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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

  • B738, Manchester UK, 2003 (On 16 July 2003, a Boeing 737-800, being operated by Excel Airlines on a passenger flight from Manchester to Kos began take off on Runway 06L without the flight crew being aware of work in progress at far end of the runway. The take off calculations, based on the full runway length resulted in the aircraft passing within 56 ft of a 14 ft high vehicle just after take off.)
  • 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.)
  • A343, London Heathrow, UK 2012 (On 5 February 2012, an Airbus A340-300 started its takeoff from an intermediate point on the runway for which no regulated takeoff weight information was available and had only become airborne very close to the end of the runway and then climbed only very slowly. The Investigation found that as the full length of the planned departure runway was not temporarily unavailable, ATC had offered either the intersection subsequently used or the full length of the available parallel runway and that despite the absence of valid performance data for the intersection, the intersection had been used.)
  • B738, Oslo Gardermoen Norway, 2005 (On a 23 October, 2005 a Boeing 737-800 operated by Pegasus Airlines, during night time, commenced a take-off roll on a parallel taxiway at Oslo Airport Gardermoen. The aircraft was observed by ATC and stop instruction was issued resulting in moderate speed rejected take-off (RTO).)

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.)
  • A320, Paris Orly France, 2013 (On 12 March 2013, a Tunis Air Airbus A320 landed on runway 08 at Paris Orly and, having slowed to just over 40 knots, were expecting, despite the covering of dry snow and some slush pre-notified and found on the runway, to vacate it without difficulty at the mid point. ATC then requested that the aircraft roll to the end of the runway before clearing. However, after a slight increase in speed, the crew were unable to subsequently slow the aircraft as the runway end approached and it overran at a low groundspeed before coming to a stop 4 seconds later.)
  • 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.)
  • SF34, Izumo Japan, 2007 (On 10 December, 2007 a SAAB 340B being operated by Japan Air Commuter on a scheduled passenger flight left the runway at Izumo Airport during the daylight landing roll in normal visibility and continued further while veering to the right before coming to a stop on the airport apron.)
  • 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.)

Veer Off

Directional Control.jpg On landing...

  • DH8C, Kimberley South Africa, 2010 (On 16 July 2010, a South African Express Airways Bombardier DHC 8-300 hit an animal during a night landing at Kimberley after a passenger flight from Johannesburg. The nose landing gear took a direct hit and collapsed but after a temporary loss of directional control, the runway centreline was regained and the aircraft brought to a stop. The Investigation found wildlife access to the aerodrome was commonplace and the attempts at control inadequate.)
  • B190, Blue River BC Canada, 2012 (On 17 March 2012, the Captain of a Beech 1900C operating a revenue passenger flight lost control of the aircraft during landing on the 18metre wide runway at destination after an unstabilised day visual approach and the aircraft veered off it into deep snow. The Investigation found that the Operator had not specified any stable approach criteria and was not required to do so. It was also noted that VFR minima had been violated and, noting a fatal accident at the same aerodrome five months previously, concluded that the Operators risk assessment and risk management processes were systemically deficient.)
  • MD81, Kiruna Sweden, 1997 (A scheduled passenger flight from Stockholm Arlanda to Kiruna left the runway during the night landing at destination performed in a strong crosswind with normal visibility.)
  • 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.)
  • SF34, Izumo Japan, 2007 (On 10 December, 2007 a SAAB 340B being operated by Japan Air Commuter on a scheduled passenger flight left the runway at Izumo Airport during the daylight landing roll in normal visibility and continued further while veering to the right before coming to a stop on the airport apron.)

Directional Control.jpg On take off..

