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Accident and Serious Incident Reports: RE

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Category: Runway Excursion Runway Excursion
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Definition

Reports relating to accidents which include Runway Excursion as an outcome.

The reports are organised in two sections. In the first section, reports are organised according to the sub-categories Overrun on Take Off, Overrun on Landing, and Veer Off. In the second section, events are organised according to the tagging system currently employed on Runway Excursion events in our database.

Events by Sub-Category

Overrun on Take Off

Overrun on Take Off.jpg

  • CRJ1, Lexington KY USA, 2006 (On 27 August 2006, a Bombardier CRJ100 cleared for a night take off from runway 22 instead began take off on unlit runway 26. It was too short and the aircraft ran off the end at speed and was destroyed by the subsequent impact and post-crash fire with the deaths of 49 of the 50 occupants - the First Officer surviving with serious injuries. The Investigation found that the actions of the flight crew had caused the accident but noted that insufficiently robust ATC procedures had been contributory and the effects of an ongoing runway extension project had been relevant.)
  • B737, Southend UK, 2010 (On 21 Nov 2010, a Boeing 737-700 being operated by Arik Air on a non revenue positioning flight from Southend to Lagos with only the two pilots on board carried out a successful take off in daylight and normal ground visibility from runway 06 but became airborne only just before the end of the runway.)
  • DC86, Manston UK, 2010 (On 11 August 2010, a Douglas DC8-63F being operated by Afghanistan-based operator Kam Air on a non scheduled cargo flight from Manston UK to Sal, Cape Verde Islands failed to get airborne until after the end of departure runway 28 during a daylight take off in normal visibility. The aircraft eventually became airborne and climbed away normally and when ATC advised of the tail strike, the aircraft commander elected to continue the flight as planned and this was achieved without further event. Minor damage to the aircraft was found after flight and there was also damage to an approach light for the reciprocal runway direction.)
  • A343, Rio de Janeiro Galeão Brazil, 2011 (On 8 December 2011, an Airbus A340-300 did not become airborne until it had passed the end of the takeoff runway at Rio de Janeiro Galeão, which was reduced in length due to maintenance. The crew were unaware of this fact nor the consequent approach lighting, ILS antennae and aircraft damage, and completed their intercontinental flight. The Investigation found that the crew had failed to use the full available runway length despite relevant ATIS and NOTAM information and that even using rated thrust from where they began their takeoff, they would not have become airborne before the end of the runway.)
  • B772, St Kitts West Indies, 2009 (On 26 September 2009, the crew of a British Airways Boeing 777-200 unintentionally began and completed their take off in good daylight visibility from the wrong intermediate runway position with less than the required take off distance available. Due to the abnormally low weight of the aircraft compared to almost all other departures by this fleet, the aircraft nevertheless became airborne just before the end if the runway. The investigation attributed the error to a poorly marked taxiway and the failure of the crew to include the expected taxi routing in their pre flight briefing.)

Overrun on Landing

Overrun on Landing.jpg

  • B733, Aqaba Jordan, 2017 (On 17 September 2017, a Boeing 737-300 requested and was approved for a visual approach to Aqaba which involved a significant tailwind component and, after approaching at excessive speed, it touched down late and overran the 3000 metre runway onto sandy ground. The Investigation found that despite EGPWS Alerts relating to both the high rate of descent and late configuration, the Captain had instructed the First Officer to continue what was clearly an unstabilised approach and when touchdown had still not occurred with around 1000 metres of runway left, the Captain took over but was unable to prevent an overrun.)
  • B734, Barcelona Spain, 2004 (On 28 November 2004, a KLM B737-400 departed laterally from the runway on landing at Barcelona due to the effects on the nosewheel steering of a bird strike which had occured as the aircraft took off from Amsterdam.)
  • CRJ7, Kanpur India, 2011 (On 20 July 2011, an Alliance Air CRJ 700 touched down over half way along the 9000 ft long runway at Kanpur after a stable ILS approach but with an unexpected limiting tailwind component and failed to stop before the end of the paved surface. Although an emergency evacuation was not necessary and there were no injuries, the aircraft was slightly damaged by impact with an obstruction. The subsequent investigation attributed the event to the commanders continued attempt at a landing when a late touchdown became increasingly likely.)
  • DH8D, Aalborg Denmark, 2007 (On 9 September 2007 the crew of an SAS Bombardier DHC8-400 approaching Aalborg were unable to lock the right MLG down and prepared accordingly. During the subsequent landing, the unlocked gear leg collapsed and the right engine propeller blades struck the runway. Two detached completely and penetrated the passenger cabin injuring one passenger. The Investigation found that the gear malfunction had been caused by severe corrosion of a critical connection and noted that no scheduled maintenance task included appropriate inspection. A Safety Recommendation to the EASA to review the design, certification and maintenance of the assembly involved was made.)
  • B733, Burbank CA USA, 2000 (On 5 March 2000, a Boeing 737-300 being operated by Southwest Airlines on a scheduled passenger flight from Las Vegas to Burbank overran the landing destination runway in normal day visibility after a steep visual approach had been flown at an abnormally high speed. The aircraft exited the airport perimeter and came to a stop on a city street near a gas station. An emergency evacuation of the 142 occupants led to 2 serious injuries and 42 minor injuries and the aircraft was extensively damaged.)

Veer Off

Directional Control.jpg On landing...

  • BE20, Nadi Fiji, 2010 (On 25 April 2010, a Beech King Air touched down at Nadi with its landing gear in the transit position after flying a night approach during which a significant electrical system failure had occurred. The landing gear retracted and the aircraft left the runway to the side and came to a stop resting on its fuselage. The Investigation attributed the electrical failure, which directly affected the landing gear operating system and required two diodes to have both failed was likely to have meant that one would have failed on an earlier occasion with no apparent consequence.)
  • CRJ1, Southampton UK, 2007 (On 17 January 2007, a Bombardier CRJ 100 being operated by French airline Brit Air on a scheduled night passenger flight from Paris CDG to Southampton could not be directionally controlled after touchdown on a dry surface in normal visibility and almost calm winds and departed the side of the runway during the landing roll. There were no injuries to any of the 36 occupants and there was no damage to the aircraft.)
  • A320, São Paulo Congonhas Brazil, 2007 (On 17 July 2007, the commander of a TAM Airlines Airbus A320 being operated with one thrust reverser locked out was unable to stop the aircraft leaving the landing runway at Congonhas at speed and it hit buildings and was destroyed by the impact and fire which followed killing all on board and others on the ground. The investigation attributed the accident to pilot failure to realise that the thrust lever of the engine with the locked out reverser was above idle, which by design then prevented both the deployment of ground spoilers and the activation of the pre-selected autobrake.)
  • JS32, Torsby Sweden, 2014 (On 31 January 2014, an Estonian-operated BAE Jetstream 32 being used under wet lease to fulfil a government-funded Swedish domestic air service requirement landed long at night and overran the end of the runway. The Investigation concluded that an unstabilised approach had been followed by a late touchdown at excessive speed and that the systemic context for the occurrence had been a complete failure of the aircraft operator to address operational safety at anything like the level appropriate to a commercial operation. Failure of the responsible State Safety Regulator to detect and act on this situation was also noted.)
  • MD10, Fort Lauderdale FL USA, 2017 (On 28 October 2017 the left main landing gear of an MD10-10F that had just touched down at Fort Lauderdale collapsed which led to the aircraft departing the side of the runway and catching fire. The Investigation found that the collapse had occurred because of metal fatigue which had developed in the absence of protective plating on part of the leg assembly. The reason for this could not be determined but it was noted that had the aircraft operator’s component overhaul interval not been longer than the corresponding manufacturer recommendation then the collapse would probably not have occurred.)

