of us , with more than the minimum experience requested nowadays for Command jobs on dodgy contracts, have, at one (or several ) stages , pushed our luck & ended up on an approach where we thought "Oh sheet, why did I decide to do it this way"
Which stage we throw it away, in my personal experience, is governed by several factors, did we get away with it before (so assume we can again)/ did we "concern" ourselves previously - sufficiently perhaps to decide it is best to acknowledge our screw-up/ is our colleague participating in a way we can relate to & accept readily, by suggesting "game over" in a fashion that we as individuals don't see as a challenge/reproach, but rather see as it probably is I.E. a helping hand . As has been suggested, we have to also be sufficiently on the ball to realise that it is all going for a can of worms, but, no matter how knackered/blinkered we are, normally the co-pilot AND the machine shouting at you should be enough.
I am not proud to say that in an earlier era, where CRM was not so "refined" as now (although I think my own wasn't SO bad) & more pertinently , pre OFDM, I have completed approaches & landings that, if you were to take me back today to the "FIVE HUNDRED"point, I would throw away within a heartbeat.
In spite of , or perhaps thanks to, that, I am happy, as I guess that means, either due to personal development/experience/OFDM /or all 3, I am a safer Commander than I was 20 odd years ago. Regretably, some cultures/companies/individuals are a bit behind the drag curve.
No doubt some of you young uns will slap your forehead in disbelief when reading this accident report, or worse still the Air India Express, or the Phillipine A320 thread, or any overun accident report.
I tend to see it differently, and ,whilst remaining grateful that I "appeared" to have been able to judge when it REALLY was "game-over" (as I also did my fair share of go-arounds) there have undoubtedly been times when, had 1 parameter gone against me, I could indeed have terminated my career, if not my life.
Experience can only be accumulated via hours/calendar time. The current profit increasing/salary & status reducing /P2F mentality imposed on our profession by so many bean-counters ,does not take any account of what is being lost.
Experience is not gained by getting it right, it is gained, painfully, by getting it less than right, & less painfully, by observing & learning from, others getting it less than right.
These accidents are a big lesson to those of us who in the past pushed our luck, & they hit home very hard because we can see "there but for the grace of god", the ones who REALLY need to learn by them however , are those who, courtesy of OFDM /Rigid SOP's , or whatever, never got close & cannot imagine getting close.
When the Magenta Line /(Ryanair) SOP for every eventuality, generation, start taking contract jobs in Africa, they will have no "native" experience/previous screw-up-history to fall back on.

It is essential to always remember ,"It CAN happen to me".

Rant/ramble over, wishing you all a good weekend (whatever one of those is, unemployed = working in that respect ,7/7 all the same)
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Old 17th Feb 2012, 22:04
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captainplaystation, totally agree - got the Tshirt etc!

Reminds me of a brand new FO a couple of years ago asked me "Why do you slow up so early?"!!

I replied by saying that the "gates" that the company had were limits and not "targets". I also added (diplomatically I hope!) that didn't it tell him something that I would slow up earlier than he would yet I was the one with more experience!

Last edited by fireflybob; 17th Feb 2012 at 22:04. Reason: Spelling
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Old 17th Feb 2012, 23:25
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From Science and Technology News, Science Articles | Discover Magazine

#78: Napping Neurons Explain Sleep-Deprived Blunders


01.05.2012 Tiny clumps of neurons doze off, even while the brain as a whole is awake.

by Valerie Ross
When tiredness sets in, poor decisions and clumsiness often follow. In a study published last April, scientists may have pinpointed the biological basis of such mistakes: tiny clusters of neurons that start napping, even as the brain stays awake. To explore the phenomenon, neuroscientist Giulio Tononi of the University of Wisconsin at Madison tempted lab rats to stay awake longer than usual by supplying them with a steady stream of new toys. At the same time, he measured their brain activity through electroencephalography (EEG). With so much exploring to do, the rats seemed alert, but measurements told a different story. Though EEG recordings indicated overall wakefulness, small groups of neurons briefly went offline. Bits of the brain seemed to be power napping—and as the rat stayed awake longer, the frequency of the naps increased. Most of the time these localized naps did not affect a rat’s behavior, but some led to errors. Similar lapses in humans may cause us to make bad decisions or forget what we are saying, a possibility the team is now investigating.


Made me think again...
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Old 17th Feb 2012, 23:35
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Can't be true, I don't believe this incident happened! Some misinformation or disinformation maybe?
Ha ha Kunta was being mischievious hinting that " this cant be! Impossible ! " A caucasian airline having this basic lack of CRM and operational, manipulation skills! Are we not skygods admonishing mere mortals in Africa about their flying skills?
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Old 22nd Feb 2012, 00:07
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but most of us , with more than the minimum experience requested nowadays for Command jobs on dodgy contracts, have, at one (or several ) stages , pushed our luck & ended up on an approach where we thought "Oh sheet, why did I decide to do it this way"
But how many of you would end up in that situation with the FO flying? That's what I find odd. I understand how a captain can end up convincing himself that he can make it, especially fatigued. There are plenty of examples of FOs not having the confidence to argue. Mangalore was mentioned upthread, Garuda comes to mind as well. Coming in high and fast and hoping you can pull it off.

But I can't think of another incident where the FO was flying. That seems particularly unreasonable, somehow.
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Old 22nd Feb 2012, 09:23
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Maybe time for SAFA to pay them a visit in LPA
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