  • B744, Maastricht-Aachen Netherlands, 2017 (On 11 November 2017, a type-experienced Boeing 747-400ERF crew making a night rolling takeoff at Maastricht-Aachen lost aircraft directional control after an outer engine suddenly failed at low speed and a veer-off onto soft ground adjacent to the runway followed. The Investigation found that rather than immediately reject the takeoff when the engine failed, the crew had attempted to maintain directional control without thrust reduction to the point where an excursion became unavoidable. The effect of ‘startle’, the Captain’s use of a noise cancelling headset and poor alerting to the engine failure by the First Officer were considered contributory.)
  • SF34, Stornoway UK, 2015 (On 2 January 2015, the commander of a Saab 340 suddenly lost directional control during a within-limits crosswind take off and the aircraft left the runway onto grass at approximately 80 knots. No call to reject the take off was made and no action was taken to shut down the engines until the aircraft had come to a stop in the soft ground with a collapsed nose gear and substantial damage to the propellers and lower forward fuselage. The Investigation concluded that the most likely explanation for the excursion was the absence of any rudder input as the aircraft accelerated.)
  • 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.)
  • JS31, Kärdla Estonia, 2013 (On 28 October 2013 a BAe Jetstream 31 crew failed to release one of the propellers from its starting latch prior to setting take off power and the aircraft immediately veered sharply off the side of the runway without directional control until the power levers were returned to idle. The aircraft was then steered on the grass towards the nearby apron and stopped. The Investigation found that the pilots had habitually used "multiple unofficial procedures" to determine propeller status prior to take off and also noted that no attempt had been made to stop the aircraft using the brakes.)
  • B738, Lyon France, 2009 (On 29 August 2009, an Air Algérie Boeing B737-800 departed the side of the runway during take off but then regained the paved surface after sustaining damage from obstructions, completed the take off without further event and continued to destination. Damage to one of the engines, to tyres and to two lights was discovered at the destination. ATC remained unaware of the excursion until the Operator asked its representative at Lyon to ask the airport to carry out a runway inspection.)

Events by A&I Tag

Excessive Airspeed

  • A320, Surat India, 2017 (On 4 October 2017, an Airbus A320 slightly overran the end of runway 22 at Surat during an early morning daylight landing. A temporarily displaced landing threshold meant the runway length was only 1,905 metres rather than the 2,905 metre full length. The aircraft remained on a paved surface and was undamaged. Its crew did not report the excursion which was only discovered when broken runway lighting was subsequently discovered. The Investigation found that the non-precision approach made was unstable and that a prolonged float in the subsequent flare meant that only 600 metres of runway remained ahead at touchdown.)
  • SW4, Sanikiluaq Nunavut Canada, 2012 (On 22 December 2012, the crew of a Swearingen SA227 attempting a landing, following an unstabilised non-precision approach at Sanikiluaq at night with questionable alternate availability in marginal weather conditions, ignored GPWS PULL UP Warnings, then failed in their attempt to transition into a low go around and the aircraft crashed into terrain beyond the runway. One occupant – an unrestrained infant – was killed and the aircraft was destroyed. The Investigation faulted crew performance, the operator and the regulator and reiterated that lap-held infants were vulnerable in crash impacts.)
  • 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.)
  • DH8D, Yangon Myanmar, 2019 (On 8 May 2019, a Bombardier DHC8-400 making its second approach to Yangon during a thunderstorm touched down over halfway along the runway after an unstabilised approach but then briefly became airborne again before descending very rapidly and sustaining extreme structural damage on impact before sliding off the end of the runway. The Investigation found that prior to the final rapid descent and impact, the Captain had placed the power levers into the beta range, an explicitly prohibited action unless an aircraft is on the ground. No cause for the accident other than the actions of the crew was identified.)
  • 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.)

RTO decision after V1

  • 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.)
  • 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.)
  • LJ60, Columbia SC USA, 2008 (On September 19 2008, a Learjet 60 departing Columbia SC USA on a non scheduled passenger overran after attempting a rejected take off from above V1 and then hit obstructions which led to its destruction by fire and the death or serious injury of all six occupants. The subsequent investigation found that the tyre failure which led to the rejected take off decision had been due to under inflation and had damaged a sensor which caused the thrust reversers to return to their stowed position after deployment with the unintended forward thrust contributing to the severity of the overrun.)
  • 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.)
  • 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.)