Directional Control.jpg On take off..

  • A306, Stockholm Sweden, 2010 (On 16 January 2010, an Iran Air Airbus A300-600 veered off the left side of the runway after a left engine failure at low speed whilst taking off at Stockholm. The directional control difficulty was attributed partly to the lack of differential braking but also disclosed wider issues about directional control following sudden asymmetry at low speeds. The Investigation concluded that deficiencies in the type certification process had contributed to the loss of directional control. It was concluded that the engine malfunction was due to the initiation of an engine stall by damage caused by debris from a deficient repair.)
  • B735, Denver USA, 2008 (Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind Conditions.)
  • B738, Nuremburg Germany, 2010 (On 8 January 2010, an Air Berlin Boeing 737-800 attempted to commence a rolling take off at Nuremburg on a runway pre-advised as having only ‘medium’ braking action. Whilst attempting to position the aircraft on the runway centreline, directional control was lost and the aircraft exited the paved surface onto soft ground at low speed before the flight crew were able to stop it. The event was attributed to the inappropriately high taxi speed onto the runway and subsequent attempt to conduct a rolling take off. Relevant Company standard operating procedures were found to be deficient.)
  • B738, Sydney Australia, 2007 (On 14 July 2007, a Boeing 737-800 being operated by New Zealand airline Polynesian Blue on a scheduled passenger service from Sydney to Christchurch New Zealand commenced take off on Runway 16R with asymmetric thrust set and veered off the side of the runway reaching the intersecting runway 07 before rejected take off action initiated by the flight crew took effect and the aircraft came to a stop.)
  • B752, Mumbai India, 2010 (On 9 June 2010, a Boeing B757-200 being operated by Chennai-based Blue Dart Aviation on a scheduled cargo flight from Mumbai to Bangalore lined up and commenced a night take off in normal ground visibility aligned with the right hand runway edge lights of 45 metre wide runway 27. ATC were not advised of the error and corrective action and once airborne, the aircraft completed the intended flight without further event. A ground engineer at Bangalore then discovered damage to the right hand landing gear assembly including one of the brake units. After being alerted, the Mumbai Airport Authorities discovered a number of broken runway edge lights.)

Events by A&I Tag

Excessive Airspeed

  • B734, Yogyakarta Indonesia, 2007 (On 7 March 2007, a Boeing 737-400 being operated by Garuda landed on a scheduled passenger flight from Jakarta to Yogyakarta overran the end of the destination runway at speed in normal daylight visibility after a late and high speed landing attempt ending up 252 metres beyond the end of the runway surface in a rice paddy field. There was a severe and prolonged fire which destroyed the aircraft (see the illustration below taken from the Investigation Report) and 21 of the 140 occupants were killed, 12 seriously injured, 100 suffered minor injuries and 7 were uninjured.)
  • E55P, St Gallen-Altenrhein Switzerland, 2012 (On 6 August 2012 an Embraer Phenom 300 initiated a late go-around from an unstabilised ILS/DME approach at St. Gallen-Altenrhein. A second approach was immediately flown with a flap fault which had occurred during the first one and was also unstabilised with touchdown on a wet runway occurring at excessive speed. The aircraft could not be stopped before an overrun occurred during which a collision with a bus on the public road beyond the aerodrome perimeter was narrowly avoided. The aircraft was badly damaged but the occupants were uninjured. The outcome was attributed to the actions and inactions of the crew.)
  • AT72, Shannon Ireland, 2011 (On 17 July 2011, an Aer Arann ATR 72-200 made a bounced daylight landing at Shannon in gusty crosswind conditions aggravated by the known effects of a nearby large building. The nose landing gear struck the runway at 2.3g and collapsed with subsequent loss of directional control and departure from the runway. The aircraft was rendered a hull loss but there was no injury to the 25 occupants. The accident was attributed to an excessive approach speed and inadequate control of aircraft pitch during landing. Crew inexperience and incorrect power handling technique whilst landing were also found to have contributed.)
  • B739, Yogyakarta Indonesia, 2015 (On 6 November 2015, a Boeing 737-900 overran the 2,200 metre-long landing runway at Yogyakarta after a tailwind approach with airspeed significantly above the applicable Vref followed by a long landing on a wet runway without optimum use of deceleration devices. The flight crew management of the situation once the aircraft had come to a stop was contrary to procedures in a number of important respects. The aircraft operator took extensive action to improve crew performance following the event. The Investigation found significant fault with the airport operator's awareness of runway surface condition and an absence of related significant risk management.)
  • JS41, Rhodes Greece, 2015 (On 2 February 2015, a Jetstream 41 made a hard and extremely fast touchdown at Rhodes and the left main gear leg collapsed almost immediately. The crew were able to prevent the consequent veer left from leading to a lateral runway excursion. The Investigation found that the approach had been significantly unstable throughout with touchdown at around 50 knots above what it should have been and that a whole range of relevant procedures had been violated by the management pilot who had flown the approach in wind shear conditions in which approaches to Rhodes were explicitly not recommended.)

RTO decision after V1

  • B732, Pekanbaru Indonesia, 2002 (On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.)
  • CL60, Teterboro USA, 2005 (On 2 February 2005, a Challenger, belonging to Platinum Jet Management, crashed after taking off from Teterboro, New Jersey, USA. The aircraft's center of gravity was well forward of the forward takeoff limit.)
  • DH8A, Ottawa Canada, 2003 (On 04 November 2003, the crew of a de Havilland DHC-8-100 which had been de/anti iced detected a pitch control restriction as rotation was attempted during take off from Ottawa and successfully rejected the take off from above V1. The Investigation concluded that the restriction was likely to have been the result of a remnant of clear ice migrating into the gap between one of the elevators and its shroud when the elevator was moved trailing edge up during control checks and observed that detection of such clear ice remnants on a critical surface wet with de-icing fluid was difficult.)
  • GLF4, Bedford MA USA, 2014 (On 31 May 2014, a Gulfstream IV attempted to take off with the flight control gust locks engaged and, when unable to rotate, delayed initiating the inevitable rejected take off to a point where an overrun at high speed was inevitable. The aircraft was destroyed by a combination of impact forces and fire and all seven occupants died. The Investigation attributed the accident to the way the crew were found to have habitually operated but noted that type certification had been granted despite the aircraft not having met requirements which would have generated an earlier gust lock status warning.)
  • MD88, Groningen Netherlands, 2003 (On 17 June 2003, a crew of a Boeing MD-88, belonging to Onur Air, executed a high speed rejected take-off at a late stage which resulted in overrun of the runway and serious damage to the aircraft.)

