B733, Aqaba Jordan, 2017
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|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.|
|Actual or Potential
|Human Factors, Runway Excursion|
|Type of Flight||Public Transport (Passenger)|
|Origin||Amman/Queen Alia International|
|Take off Commenced||Yes|
|Location - Airport|
|Tag(s)||Approach not stabilised,|
Inadequate Aircraft Operator Procedures,
Ineffective Regulatory Oversight,
Landing Flare Difficulty,
Deficient Crew Knowledge-systems,
Deficient Crew Knowledge-handling,
Unplanned PF Change less than 1000ft agl,
Deficient Pilot Knowledge
Inappropriate crew response - skills deficiency,
Plan Continuation Bias,
Procedural non compliance,
Ineffective Monitoring - SIC as PF
|Tag(s)||Overrun on Landing,|
Collision Avoidance Action,
Significant Tailwind Component,
Significant Crosswind Component,
Incorrect Aircraft Configuration,
Continued Landing Roll
|Safety Net Mitigations|
|Malfunction of Relevant Safety Net||No|
|GPWS||Available but ineffective|
|Damage or injury||Yes|
|Causal Factor Group(s)|
On 17 September 2017, a Boeing 737-300 (JY-SOA) being operated by Solitaire Air on behalf of Royal Wings on an international charter flight from Amman to Dubai World Central via Aqaba as RWY 6888 departed the end of the Aqaba runway after a fast and late touchdown following an unstable approach in day VMC. None of the occupants were injured but the overrun led to serious left engine impact damage, right engine sand/dust ingestion, damage to the right main landing gear, superficial damage to the lower fuselage and minor damage to the passenger cabin trim. After recovery, the aircraft was withdrawn from service for repairs. Left engine impact also led to some of the runway 01 approach lights being damaged.
An Investigation was carried out by the Jordan Civil Aviation Regulatory Commission (CARC). Data from the DFDR and CVR were downloaded and used to inform the Investigation. It was noted that the 43 year-old Captain had a total of 7,102 flying hours, all but 102 hours on type. He had joined the airline on 1 May 2017 and had been appointed as the nominated Flight Operations Post Holder for the airline later the same month. The 29 year-old First Officer had a total of 1,662 hours, all but 213 hours on type having joined the Company three months prior to the accident in his first appointment as a professional pilot.
It was established that after a delayed departure from Amman on a two sector flight which was scheduled as an 11:30 hours flight duty period (FDP) with an applicable maximum FDP of 12 hours, the Captain was keen to make up time. En-route to Aqaba on what was going to be an approximately 35 minute flight, the Captain, who was acting as PM, contacted Aqaba ATC to request a straight in approach to runway 19 and the request was noted. Whilst awaiting a decision, the Captain briefly took over as PF so that the First Officer could set up for the anticipated 19 approach, which would be conducted using VNAV as the 19 ILS was out of service. When ATC subsequently called the flight to ask if they would be able to maintain high speed for a runway 19 landing, the Captain, now PM again, responded in the affirmative and this was approved. The crew were aware throughout that the crosswind component for a landing on runway 19 based on the received METAR was 10/12 knots and that this potentially exceeded the 10 knot AFM limitation for landing. The Captain explicitly accepted this when reminded of it by the Aqaba APP controller.
The visual approach was initially flown with the AP engaged and LVL CHG and LNAV modes selected. Engine thrust remained at Idle throughout the approach. As the aircraft descended through 2,500 feet agl approximately 1½ minutes from touchdown, it was descending at around 3,000 fpm at around 260 KCAS. Landing clearance was given at around 1500 feet agl with a spot wind of 010° at 12 knots. Half a minute later, at 1,215 feet agl, the AP and A/T were recorded as having disconnected and a few seconds later, at approximately 900 feet agl, the first EGPWS ‘SINK RATE’ Alert was annunciated. At around 850 feet agl, the VNAV ‘LVL CHG’ mode began to transition to ‘ALT ACQ’ and at 650 feet, the Flap 1 was selected. Passing 500 feet agl, with the computed airspeed 218 KCAS and the rate of descent now reduced to 1,200 fpm, Flap 2 was selected and further EGPWS ‘SINK RATE’ and ‘TOO LOW TERRAIN’ Alerts followed, the latter due to the flaps not yet being at a landing setting. At 220 feet agl, Flap 5 was selected and at approximately 135 feet agl, more EGPWS ‘SINK RATE’ and ‘TOO LOW TERRAIN’ Alerts occurred with the latter being repeated at 90 feet agl as Flap 30 was selected with the speed still at 200 KCAS and repeated again at about 60 feet agl because the flaps were still in transit to 30. On reaching 25 feet agl, the rate of descent reduced to zero and remained there with pitch attitude also zero as the aircraft floated above the runway and the excess speed bled off. Flap 30 was reached 4 seconds later.
With the aircraft still floating in an almost level attitude and the First Officer unable to put it on the runway, the Captain was recorded as calling “my control” which was immediately acknowledged and touchdown eventually occurred at 159 KCAS with just over 800 metres of the 3,000 metre-long runway remaining. Flap 40 was selected 3 seconds after touchdown along with reverse thrust, ground spoilers and maximum braking which all began to slow the aircraft down. However, it still left the end of the paved surface 14 seconds after touchdown at 50 KCAS and, after deviating slightly to the right to try and avoid further impact with the runway 01 approach lighting, finally came to a stop after further 14 seconds some 270 metres beyond the end of the runway and 60 metres to the right of its extended centreline. The thrust reversers were not stowed until the recorded speed reached 25 knots over the sandy surface. Passengers and crew were subsequently disembarked using steps and taken to the terminal.