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

Unable to rotate at VR

  • A332, Montego Bay Jamaica, 2008 (On 28 October 2008, an Airbus A330-200 could not be rotated for liftoff whist making a night takeoff from Montego Bay until the Captain had increased the reduced thrust set to TOGA, after which the aircraft became airborne prior to the end of the runway and climbed away normally. The Investigation found that the takeoff performance data used had been calculated for the flight by Company Despatch and the fact that it had been based on a takeoff weight which was 90 tonnes below the actual take off weight had not been noticed by any of the flight crew.)
  • 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.)
  • 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.)
  • AT43, Madang Papua New Guinea, 2013 (On 19 October 2013, an ATR42 freighter departing Madang had to reject its takeoff when it was impossible to rotate and it ended up semi-submerged in a shallow creek beyond the airfield perimeter. The Investigation found that loading had been contrary to instructions and the aircraft had a centre of gravity outside the permitted range and was overweight. This was attributed to the aircraft operator’s lack of adequate procedures for acceptance and loading of cargo. A lack of appreciation by all parties of the need to effectively mitigate runway overrun risk in the absence of a RESA was also highlighted.)
  • JS32, Münster/Osnabrück Germany, 2019 (On 8 October 2019, a BAe Jetstream 32 departing Münster/Osnabrück couldn’t be rotated and after beginning rejected takeoff from well above V1, the aircraft departed the side of the runway passing close to another aircraft at high speed before regaining the runway for the remainder of its deceleration. The Investigation noted that the flight was the first supervised line training sector for the very inexperienced First Officer but attributed the whole event to the Training Captain’s poor performance which had, apart many from other matters, led indirectly to the inability to rotate and to the subsequent directional control problem.)

Collision Avoidance Action

  • 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.)
  • 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, 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

  • 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.)
  • B738, vicinity Skavsta Sweden, 2004 (On 2 July 2004, a Boeing 737-800 being operated by Irish operator Ryanair on a scheduled passenger flight from London Stansted to Skavsta Sweden, completed an extremely high speed and unstable approach in day VMC to destination during which relevant Operator SOPs were comprehensively ignored, EGPWS warnings were not actioned and AFM limits for trailing edge flap deployment were breached. Despite this, a landing at excessive speed was accommodated by just within the full length of the 2878 metre long dry runway.)
  • B737, Fort Nelson BC Canada, 2012 (On 9 January 2012, an Enerjet Boeing 737-700 overran the landing runway 03 at Fort Nelson by approximately 70 metres after the newly promoted Captain continued an unstabilised approach to a mis-managed late-touchdown landing. The subsequent Investigation attributed the accident to poor crew performance in the presence of a fatigued aircraft commander.)
  • 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.)
  • 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.)

Significant Tailwind Component

  • B737, New York La Guardia USA, 2016 (On 27 October 2016, a Boeing 737-700 crew made a late touchdown on the runway at La Guardia and did not then stop before reaching the end of the runway and entered - and exited the side of - the EMAS before stopping. The Investigation concluded that the overrun was the consequence of a failure to go around when this was clearly necessary after a mishandled touchdown and that the Captain's lack of command authority and a lack of appropriate crew training provided by the Operator to support flight crew decision making had contributed to the failure to go around.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)

Significant Crosswind Component

  • AT45, Sienajoki Finland, 2006 (On 11 December 2006, a Finnish Commuter Airlines ATR 42-500 veered off the runway on landing at Seinäjoki, Finland.)
  • GLF4, Teterboro NJ USA, 2010 (On 1 October 2010, a Gulfstream G-IV being operated by General Aviation Flying Service as ‘Meridian Air Charter’ on a corporate flight from Toronto International to Teterboro made a deep landing on 1833m-long runway 06 at destination in normal day visibility and overran the end of the runway at a speed of 40 to 50 knots before coming to a stop 30m into a 122m long EMAS installation.)
  • MD81, Kiruna Sweden, 1997 (A scheduled passenger flight from Stockholm Arlanda to Kiruna left the runway during the night landing at destination performed in a strong crosswind with normal visibility.)
  • B735, Denver USA, 2008 (Runway Side Excursion During Attempted Take-off in Strong and Gusty Crosswind Conditions.)
  • 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