High Speed RTO (V above 80 but no above V1)

Unable to rotate at VR

  • MD83, Ypsilanti MI USA, 2017 (On 8 March 2017, a Boeing MD83 departing Ypsilanti could not be rotated and the takeoff had to be rejected from above V1. The high speed overrun which followed substantially damaged the aircraft but evacuation was successful. The Investigation found that the right elevator had been locked in a trailing-edge-down position as a result of damage caused to the aircraft by high winds whilst it was parked unoccupied for two days prior to the takeoff. It was noted that on an aircraft with control tab initiated elevator movement, this condition was undetectable during prevailing pre flight system inspection or checks.)
  • B763, Copenhagen Denmark, 1999 (On 24 August 1999, a Boeing 767-300 being operated by SAS on a scheduled passenger flight from Copenhagen to Tokyo was unable to get airborne from the take off roll on Runway 22R in normal daylight visibility and made a rejected take off from high speed. The aircraft was taxied clear of the runway and after a precautionary attendance of the RFFS because of overheated brakes, the passengers were disembarked and transported to the terminal. There was minor damage to the aircraft landing gear and rear fuselage.)
  • DH8A, Ottawa Canada, 2003 (On 04 November 2003, the crew of a de Havilland DHC-8-100 which had been de/anti iced detected a pitch control restriction as rotation was attempted during take off from Ottawa and successfully rejected the take off from above V1. The Investigation concluded that the restriction was likely to have been the result of a remnant of clear ice migrating into the gap between one of the elevators and its shroud when the elevator was moved trailing edge up during control checks and observed that detection of such clear ice remnants on a critical surface wet with de-icing fluid was difficult.)
  • A345, Melbourne Australia, 2009 (On 20 March 2009 an Airbus A340-500, operated by Emirates, commenced a take-off roll for a normal reduced-thrust take-off on runway 16 at Melbourne Airport. The attempt to get the aircraft airborne resulted in a tail strike and an overrun because insufficient thrust had been set based upon an incorrect flight crew data entry.)
  • A332, Montego Bay Jamaica, 2008 (Prior to the departure of a Thomas Cook Airlines Airbus A330-200 from Montego Bay Jamaica during the hours of darkness and in normal visibility on 28 October 2008, incorrect takeoff speeds had been input to the FMS by the flight crew without this being recognised. When rotation during take off was, as a consequence, initiated too early, the aircraft failed to become airborne as expected. The aircraft commander, acting as PF, quickly selected TOGA power and the aircraft became airborne before the end of the available runway had been reached and climbed away safely.)

Collision Avoidance Action

  • E135, George South Africa, 2009 (On 7 December 2009, an South African Airlink Embraer 135 overran the recently refurbished wet landing runway at George after braking was ineffective and exited the aerodrome perimeter to end up on a public road. There was no fire and all occupants were able to evacuate the aircraft. The subsequent investigation attributed the overrun principally to inadequate wet runway friction following the surface maintenance activities and noted various significant non-compliances with ICAO Annex 14.)
  • B733 / DH8D, Fort McMurray Canada, 2014 (On 4 August 2014, a Boeing 737-300 making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown by the crew of a DHC8-400 which was taxiing along the same taxiway in the opposite direction. This resulted in a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.)
  • B733, Aqaba Jordan, 2017 (On 17 September 2017, a Boeing 737-300 requested and was approved for a visual approach to Aqaba which involved a significant tailwind component and, after approaching at excessive speed, it touched down late and overran the 3000 metre runway onto sandy ground. The Investigation found that despite EGPWS Alerts relating to both the high rate of descent and late configuration, the Captain had instructed the First Officer to continue what was clearly an unstabilised approach and when touchdown had still not occurred with around 1000 metres of runway left, the Captain took over but was unable to prevent an overrun.)

Parallel Approach Operations

Late Touchdown

  • B736, Montréal QC Canada, 2015 (On 5 June 2015, a Boeing 737-600 landed long on a wet runway at Montréal and the crew then misjudged their intentionally-delayed deceleration because of an instruction to clear the relatively long runway at its far end and were then unable to avoid an overrun. The Investigation concluded that use of available deceleration devices had been inappropriate and that deceleration as quickly as possible to normal taxi speed before maintaining this to the intended runway exit was a universally preferable strategy. It was concluded that viscous hydroplaning had probably reduced the effectiveness of maximum braking as the runway end approached.)
  • LJ25, Northolt London UK,1996 (On 13 August 1996, a Bombardier Learjet 25B being operated by a Spanish Air Taxi Operator on a private charter flight from Palma de Mallorca Spain to Northolt made a high speed overrun of the end of the landing runway after an approach in day VMC and collided with traffic on a busy main road after exiting the airport perimeter. All three occupants - the two pilots and one passenger - suffered minor injuries as did the driver of a vehicle hit by the aircraft. The aircraft was destroyed by impact forces but there was no fire.)
  • A320, Toronto ON Canada, 2017 (On 25 February 2017, an Airbus A320 left the side of the landing runway at Toronto when, for undetermined reasons, the Captain, as Pilot Flying, set up a drift to the right just before touchdown. This was then followed by a lateral runway excursion into wet grass in rain-reduced visibility which continued for 1,650 metres before the aircraft regained the runway and stopped. The Investigation noted that both the absence of runway centreline lighting and the aircraft operator’s policy of not activating the aircraft rain repellent system or applying the alternative hydrophobic windshield coating may have increased the excursion risk.)
  • DC10, Tahiti French Polynesia, 2000 (On 24 December 2000, a Hawaiian Airlines DC10 overran the runway at Tahiti after landing long on a wet runway having encountered crosswinds and turbulence on approach in thunderstorms.)
  • B737, New York La Guardia USA, 2013 (On 22 July 2013 the Captain of a Boeing 737-700 failed to go around when the aircraft was not stabilised on final approach at La Guardia and then took control from the First Officer three seconds before touchdown and made a very hard nose first touchdown which substantially damaged the aircraft. The Investigation concluded that the accident had been a consequence of the continued approach and the attempt to recover with a very late transfer of control instead of a go around as prescribed by the Operator. The aircraft was "substantially damaged".)