The available CVR data indicated that the crew did not conduct the descent, approach or landing checks and showed that after each of the first three EGPWS ‘SINK RATE’ Alerts had occurred, the Captain had followed it with the successive responses “no problem”, “leave it, leave you fly” and “continue”. Although no Vref appeared to have been calculated, the aircraft ELW of 49 tonnes (the MLW was 51.7 tonnes) would imply a Vref of 135 KIAS which would have meant the eventual touchdown was made at Vref + 25.
The Investigation found that the Captain had not received all the training specified in the company Air Operations Manual after missing a ground school CRM course because he was required to fly. It was found that his attendance had nevertheless been falsely signed off by the former Accountable Manager as CRM Instructor. After the event under investigation, CARC Inspectors were reported to have found that implementation of the mandated Company SMS was minimal and “behind the required position on the implementation phased approach plan”. It was particularly noted that whilst the Company’s aircraft were fitted with QARs, “these recorders were not utilised as a source of reliable information that enabled the Solitaire Air SMS to identify operational risks such as unstabilised approaches”.
Since the Investigation was easily able to determine that the identified “Active Failures” had occurred within a context of “Latent Failures”, a detailed analysis was undertaken using the HFACS system and this identified related contributory factors in both categories. In respect of the way the Company was being run generally, it was concluded that there was considerable evidence of a complete lack of a meaningful safety culture at Solitaire Air and there had been a systemic failure of its management to correct known problems.
The formally-stated Cause of the excursion was “flight crew failure to discontinue the unstabilised approach and their persistence in continuing with the landing despite a number of EGPWS alerts”.
Fifteen Contributory Factors were documented identified as follows:
- The 47 minute delay prior to departure from Amman influenced the crew decision to land on runway 19 at Aqaba to save time.
- The straight in unstabilised approach was the main result of the aircraft high energy for consecutive phases between 1000 feet aal and the touchdown point.
- The higher than permitted tailwind component which was recorded as an average of 16 knots during the final approach and landing phases.
- An incorrect landing configuration contributed to the high speed of the aircraft and explained both the First Officers inability to control the prolonged float of the aircraft and the Captain’s inability to complete the roll out on the runway after taking control.
- The Captain, as pilot monitoring during the approach, was aware of the tailwind, however he accepted the prevailing conditions without discussing the operational limitations of the aircraft with the pilot flying.
- The failure of the crew to discontinue the unstabilised approach and make a go around helped to develop the situation.
- Poor situational awareness of the crew and their lack of coordination.
- The deliberate disregard of EGPWS alerts without correcting the aircraft attitude.
- A lack of CRM for task sharing and decision making – CRM was not evident during the approach phase of flight.
- The failure of the airline to provide its pilots with clear and consistent guidance and training regarding company policies and procedures related to stabilisation criteria and the necessary actions to be followed including the conduct of go around.
- An inability to recognise the two critical elements, namely fixation and complacency that affected the decision to land the aircraft when the approach had not met the stabilisation criteria.
- The negative organisational factors were evidenced in terms of operational pressure that was exerted by the management of Solitaire Air.
- Inadequate risk management by the operator in that repeated reports of duty time exceedances were not known to or observed by its operational safety management personnel.
- Non-compliance with State Regulations on the proper training of crews was found in respect of incorrect completion of the Captain’s CRM conversion training.
- The non availability of properly customised flight safety documentation (FCOM, FCTM and QRH) which includes the manufacturer-recommended standard operating procedures.
Twelve Safety Recommendations were made as follows:
- that Solitaire Air reviews its crew resource management and threat and error management training, provides refreshers for all flight crew and incorporates threat and error management in both ground school and simulator training.
- that Solitaire Air emphasises the need for go around manoeuvres whenever required and especially when an approach becomes unstabilised during both instrument and visual meteorological conditions and encourages company pilots to report unstabilised approaches whenever they occur.
- that Solitaire Air provides its First Officers with the necessary training related to assertiveness.
- that Solitaire Air reviews its reporting policy and monitors the effective implementation of it in terms of maintaining the confidentiality of reporters and developing the required management follow up and control measures. The Operator should have a sound and effective non-punitive safety reporting system that shall be implemented throughout the organisation in all areas where operations are conducted.
- that Solitaire Air reviews the company safety management system and provides staff with the required and effective SMS training by emphasising the methods required to create a safety culture within the organisation.
- that Solitaire Air reviews crew duty time rules in a way that results in a more realistic duty time calculation which includes factors that may affect the compliance with CARC regulations.
- that Solitaire Air develops a more effective flight data monitoring programme that enables the management to address the hazards encountered during ongoing operations and helps to provide corrective actions proactively through trend analysis of captured operational deviations. This can be made by more frequent data download and analysis.
- that Solitaire Air conduct more frequent co-ordination meetings between its various operational departments to discuss the challenges encountered and provide ongoing follow ups for the corrective actions required.
- that Solitaire Air provide correctly validated operations and flight safety documents (FCOM, QRH, FCTM, etc.) so that their operating crew are provided with the correct and customised SOPs.
- that the Civil Aviation Regulatory Commission (CARC) Flight Standards Directorate increases surveillance of AOC holders with emphasis on the actions of flight crew and their adherence to SOPs by conducting more frequent flight deck observations.
- that the Civil Aviation Regulatory Commission (CARC) Flight Standards Directorate reviews regulated operators’ flight safety documentation to ensure that it is customised for the types and registrations of aircraft operated by each operator.
- that the Civil Aviation Regulatory Commission (CARC) Inspectorate evaluate the Accountable Manager and Post Holders in terms of their responsibilities and authorities to ensure that they are able to demonstrate a commitment to the management of safety and a sound knowledge of safety management system principles and practices within the organisation for which they are responsible including, in particular, knowledge of their own role.
The Final Report of the Investigation was completed on 3 December 2018 and subsequently released.