  • MD83, Port Harcourt Nigeria, 2018 (On 20 February 2018, a Boeing MD-83 attempting a night landing at Port Harcourt during a thunderstorm and heavy rain touched down well beyond the touchdown zone and departed the side of the runway near its end before continuing 300 metres beyond it. The Investigation found that a soft touchdown had occurred with 80% of the runway behind the aircraft and a communications failure on short final meant a wind velocity change just before landing leading to a tailwind component of almost 20 knots was unknown to the crew who had not recognised the need for a go around.)
  • B739, Pekanbaru Indonesia, 2011 (On 14 February 2011, a Lion Air Boeing 737-900 making a night landing at Pekanbaru overran the end of the 2240 metre long runway onto the stopway after initially normal deceleration largely attributable to the thrust reversers was followed by a poor response to applied maximum braking in the final 300 metres. Whilst performance calculations showed that a stop on the runway should have been possible, it was concluded that a combination of water patches with heavy rubber contamination had reduced the friction properties of the surface towards the end of the runway and hence the effectiveness of brake application.)
  • 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.)
  • B738, Mumbai India, 2018 (On 10 July 2018, a Boeing 737-800 marginally overran the wet landing runway at Mumbai after the no 1 engine thrust reverser failed to deploy when full reverse was selected after a late touchdown following a stabilised ILS approach. The Investigation found that the overrun was the result of touchdown with almost 40% of the runway behind the aircraft followed by the failure of normal thrust reverser deployment when attempted due to a failed actuator in one of the reversers. The prevailing moderate rain and the likelihood that dynamic aquaplaning had occurred were identified as contributory.)
  • 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.)

Off side of Runway

  • C25A, Bern Switzerland, 2018 (On 2 March 2018, a Cessna 525A touched down at Bern aligned with the left hand edge of the runway and then left it completely before re-entering it after a little over 300 metres and completing the landing roll without further event. Damage to the aircraft and six runway edge and taxi lights was subsequently found. The Investigation noted that the crew stated that they had retained full visual contact with the runway during final approach and that the recorded braking action was good. It was not possible to establish why neither pilot had been aware of the misalignment.)
  • 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.)
  • 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.)
  • B744, Maastricht-Aachen Netherlands, 2017 (On 11 November 2017, a type-experienced Boeing 747-400ERF crew making a night rolling takeoff at Maastricht-Aachen lost aircraft directional control after an outer engine suddenly failed at low speed and a veer-off onto soft ground adjacent to the runway followed. The Investigation found that rather than immediately reject the takeoff when the engine failed, the crew had attempted to maintain directional control without thrust reduction to the point where an excursion became unavoidable. The effect of ‘startle’, the Captain’s use of a noise cancelling headset and poor alerting to the engine failure by the First Officer were considered contributory.)
  • B737, Chicago Midway IL, USA 2011 (On 26 April 2011 a Southwest Boeing 737-700 was assessed as likely not to stop before the end of landing runway 13C at alternate Chicago Midway in daylight and was intentionally steered to the grass to the left of the runway near the end, despite the presence of a EMAS. The subsequent investigation determined that the poor deceleration was a direct consequence of a delay in the deployment of both speed brakes and thrust reverser. It was noted that the crew had failed to execute the ‘Before Landing’ Checklist which includes verification of speed brake arming.)

Taxiway Take Off/Landing

  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)

Runway Length Temporarily Reduced

  • A320, Surat India, 2017 (On 4 October 2017, an Airbus A320 slightly overran the end of runway 22 at Surat during an early morning daylight landing. A temporarily displaced landing threshold meant the runway length was only 1,905 metres rather than the 2,905 metre full length. The aircraft remained on a paved surface and was undamaged. Its crew did not report the excursion which was only discovered when broken runway lighting was subsequently discovered. The Investigation found that the non-precision approach made was unstable and that a prolonged float in the subsequent flare meant that only 600 metres of runway remained ahead at touchdown.)
  • 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.)
  • IL76, Yerevan Armenia, 2019 (On 16 May 2019, an Ilyushin Il-76 overran the end of the landing runway at Yerevan after completing an ILS approach because the crew hadn’t realised until it was too late to stop that the available landing distance was reduced at the far end of the runway. The Investigation noted that it would have been possible to stop the aircraft in the distance available and attributed the lack of flight crew awareness to a combination of their own lack of professionalism and that exhibited by the Dispatcher and to the inadequacy and lack of clarity in the NOTAM communications advising the change.)
  • 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.)
  • B738, Manchester UK, 2003 (On 16 July 2003, a Boeing 737-800, being operated by Excel Airlines on a passenger flight from Manchester to Kos began take off on Runway 06L without the flight crew being aware of work in progress at far end of the runway. The take off calculations, based on the full runway length resulted in the aircraft passing within 56 ft of a 14 ft high vehicle just after take off.)