Significant Tailwind Component

  • CRJ7, Kanpur India, 2011 (On 20 July 2011, an Alliance Air CRJ 700 touched down over half way along the 9000 ft long runway at Kanpur after a stable ILS approach but with an unexpected limiting tailwind component and failed to stop before the end of the paved surface. Although an emergency evacuation was not necessary and there were no injuries, the aircraft was slightly damaged by impact with an obstruction. The subsequent investigation attributed the event to the commanders continued attempt at a landing when a late touchdown became increasingly likely.)
  • C550, Southampton UK, 1993 (On 26 May 1993, a Cessna Citation II being operated by a UK Air Taxi Company on a positioning flight from Oxford to Southampton to collect passengers with just the flight crew on board overran the ‘very wet’ landing runway at the destination in normal daylight visibility and ended up on an adjacent motorway where it collided with traffic, caught fire and was destroyed. The aircraft occupants and three people in cars received minor injuries.)
  • B738, Hobart Australia, 2010 (On 24 November 2010, a Boeing 737-800 being operated by Virgin Blue Airlines on a scheduled passenger flight from Melbourne, Victoria to Hobart, Tasmania marginally overran the destination runway after aquaplaning during the daylight landing roll in normal ground visibility.)
  • AT72, Mumbai India, 2009 (On 10 November 2010, a Kingfisher Airlines ATR 72-200 made an excessively steep and unstabilised tailwind approach in light rain to runway 27 at Mumbai in visual daylight conditions. After touching down late, the aircraft was steered off the side of the runway when it became obvious that an overrun would otherwise occur. The Investigation found that ATC had failed to advise of water patches on the runway and aquaplaning had occurred. It also found that without aquaplaning, the available distance from the actual touchdown point would have been sufficient to stop the aircraft in.)
  • B733, Aqaba Jordan, 2017 (On 17 September 2017, a Boeing 737-300 requested and was approved for a visual approach to Aqaba which involved a significant tailwind component and, after approaching at excessive speed, it touched down late and overran the 3000 metre runway onto sandy ground. The Investigation found that despite EGPWS Alerts relating to both the high rate of descent and late configuration, the Captain had instructed the First Officer to continue what was clearly an unstabilised approach and when touchdown had still not occurred with around 1000 metres of runway left, the Captain took over but was unable to prevent an overrun.)

Significant Crosswind Component

  • A333, Montréal QC Canada, 2014 (On 7 October 2014, an Airbus A330-300 failed to maintain the runway centreline as it touched down at Montréal in suddenly reduced forward visibility and part of the left main gear departed the runway edge, paralleling it briefly before returning to it and regaining the centreline as the landing roll was completed. The Investigation attributed the excursion to a delay in corrective action when a sudden change in wind velocity occurred at the same time as degraded visual reference. It was found that the runway should not have been in use in such poor visibility without serviceable lighting.)
  • MD11, Dublin Ireland, 2002 (On 3 February 2002, a Delta Airlines MD-11 encountered a sudden exceptional wind gust (43 kts) during the landing roll at Dublin, Ireland. The pilot was unable to maintain the directional control of the aircraft and a runway excursion to the side subsequently occurred.)
  • B735, Denver USA, 2008 (Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind Conditions.)
  • DC10, Tahiti French Polynesia, 2000 (On 24 December 2000, a Hawaiian Airlines DC10 overran the runway at Tahiti after landing long on a wet runway having encountered crosswinds and turbulence on approach in thunderstorms.)
  • AT72, Trollhättan Sweden, 2018 (On 9 October 2018, an ATR 72-200 left the runway during a night landing at Trollhättan before regaining it undamaged and taxiing in normally. The excursion was not reported or observed except by the flight crew. The subsequent discovery of tyre mark evidence led to an Investigation which concluded that the cause of the excursion had been failure of the left seat pilot to adequately deflect the ailerons into wind on routinely taking over control from the other pilot after landing because there was no steering tiller on the right. The non-reporting was considered indicative of the operator’s dysfunctional SMS.)

Thrust Reversers not fitted

  • E145, Hannover Germany, 2005 (On 14 August 2005, a British Airways Regional Embraer 145 overran Runway 27L at Hannover by 160 metes after flying a stable approach in daylight but then making a soft and late touchdown on a water covered runway. Dynamic aquaplaning began and this was followed by reverted rubber aquaplaning towards the end of the paved surface when the emergency brake was applied. The aircraft suffered only minor damage and only one of the 49 occupants was slightly injured.)
  • E135, George South Africa, 2009 (On 7 December 2009, an South African Airlink Embraer 135 overran the recently refurbished wet landing runway at George after braking was ineffective and exited the aerodrome perimeter to end up on a public road. There was no fire and all occupants were able to evacuate the aircraft. The subsequent investigation attributed the overrun principally to inadequate wet runway friction following the surface maintenance activities and noted various significant non-compliances with ICAO Annex 14.)
  • B462, Stord Norway, 2006 (On 10 October 2006, a BAE Systems 146-200 being operated by Danish airline Atlantic Airways on a passenger flight from Sola to Stord overran the end of runway 33 at destination at a slow speed in normal visibility at dawn (but just prior to the accepted definition of daylight) before plunging down a steep slope sustaining severe damage and catching fire immediately it had come to rest. The rapid spread of the fire and difficulties in evacuation resulted in the death of four of the 16 occupants and serious injury to six others. The aircraft was completely destroyed.)

Landing Performance Assessment

  • LJ25, Northolt London UK,1996 (On 13 August 1996, a Bombardier Learjet 25B being operated by a Spanish Air Taxi Operator on a private charter flight from Palma de Mallorca Spain to Northolt made a high speed overrun of the end of the landing runway after an approach in day VMC and collided with traffic on a busy main road after exiting the airport perimeter. All three occupants - the two pilots and one passenger - suffered minor injuries as did the driver of a vehicle hit by the aircraft. The aircraft was destroyed by impact forces but there was no fire.)
  • DHC6, Jomson Nepal, 2013 (On 16 May 2013, a DHC6-300 on a domestic passenger flight made a tailwind touchdown at excessive speed in the opposite direction of the of 740 metre-long runway to the notified direction in use and, after departing the runway to one side during deceleration, re-entered the runway and attempted to take off. This failed and the aircraft breached the perimeter fence and fell into a river. The Investigation identified inappropriate actions of the aircraft commander in respect of both the initial landing and his response to the subsequent runway excursion and also cited the absence of effective CRM.)
  • MD11, New York JFK USA, 2003 (A McDonnell Douglas MD11F failed to complete its touchdown on runway 04R at New York JFK until half way along the 2560 metre-long landing runway and then overran the paved surface by 73 metres having been stopped by the installed EMAS. The Investigation found no evidence that the aircraft was not serviceable and noted that the and that the landing had been attempted made with a tailwind component which meant that the runway was the minimum necessary for the prevailing aircraft landing weight.)
  • SW4, New Plymouth New Zealand, 2009 (A visual approach by a Swearingen SA227 at New Plymouth was rushed and unstable with the distraction of a minor propeller speed malfunction and with un-actioned GPWS warnings caused by excessive sink and terrain closure rates. After a hard touchdown close to the beginning of the runway, directional control was lost and the aircraft left the runway to the side before continuing parallel to it for the rest of the landing roll.)
  • B742, Montreal Canada, 2000 (On 23 July 2000, a Boeing 747-200 being operated by Royal Air Maroc on a scheduled passenger flight from New York to Montreal overran the temporarily restricted available landing runway length after the aircraft failed to decelerate sufficiently during a daylight landing with normal on-ground visibility. It struck barriers at the displaced runway end before stopping 215 metres further on. Shortly before it stopped, ATC observed flames coming out of the No. 2 engine and advised the flight crew and alerted the RFFS. However, no sustained fire developed and the aircraft was undamaged except for internal damage to the No 2 engine. No emergency evacuation was deemed necessary by the aircraft commander and there were no occupant or other injuries)

Off side of Runway

  • BE20, Nadi Fiji, 2010 (On 25 April 2010, a Beech King Air touched down at Nadi with its landing gear in the transit position after flying a night approach during which a significant electrical system failure had occurred. The landing gear retracted and the aircraft left the runway to the side and came to a stop resting on its fuselage. The Investigation attributed the electrical failure, which directly affected the landing gear operating system and required two diodes to have both failed was likely to have meant that one would have failed on an earlier occasion with no apparent consequence.)
  • B734, Lahore Pakistan, 2015 (On 3 November 2015, a Boeing 737-400 continued an unstabilised day approach to Lahore. When only the First Officer could see the runway at MDA, he took over from the Captain but the Captain took it back when subsequently sighting it. Finally, the First Officer took over again and landed after recognising that the aircraft was inappropriately positioned. Both main gear assemblies collapsed as the aircraft veered off the runway. The Investigation attributed the first collapse to the likely effect of excessive shimmy damper play and the second collapse to the effects of the first aggravated by leaving the runway.)
  • AT72, Trollhättan Sweden, 2018 (On 9 October 2018, an ATR 72-200 left the runway during a night landing at Trollhättan before regaining it undamaged and taxiing in normally. The excursion was not reported or observed except by the flight crew. The subsequent discovery of tyre mark evidence led to an Investigation which concluded that the cause of the excursion had been failure of the left seat pilot to adequately deflect the ailerons into wind on routinely taking over control from the other pilot after landing because there was no steering tiller on the right. The non-reporting was considered indicative of the operator’s dysfunctional SMS.)
  • MD88, New York La Guardia USA, 2015 (On 5 March 2015 a Boeing MD88 veered off a snow-contaminated runway 13 at New York La Guardia soon after touchdown after the experienced flight crew applied excessive reverse thrust and thus compromised directional control due to rudder blanking, a known phenomenon affecting the aircraft type. The aircraft stopped partly outside the airport perimeter with the forward fuselage over water. In addition to identifying the main cause of the accident, the Investigation found that exposure to rudder blanking risks was still widespread. It also noted that the delayed evacuation was partly attributable to inadequate crew performance and related Company procedures.)
  • A320, Varadero Cuba, 2010 (On 31 January 2010, an Airbus A320-200 being operated by the Canadian Airline Skyservice on a passenger flight from Toronto Canada to Varadero Cuba made a procedural night ILS approach to destination in heavy rain and, soon after touchdown on a flooded runway, drifted off the side and travelled parallel to it for a little over 500 metres before subsequently re-entering it at low speed. There were no injuries to the 186 occupants and the aircraft sustained only minor damage.)

Taxiway Take Off/Landing

  • B763, Singapore, 2015 (On 12 July 2015, a Japanese-operated Boeing 767-300 deviated from its acknowledged clearance and lit-centreline taxi routing and began take-off from a parallel taxiway in good night visibility, crossing a lit red stop bar in the process. When ATC observed this, the aircraft was instructed to stop which was achieved without further event. A subsequent take-off was uneventful. The crew did not report the event to their airline or their State authorities because the Captain "determined that this case did not need to be reported" and these organisations only became aware when subsequently contacted by the Investigating Agency.)
  • A343, Hong Kong China, 2010 (On 27 November 2010, a Finnair Airbus A340-300 unintentionally attempted a night take off from Hong Kong in good visibility from the taxiway parallel to the runway for which take off clearance had been given. ATC observed the error and instructed the crew to abandon the take off, which they then did. The Investigation attributed the crew error partly to distraction. It was considered that the crew had become distracted and that supporting procedures and process at the Operator were inadequate.)
  • A320, Oslo Norway, 2010 (On 25 February 2010, an Aeroflot Airbus A320-200 unintentionally made a daylight take off from Oslo in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation identified contributory factors attributable to the airline, the airport and the ANSP.)
  • B734, Sharjah UAE, 2015 (On 24 September 2015, a Boeing 737-400 cleared for a night take-off from Sharjah took off from the parallel taxiway. The controller decided that since the taxiway was sterile and the aircraft speed was unknown, the safest option was to allow the take-off to continue. The Investigation noted that the taxiway used had until a year previously been the runway, becoming a parallel taxiway only when a new runway had been opened alongside it. It was noted that the controller had "lost visual watch" on the aircraft and regained it only once the aircraft was already at speed.)
  • B733, Amsterdam Netherlands, 2010 (On 10 February 2010 a KLM Boeing 737-300 unintentionally made a night take off from Amsterdam in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation noted the familiarity of the crew with the airport and identified apparent complacency.)

Runway Length Temporarily Reduced

  • B738, Paris CDG France, 2008 (On 16 August 2008, an AMC Airlines’ Boeing 737-800 inadvertently began a night take off from an intersection on runway 27L at Paris CDG which left insufficient take off distance available before the end of the temporarily restricted runway length. It collided with and damaged obstructions related to construction works in progress on the closed section of the runway but sustained only minor damage and completed the intended flight to Luxor. The context for the flight crew error was identified as inadequate support from the Operator and inadequate airport risk assessment for operations with a reduced runway length.)
  • SB20, Werneuchen Germany, 2002 (On 10 July 2002, a Saab 2000 being operated by Swiss Air Lines on a scheduled public transport service from Basel to Hamburg encountered extensive thunderstorms affecting both the intended destination and the standard alternates and due to a shortage of fuel completed the flight with a landing in day VMC at an unmanned general aviation airstrip where the aircraft collided with an unseen obstruction. After the aircraft came to a stop with the landing gear torn off, the two cabin crew conducted the passenger evacuation on their own initiative. There was no fire and only one of the 20 occupants was injured. The aircraft was declared a hull loss due to the damage sustained relative to the location.)
  • A306, Yerevan Armenia, 2015 (On 17 May 2015, an Airbus A300-600 crew descended their aircraft below the correct vertical profile on a visual daytime approach at Yerevan and then landed on a closed section of the runway near the displaced runway threshold. The Investigation found that the crew had failed to review relevant AIS information prior to departing from Tehran and had not been expecting anything but a normal approach and landing. The performance of the Dispatcher in respect of briefing and the First Officer in respect of failure to adequately monitor the Captain's flawed conduct of the approach was highlighted.)
  • A342, Perth Australia, 2005 (On 24 April 2005, an Airbus A340-200 landed short of the temporarily displaced runway threshold at Perth in good daylight visibility despite their prior awareness that there was such a displacement. The Investigation concluded that the crew had failed to correctly identify the applicable threshold markings because the markings provided were insufficiently clear to them and probably also because of the inappropriately low intensity setting of the temporary PAPI. No other Serious Incidents were reported during the same period of runway works.)
  • AT72, Mumbai India, 2009 (On 10 November 2010, a Kingfisher Airlines ATR 72-200 made an excessively steep and unstabilised tailwind approach in light rain to runway 27 at Mumbai in visual daylight conditions. After touching down late, the aircraft was steered off the side of the runway when it became obvious that an overrun would otherwise occur. The Investigation found that ATC had failed to advise of water patches on the runway and aquaplaning had occurred. It also found that without aquaplaning, the available distance from the actual touchdown point would have been sufficient to stop the aircraft in.)