Intentional Premature Rotation

  • B773, London Heathrow UK, 2016 (On 30 August 2016, a Boeing 777-300 crew began takeoff from London Heathrow at an intersection one third of the way along the runway using the reduced thrust calculated for a full-length take off instead of the rated thrust calculated for the intersection takeoff. As a result, the aircraft was only just airborne as it crossed the airport boundary and an adjacent public road. The Investigation attributed the data input error to crew failure to respond appropriately on finding that they had provisionally computed performance data based on different assumptions and concluded that the relevant Operator procedures were insufficiently robust.)
  • 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

  • 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.)
  • E190, Kupang Indonesia, 2015 (On 21 December 2015, an Embraer 195 crew continued a significantly unstable approach which included prolonged repetition of 'High Speed' and a series of EGPWS Alerts which were both ignored and which culminated in a high speed late touchdown which ended in a 200 metre overrun. The Investigation attributed the event to poor flight management and noted the systemic lack of any effective oversight of pilot operating standards compounded in the investigated event by the effects of a steep flight deck authority gradient and the failure to detect anomalies in the normal operating behaviour of both the pilots involved.)
  • 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.)
  • B772, Dhaka Bangladesh, 2018 (On 24 July 2018, a Boeing 777-200 making its second attempt to land at Dhaka in moderate to heavy rain partly left the runway during its landing roll and its right main landing gear sustained serious impact damage before the whole aircraft returned to the runway with its damaged gear assembly then causing runway damage. The Investigation attributed the excursion to the flight crew’s inadequate coordination during manual handling of the aircraft and noted both the immediate further approach in unchanged weather conditions and the decision to continue to a landing despite poor visibility instead of going around again.)
  • BCS3, Porto Portugal, 2018 (On 15 July 2018, an Airbus 220-300 crew were slow to recognise that the maximum de-rate thrust required for their takeoff from Porto had not been reached but after increasing it were able to get safely airborne prior to the end of the runway. The Investigation found that applicable SOPs had not been followed and that the function of both the spoiler and autothrottle systems was inadequately documented and understood and in the case of the former an arguably flawed design had been certified. Five similar events had been recorded by the aircraft operator involved in less than six months.)

Reduced Thrust Take Off

  • 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.)
  • A332, Montego Bay Jamaica, 2008 (On 28 October 2008, an Airbus A330-200 could not be rotated for liftoff whist making a night takeoff from Montego Bay until the Captain had increased the reduced thrust set to TOGA, after which the aircraft became airborne prior to the end of the runway and climbed away normally. The Investigation found that the takeoff performance data used had been calculated for the flight by Company Despatch and the fact that it had been based on a takeoff weight which was 90 tonnes below the actual take off weight had not been noticed by any of the flight crew.)
  • A319, Nice France, 2019 (On 29 August 2019, an Airbus A319 crew used more runway than expected during a reduced thrust takeoff from Nice, although not enough to justify increasing thrust. It was subsequently found that an identical error made by both pilots when independently calculating takeoff performance data for the most limiting runway intersection had resulted in use of data for a less limiting intersection than the one eventually used. The Investigation concluded that the only guaranteed way to avoid such an error would be an automatic cross check, a system upgrade which was not possible on the particular aircraft involved.)
  • B748, Tokyo Narita Japan, 2017 (On 15 July 2017, a Boeing 747-8F close to its maximum takeoff weight only became airborne just before the end of the 2,500 metre-long north runway at Narita after the reduced thrust applicable to the much longer south runway was used for the takeoff. The aircraft cleared the upwind runway threshold by only 16 feet. The Investigation found that the Captain and the First Officer had both failed to follow elements of the applicable takeoff performance change procedures after the departure runway anticipated during pre-start flight preparations prior to ATC clearance delivery had changed.)
  • B773, Auckland Airport New Zealand, 2007 (On 22 March 2007, an Emirates Boeing 777-300ER, started its take-off on runway 05 Right at Auckland International Airport bound for Sydney. The pilots misunderstood that the runway length had been reduced during a period of runway works and started their take-off with less engine thrust and flap than were required. During the take-off they saw work vehicles in the distance on the runway and, realising something was amiss, immediately applied full engine thrust and got airborne within the available runway length and cleared the work vehicles by about 28 metres.)

Fixed Obstructions in Runway Strip

  • 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.)
  • 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.)
  • 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.)
  • 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.)

Ineffective Use of Retardation Methods

  • AT72, Copenhagen Denmark, 2013 (On 14 January 2013, selection of the power levers to ground idle after an ATR 72-200 touchdown at Copenhagen produced only one of the two expected low pitch indications. As the First Officer called 'one low pitch' in accordance with SOP, the Captain selected both engines into reverse. He was unable to prevent the resultant veer off the runway. After travelling approximately 350 metres on grass alongside the runway as groundspeed reduced, the runway was regained. A propeller control fault which would have prevented low pitch transition on the right engine was recorded but could not subsequently be replicated.)
  • B738, Goa India, 2016 (On 27 December 2016, the crew of a Boeing 737-800 taking off from Goa at night lost control shortly after setting takeoff thrust following which the aircraft almost immediately began to drift right and off the runway. It then continued at speed over rough ground for almost 300 metres before eventually stopping after which a MAYDAY call was followed by an emergency evacuation. The Investigation found that the Captain had increased thrust to takeoff without first ensuring that both engines were stabilised and then attempted to correct the drift by left rudder and brake rather than rejecting the takeoff.)
  • 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.)
  • B738, Sochi Russia, 2018 (On 1 September 2018, a Boeing 737-800, making its second night approach to Sochi beneath a large convective storm with low level windshear reported, floated almost halfway along the wet runway before overrunning it by approximately 400 metres and breaching the perimeter fence before stopping. A small fire did not prevent all occupants from safely evacuating. The Investigation attributed the accident to crew disregard of a number of windshear warnings and a subsequent encounter with horizontal windshear resulting in a late touchdown and noted that the first approach had meant that the crew had been poorly prepared for the second.)
  • 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.)

Continued Take Off

  • 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.)
  • FA50 / Vehicle, Moscow Vnukovo Russia, 2014 (On 20 October 2014 a Dassault Falcon 50 taking off at night from Moscow Vnukovo collided with a snow plough which had entered the same runway without clearance shortly after rotation. Control was lost and all occupants died when it was destroyed by impact forces and post crash fire. The uninjured snow plough driver was subsequently discovered to be under the influence of alcohol. The Investigation found that the A-SMGCS effective for over a year prior to the collision had not been properly configured nor had controllers been adequately trained on its use, especially its conflict alerting functions.)
  • 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.)
  • 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, Lyon France, 2009 (On 29 August 2009, an Air Algérie Boeing B737-800 departed the side of the runway during take off but then regained the paved surface after sustaining damage from obstructions, completed the take off without further event and continued to destination. Damage to one of the engines, to tyres and to two lights was discovered at the destination. ATC remained unaware of the excursion until the Operator asked its representative at Lyon to ask the airport to carry out a runway inspection.)

Continued Landing Roll

  • 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.)
  • F28, Gällivare Sweden, 2016 (On 6 April 2016, a Romanian-operated Fokker F28 overran the runway at Gällivare after a bounced night landing. There were no occupant injuries and only slight aircraft damage. The Investigation concluded that after a stabilised approach, the handling of the aircraft just prior and after touchdown, which included late and inappropriate deployment of the thrust reversers, was not compatible with a safe landing in the prevailing conditions, that the crew briefing for the landing had been inadequate and that the reported runway friction coefficients were "probably unreliable". Safety Recommendations were made for a generic 'Safe Landing' concept to be developed.)
  • 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.)
  • 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.)
  • AT72, Copenhagen Denmark, 2013 (On 14 January 2013, selection of the power levers to ground idle after an ATR 72-200 touchdown at Copenhagen produced only one of the two expected low pitch indications. As the First Officer called 'one low pitch' in accordance with SOP, the Captain selected both engines into reverse. He was unable to prevent the resultant veer off the runway. After travelling approximately 350 metres on grass alongside the runway as groundspeed reduced, the runway was regained. A propeller control fault which would have prevented low pitch transition on the right engine was recorded but could not subsequently be replicated.)