Intentional Premature Rotation

  • MD88, Groningen Netherlands, 2003 (On 17 June 2003, a crew of a Boeing MD-88, belonging to Onur Air, executed a high speed rejected take-off at a late stage which resulted in overrun of the runway and serious damage to the aircraft.)
  • B763, Manchester UK, 2008 (On 13 December 2008, a Thomsonfly Boeing 767-300 departing from Manchester for Montego Bay Jamaica was considered to be accelerating at an abnormally slow rate during the take off roll on Runway 23L. The aircraft commander, who was the pilot not flying, consequently delayed the V1 call by about 10 - 15 because he thought the aircraft might be heavier than had been calculated. During the rotation the TAILSKID message illuminated momentarily, indicating that the aircraft had suffered a tail strike during the takeoff. The commander applied full power and shortly afterwards the stick shaker activated briefly. The aircraft continued to climb away and accelerate before the flaps were retracted and the after-takeoff check list completed. The appropriate drills in the Quick Reference Handbook (QRH) were subsequently actioned, fuel was dumped and the aircraft returned to Manchester for an overweight landing without further incident.)

Incorrect Aircraft Configuration

  • E145, Bristol UK, 2017 (On 22 December 2017, an Embraer 145 departed the side of the runway shortly after touching down at Bristol and finally stopped 120 metres from the runway edge. The Investigation found that the aircraft had landed after the emergency/parking brake had been inadvertently selected on during the approach when the intention had been to deploy the speed brakes. It was noted that the Captain designated as Pilot Flying had been new to both the aircraft type and the Operator and had been flying under supervision as part of the associated type conversion requirement for line training.)
  • GLF4, Le Castellet France, 2012 (On 13 July 2012, a Gulfstream G-IV left the side of the runway at high speed during the landing roll at Le Castellet following a positioning flight after ineffective deceleration after the flight crew had forgotten to arm the ground spoilers. The Investigation found that pilot response to this situation had been followed by a loss of directional control, collision with obstructions and rapid onset of an intense fire. Contributory factors identified included poor procedural compliance by the pilots, their lack of training on a relevant new QRH procedure which Gulfstream had ineffectively communicated and ineffective FAA oversight of the operation.)
  • B738, Pardubice Czech Republic, 2013 (On 25 August 2013, the type-experienced crew of a Boeing 737-800 operating with one thrust reverser locked out made a late touchdown with a significant but allowable tail wind component present and overran the end of the runway at Pardubice onto grass at 51 knots. No damage was caused to the aircraft and no emergency evacuation was performed. The Investigation concluded that the aircraft had been configured so that even for a touchdown within the TDZ, there would have been insufficient landing distance available. The flight crew were found not to have followed a number of applicable operating procedures.)
  • SF34, Marsh Harbour Bahamas, 2013 (On 13 June 2013, a rushed and unstable visual approach to Marsh Harbour by a Saab 340B was followed by a mishandled landing and a runway excursion. The Investigation concluded that the way the aircraft had been operated had been contrary to expectations in almost every respect. This had set the scene for the continuation of a visual approach to an attempted landing in circumstances where there had been multiple indications that there was no option but to break off the approach, including a total loss of forward visibility in very heavy rain as the runway neared.)
  • B738, Georgetown Guyana, 2011 (On 30 July 2011, a Boeing 737-800 overran the wet landing runway at Georgetown after a night non-precision approach, exited the airport perimeter and descended down an earth embankment. There were no fatalities but the aircraft sustained substantial damage and was subsequently declared a hull loss. The Investigation attributed the overrun to a touchdown almost two thirds of the way down the runway and failure to utilise the aircraft’s full deceleration capability. Loss of situational awareness and indecision as to the advisability of a go-around after a late touchdown became inevitable was also cited as contributory to the outcome.)

Reduced Thrust Take Off

  • A345, Melbourne Australia, 2009 (On 20 March 2009 an Airbus A340-500, operated by Emirates, commenced a take-off roll for a normal reduced-thrust take-off on runway 16 at Melbourne Airport. The attempt to get the aircraft airborne resulted in a tail strike and an overrun because insufficient thrust had been set based upon an incorrect flight crew data entry.)
  • A332, Montego Bay Jamaica, 2008 (Prior to the departure of a Thomas Cook Airlines Airbus A330-200 from Montego Bay Jamaica during the hours of darkness and in normal visibility on 28 October 2008, incorrect takeoff speeds had been input to the FMS by the flight crew without this being recognised. When rotation during take off was, as a consequence, initiated too early, the aircraft failed to become airborne as expected. The aircraft commander, acting as PF, quickly selected TOGA power and the aircraft became airborne before the end of the available runway had been reached and climbed away safely.)
  • A320, Porto Portugal, 2013 (On 1 October 2013, an Airbus A320 took off from a runway intersection at Porto which provided 1900 metres TORA using take off thrust that had been calculated for the full runway length of 3480 metres TORA. It became airborne 350 metres prior to the end of the runway but the subsequent Investigation concluded that it would not have been able to safely reject the take-off or continue it, had an engine failed at high speed. The event was attributed to distraction and the inappropriate formulation of the operating airline's procedures for the pre take-off phase of flight.)
  • B742, Halifax Canada, 2004 (On 14 October 2004, a B742 crashed on take off from Halifax International Airport, Canada, and was destroyed by impact forces and a post-crash fire. The crew had calculated incorrect V speeds and thrust setting using an EFB.)
  • H25B, vicinity Owatonna MN USA, 2008 (On 31 July 2008, the crew of an HS125-800 attempted to reject a landing at Owatonna MN after a prior deployment of the lift dumping system but their aircraft overran the runway then briefly became airborne before crashing. The aircraft was destroyed and all 8 occupants were killed. The Investigation attributed the accident to poor crew judgement and general cockpit indiscipline in the presence of some fatigue and also considered that it was partly consequent upon the absence of any regulatory requirement for either pilot CRM training or operator SOP specification for the type of small aircraft operation being undertaken.)