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.)
  • B763, Halifax NS Canada, 2019 (On 4 March 2019, a Boeing 767-300 crew lost directional control of their aircraft as speed reduced following their touchdown at Halifax and were unable to prevent it being rotated 180° on the icy surface before coming to a stop facing the runway landing threshold. The Investigation found that the management of the runway safety risk by the airport authority had been systemically inadequate and that the communication of what was known by ATC about the runway surface condition had been incomplete. A number of subsequent corrective actions taken by the airport authority were noted.)

Excessive Water Depth

  • B738, Mumbai India, 2018 (On 10 July 2018, a Boeing 737-800 marginally overran the wet landing runway at Mumbai after the no 1 engine thrust reverser failed to deploy when full reverse was selected after a late touchdown following a stabilised ILS approach. The Investigation found that the overrun was the result of touchdown with almost 40% of the runway behind the aircraft followed by the failure of normal thrust reverser deployment when attempted due to a failed actuator in one of the reversers. The prevailing moderate rain and the likelihood that dynamic aquaplaning had occurred were identified as contributory.)
  • A320, Sylt Germany, 2017 (On 30 September 2017, an Airbus A320 touched down late after an ILS approach to runway 32 at Sylt with a significant tailwind component being reported and failed to stop before overrunning the end of the runway and subsequently stopped on grass 80 metres beyond it. The Investigation noted that the calculated required landing distance was close to the landing distance available, the actual approach speed was 20 knots above the calculated one and that the aircraft had floated in the flare above a wet runway. It was concluded that the runway excursion was attributable to non-performance of a go-around.)

Intentional Veer Off Runway

  • 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.)
  • 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.)

Misaligned take off

  • DH8A, Rouyn-Noranda QC Canada, 2019 (On 23 January 2019, a Bombardier DHC8-100 failed to complete its intended night takeoff from Rouyn-Noranda after it had not been commenced on or correctly aligned parallel to the (obscured) centreline and the steadily increasing deviation had not been recognised until a runway excursion was imminent. The Investigation attributed this to the failure of the crew to pay sufficient attention to the external perspective provided by the clearly-visible runway edge lighting whilst also noting the Captain’s likely underestimation of the consequences of a significant flight deck authority gradient and a failure to fully follow relevant applicable operating procedures.)
  • 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.)
  • AT72, Cologne-Bonn Germany, 2020 (On 27 April 2020, an ATR 72-200 freighter crew attempted a night takeoff in good visibility aligned with the edge of runway 06 and did not begin rejecting it until within 20 knots of the applicable V1 despite hearing persistent regular noises which they did not recognise as edge light impacts and so completed the rejection on the same alignment. The Investigation noted both pilots’ familiarity with the airport and their regular work together and attributed their error to their low attention level and a minor distraction during the turnround after backtracking.)
  • 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.)

Runway Condition not as reported

  • B738, Sochi Russia, 2018 (On 1 September 2018, a Boeing 737-800, making its second night approach to Sochi beneath a large convective storm with low level windshear reported, floated almost halfway along the wet runway before overrunning it by approximately 400 metres and breaching the perimeter fence before stopping. A small fire did not prevent all occupants from safely evacuating. The Investigation attributed the accident to crew disregard of a number of windshear warnings and a subsequent encounter with horizontal windshear resulting in a late touchdown and noted that the first approach had meant that the crew had been poorly prepared for the second.)
  • 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.)
  • B763, Halifax NS Canada, 2019 (On 4 March 2019, a Boeing 767-300 crew lost directional control of their aircraft as speed reduced following their touchdown at Halifax and were unable to prevent it being rotated 180° on the icy surface before coming to a stop facing the runway landing threshold. The Investigation found that the management of the runway safety risk by the airport authority had been systemically inadequate and that the communication of what was known by ATC about the runway surface condition had been incomplete. A number of subsequent corrective actions taken by the airport authority were noted.)

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