Fixed Obstructions in Runway Strip

  • DH8D, Hubli India, 2015 (On 8 March 2015, directional control of a Bombardier DHC 8-400 which had just completed a normal approach and landing was lost and the aircraft departed the side of the runway following the collapse of both the left main and nose landing gear assemblies. The Investigation found that after being allowed to drift to the side of the runway without corrective action, the previously airworthy aircraft had hit a non-frangible edge light and the left main gear and then the nose landing gear had collapsed with a complete loss of directional control. The aircraft had then exited the side of the runway sustaining further damage.)
  • E55P, Blackbushe UK, 2015 (On 31 July 2015 a Saudi-operated Embraer Phenom on a private flight continued an unstabilised day visual approach to Blackbushe in benign weather conditions. The aircraft touched down with excess speed with almost 70% of the available landing distance behind the aircraft. It overran and was destroyed by impact damage and fire and all occupants died. The Investigation concluded that the combination of factors which created a very high workload for the pilot "may have saturated his mental capacity, impeding his ability to handle new information and adapt his mental model" leading to his continuation of a highly unstable approach.)
  • A30B, Bratislava Slovakia, 2012 (On 16 November 2012, an Air Contractors Airbus A300 departed the left the side of the landing runway at Bratislava after an abnormal response to directional control inputs. Investigation found that incorrect and undetected re-assembly of the nose gear torque links had led to the excursion and that absence of clear instructions in maintenance manuals, since rectified, had facilitated this. It was also considered that the absence of any regulation requiring equipment in the vicinity of the runway to be designed to minimise potential damage to aircraft departing the paved surface had contributed to the damage caused by the accident.)
  • B738, Manila Philippines, 2018 (On 16 August 2018, a Boeing 737-800 made a stabilised approach to Manila during a thunderstorm with intermittent heavy rain but the crew lost adequate visual reference as they arrived over the runway. After a drift sideways across the 60 metre-wide landing runway, a veer off occurred and was immediately followed by a damaging collision with obstructions not compliant with prevailing airport safety standards. The Investigation found that the Captain had ignored go around calls from the First Officer and determined that the corresponding aircraft operator procedures were inadequate as well as faulting significant omissions in the Captain’s approach brief.)

Ineffective Use of Retardation Methods

  • B736, Montréal QC Canada, 2015 (On 5 June 2015, a Boeing 737-600 landed long on a wet runway at Montréal and the crew then misjudged their intentionally-delayed deceleration because of an instruction to clear the relatively long runway at its far end and were then unable to avoid an overrun. The Investigation concluded that use of available deceleration devices had been inappropriate and that deceleration as quickly as possible to normal taxi speed before maintaining this to the intended runway exit was a universally preferable strategy. It was concluded that viscous hydroplaning had probably reduced the effectiveness of maximum braking as the runway end approached.)
  • MD88, New York La Guardia USA, 2015 (On 5 March 2015 a Boeing MD88 veered off a snow-contaminated runway 13 at New York La Guardia soon after touchdown after the experienced flight crew applied excessive reverse thrust and thus compromised directional control due to rudder blanking, a known phenomenon affecting the aircraft type. The aircraft stopped partly outside the airport perimeter with the forward fuselage over water. In addition to identifying the main cause of the accident, the Investigation found that exposure to rudder blanking risks was still widespread. It also noted that the delayed evacuation was partly attributable to inadequate crew performance and related Company procedures.)
  • B739, Yogyakarta Indonesia, 2015 (On 6 November 2015, a Boeing 737-900 overran the 2,200 metre-long landing runway at Yogyakarta after a tailwind approach with airspeed significantly above the applicable Vref followed by a long landing on a wet runway without optimum use of deceleration devices. The flight crew management of the situation once the aircraft had come to a stop was contrary to procedures in a number of important respects. The aircraft operator took extensive action to improve crew performance following the event. The Investigation found significant fault with the airport operator's awareness of runway surface condition and an absence of related significant risk management.)
  • B737, Chicago Midway USA, 2005 (On 8 December 2005, a delay in deploying the thrust reversers after a Boeing 737-700 touchdown at night on the slippery surface of the 1176 metre-long runway at Chicago Midway with a significant tailwind component led to it running off the end, subsequently departing the airport perimeter and hitting a car before coming to a stop. The Investigation concluded that pilots’ lack of familiarity with the autobrake system on the new 737 variant had distracted them from promptly deploying the reversers and that inadequate pilot training provision and the ATC failure to provide adequate braking action information had contributed.)
  • B734, Timbuktu Mali, 2017 (On 5 May 2017, a Boeing 737-400 made a visual approach to Timbuktu and slightly overran the end of the 2,170 metre-long runway into soft ground causing one of the engines to ingest significant quantities of damaging debris. The Investigation found that the landing had been made with a significantly greater than permitted tailwind component but that nevertheless had the maximum braking briefed been used, the unfactored landing distance required would have been well within that available. The preceding approach was found to have been comprehensively unstable throughout with no call for or intent to make a go around.)

Continued Take Off

  • DHC6, Jomson Nepal, 2013 (On 16 May 2013, a DHC6-300 on a domestic passenger flight made a tailwind touchdown at excessive speed in the opposite direction of the of 740 metre-long runway to the notified direction in use and, after departing the runway to one side during deceleration, re-entered the runway and attempted to take off. This failed and the aircraft breached the perimeter fence and fell into a river. The Investigation identified inappropriate actions of the aircraft commander in respect of both the initial landing and his response to the subsequent runway excursion and also cited the absence of effective CRM.)
  • B738, Paris CDG France, 2008 (On 16 August 2008, an AMC Airlines’ Boeing 737-800 inadvertently began a night take off from an intersection on runway 27L at Paris CDG which left insufficient take off distance available before the end of the temporarily restricted runway length. It collided with and damaged obstructions related to construction works in progress on the closed section of the runway but sustained only minor damage and completed the intended flight to Luxor. The context for the flight crew error was identified as inadequate support from the Operator and inadequate airport risk assessment for operations with a reduced runway length.)
  • A343, Auckland New Zealand, 2013 (On 18 May 2013 an Airbus A340 with the Captain acting as 'Pilot Flying' commenced its night take off from Auckland in good visibility on a fully lit runway without the crew recognising that it was lined up with the runway edge. After continuing ahead for approximately 1400 metres, the aircraft track was corrected and the take off completed. The incident was not reported to ATC and debris on the runway from broken edge lights was not discovered until a routine inspection almost three hours later. The Investigation concluded that following flights were put at risk by the failure to report.)
  • AT72, Dresden Germany, 2002 (On 5 March 2002, an ATR72-202 departed from runway 22 at Dresden in good visibility at night aligned with the edge lights of the runway without the crew apparently being aware of their error. Damage to both the edge lights and the aircraft was subsequently discovered. The Investigation attributed the error to the crew, concluding that a contributing factor had been that the correctly promulgated and lit runway width represented a reduction from a previously greater width with the surface now outside the runway being of a similar appearance to the actual runway surface.)
  • A318/B738, Nantes France, 2010 (On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.)

Continued Landing Roll

  • A318/B738, Nantes France, 2010 (On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.)
  • B738, Mangalore India, 2012 (On 14 August 2012, a Boeing 737-800 crew continued a previously stable ILS Cat 1 approach below the prescribed MDA without having acquired the prescribed visual reference. The aircraft was then damaged by a high rate of descent at the initial touchdown in the undershoot in fog. The occurrence was not reported by either the crew or the attending licensed engineer who discovered consequent damage to the aircraft. Dense fog had prevented ATC visual awareness. The Investigation attributed the undershoot to violation of minima and to both pilots looking out for visual reference leaving the flight instruments unmonitored.)
  • B739, Yogyakarta Indonesia, 2015 (On 6 November 2015, a Boeing 737-900 overran the 2,200 metre-long landing runway at Yogyakarta after a tailwind approach with airspeed significantly above the applicable Vref followed by a long landing on a wet runway without optimum use of deceleration devices. The flight crew management of the situation once the aircraft had come to a stop was contrary to procedures in a number of important respects. The aircraft operator took extensive action to improve crew performance following the event. The Investigation found significant fault with the airport operator's awareness of runway surface condition and an absence of related significant risk management.)
  • B737, Chicago Midway USA, 2005 (On 8 December 2005, a delay in deploying the thrust reversers after a Boeing 737-700 touchdown at night on the slippery surface of the 1176 metre-long runway at Chicago Midway with a significant tailwind component led to it running off the end, subsequently departing the airport perimeter and hitting a car before coming to a stop. The Investigation concluded that pilots’ lack of familiarity with the autobrake system on the new 737 variant had distracted them from promptly deploying the reversers and that inadequate pilot training provision and the ATC failure to provide adequate braking action information had contributed.)
  • E55P, Blackbushe UK, 2015 (On 31 July 2015 a Saudi-operated Embraer Phenom on a private flight continued an unstabilised day visual approach to Blackbushe in benign weather conditions. The aircraft touched down with excess speed with almost 70% of the available landing distance behind the aircraft. It overran and was destroyed by impact damage and fire and all occupants died. The Investigation concluded that the combination of factors which created a very high workload for the pilot "may have saturated his mental capacity, impeding his ability to handle new information and adapt his mental model" leading to his continuation of a highly unstable approach.)

Excessive Exit to Taxiway Speed

  • JS32, Torsby Sweden, 2014 (On 31 January 2014, an Estonian-operated BAE Jetstream 32 being used under wet lease to fulfil a government-funded Swedish domestic air service requirement landed long at night and overran the end of the runway. The Investigation concluded that an unstabilised approach had been followed by a late touchdown at excessive speed and that the systemic context for the occurrence had been a complete failure of the aircraft operator to address operational safety at anything like the level appropriate to a commercial operation. Failure of the responsible State Safety Regulator to detect and act on this situation was also noted.)

Frozen Deposits on Runway

  • CRJX, Madrid Spain, 2015 (On 1 February 2015, a Bombardier CRJ 1000 departed from Pamplona with slush likely to have been in excess of the regulatory maximum depth on the runway. On landing at Madrid, the normal operation of the brake units was compromised by ice and one tyre burst damaging surrounding components and leaving debris on the runway, and the other tyre was slow to spin up and sustained a serious flat spot. The Investigation concluded that the Pamplona apron, taxiway and runway had not been properly cleared of frozen deposits and that the flight crew had not followed procedures appropriate for the prevailing conditions.)

Excessive Water Depth

Intentional Veer Off Runway

  • C402, Virgin Gorda British Virgin Islands, 2017 (On 11 February 2017, a Cessna 402 failed to stop on the runway when landing at Virgin Gorda and was extensively damaged. The Investigation noted that the landing distance required was very close to that available with no safety margin so that although touchdown was normal, when the brakes failed to function properly, there was no possibility of safely rejecting the landing or stopping normally on the runway. Debris in the brake fluid was identified as causing brake system failure. The context was considered as the Operator’s inadequate maintenance practices and a likely similar deficiency in operational procedures and processes.)
  • AN72, Sao Tome, Sao Tome & Principe, 2017 (On 29 July 2017, an Antonov AN-74 crew sighted several previously unseen large “eagles” rising from the long grass next to the runway as they accelerated for takeoff at Sao Tome and, concerned about the risk of ingestion, made a high speed rejected takeoff but were unable to stop on the runway and entered a deep ravine just beyond it which destroyed the aircraft. The Investigation found that the reject had been unnecessarily delayed until above V1, that the crew forgot to deploy the spoilers which would have significantly increased the stopping distance and that relevant crew training was inadequate.)

Misaligned take off

  • AT72, Karup Denmark, 2016 (On 25 January 2016, an ATR 72-200 crew departing from and very familiar with Karup aligned their aircraft with the runway edge lights instead of the lit runway centreline and began take-off, only realising their error when they collided with part of the arrester wire installation at the side of the runway after which the take-off was rejected. The Investigation attributed the error primarily to the failure of the pilots to give sufficient priority to ensuring adequate positional awareness and given the familiarity of both pilots with the aerodrome noted that complacency had probably been a contributor factor.)
  • E120, Amsterdam Netherlands, 2016 (On 18 January 2016, an Embraer 120 crew made a night takeoff from Amsterdam Runway 24 unaware that the aircraft was aligned with the right side runway edge lights. After completion of an uneventful flight, holes in the right side fuselage and damage to the right side propeller blades, the latter including wire embedded in a blade leading edge, were found. The Investigation concluded that poor visual cues guiding aircraft onto the runway at the intersection concerned were conducive to pilot error and noted that despite ATS awareness of intersection takeoff risks, no corresponding risk mitigation had been undertaken.)

Runway Condition not as reported

  • CRJ9, Turku Finland, 2017 (On 25 October 2017, a Bombardier CRJ-900 crew lost directional control after touchdown at Turku in the presence of a tailwind component on a contaminated runway at night whilst heavy snow was falling. After entering a skid the aircraft completed a 180° turn before finally stopping 160 metres from the end of the 2500 metre-long runway. The Investigation found that skidding began immediately after touchdown with the aircraft significantly above the aquaplaning threshold and that the crew did not follow the thrust reverser reset procedure after premature deployment or use brake applications and aileron inputs appropriate to the challenging conditions.)

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