Landing Overruns

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Landing Overruns

  1. 1. Landing Overruns- Human Factors Captain David Oliver General Manager Flight Technical Qantas Airways Limited W037c.1
  2. 2. Landing Overruns - Human Factors A review of the events leading to, and lessons learnt from the over-run of flight QF1 at Bangkok Thailand, September 23, 1999. W037c.2 Qantas Airways Limited
  3. 3. Landing Configuration • Operating Boeing 747-400 since 1989 • Standard landing configuration up until 1996 was “Flap 30, Full Reverse Thrust” W037c.3 Qantas Airways Limited
  4. 4. Landing Configuration (continued) • Review of landing configuration was undertaken due to: – Noise levy at Sydney Flap 25 chosen for lower noise, better fuel economy – Carbon Brake Wear Idle reverse thrust chosen for less noise and longer, harder brake application W037c.4 Qantas Airways Limited
  5. 5. Landing Configuration (continued) • Landing configuration Policy from late 1996 was: – Flap 25, idle reverse thrust provided the runway length was not limiting W037c.5 Qantas Airways Limited
  6. 6. The Landing • F/O was pilot flying • The runway was wet – The last landing airplane had reported “good” braking action – The airplane preceding QF1 executed a Missed Approach due to poor visibility in heavy rain – This was not relayed to the crew of QF1 W037c.6 Qantas Airways Limited
  7. 7. The Landing (continued) • Airplane crossed the threshold high and fast (but within Company limits) and “floated” 10ft above the runway in heavy rain • Within a period of just a few seconds: – The Captain called for “Go- Around” – The main gear touched down – The rain eased and visibility improved – Captain reached over and took control of the thrust levers W037c.7 Qantas Airways Limited
  8. 8. The Landing (continued) • The Captain initially only retarded # 2, 3 and 4 Thrust Levers • The F/O immediately realized this and retarded #1 to idle, however: – With main gear on the ground and # 1 or 4 T/L advanced, the autobrakes disarmed – Speedbrakes deployed automatically after #1 T/L was retarded by the F/O W037c.8 Qantas Airways Limited
  9. 9. The Landing (continued) • The EICAS message “AUTOBRAKES” was not initially noticed by the Flight Crew • Manual braking was not applied until 8 seconds after touchdown, approx 5000 feet down the runway • No reverse thrust was applied for the whole of the landing roll W037c.9 Qantas Airways Limited
  10. 10. The Landing (continued) • When manual braking was applied NO deceleration was felt • Both pilots exerted maximum force on the brake pedals, still with no deceleration – The airplane was aquaplaning • The airplane only began to decelerate as it entered the last 1000 feet of the runway and the groundspeed reduced below 110kts W037c.10 Qantas Airways Limited
  11. 11. Acft drifting left Nose gear squat Nose gear SPLR deployed of rw y C/L sw itch air mode departs sw y CAS 160 kts CAS 158kts Acft returning CAS 143kts CAS 88kts GS 158 kts Touchdow n GS 156kts to rw y C/L GS 141kts GS 87kts Air-gnd logic CAS 107kts Manual Nose gear Nose gear squat Acft on rw y C/L to gnd mode SPLR start deploy GS 106kts braking touchdow n sw itch gnd mode at threshold CAS 156 kts CAS 160 kts indications CAS 146kts CAS 139kts CAS 96kts GS 158 kts GS 158 kts V S CAS 154kts GS 145kts GS 138kts GS 92kts W GS 1 2k DECELERATION ft /sec2 -7.00 Acft accelerating Aerodynamic Aerodynamic due to braking and -6.00 residual thrust only w heel braking -5.00 -4.00 -3.00 -2.00 -1.00 3287ft 4000f 5000ft 6000ft 7000ft 8000ft 9000ft 10000ft 1002m t 1524m 1829m 2134m 2438m 2743m 3048m Decelerat ion at main gear posit ion Distance from Rwy 21L displaced threshold W037c.11 Qantas Airways Limited
  12. 12. Comparison of rollout deceleration on various runway surfaces and VH-OJH 23 September 1999 -14 Dry runw ay * Mu 0.35 - 0.41 -12 -10 Wet runw ay * Mu 0.20 -8 * Good braking action Deceleration (ft/sec2) -6 Flooded runw ay * Mu 0.05 * Poor braking action -4 Manual braking Aircraft on Aircraft indications 5002ft to rw y centreline at nosegear Aircraft passing Aircraft Aircraft passing over 2015ft to -2 end start of sw y departs end over rw y mkgs and returning to rw y rw y mkgs and abeam rw y end of sw y approaching tw y S centreline 770ft Aircraft drifting left of tw y W 2536ft to rw y 1100ft to rw y end to rw y end centreline 5522ft to rw y end 0 Autobrakes end disarmed 2 Spoilers deploy 4 160 150 140 130 120 110 100 90 80 Acf tconfig for various runw ay surfaces: Ambient conditions: Groundspeed (knots) * 252,000 kg Vref25 + 5 kts OAT 25 deg C * Maximum manual braking QNH 1013.2 23 Sep BKK Dry Rwy Contam Rwy (Good brkg) Contam Rwy (Poor brkg) * Spoilers deployed, Idle forw ard thrust WIND 3.6 kt HWC W037c.12 Qantas Airways Limited
  13. 13. Human Factors • Why did this happen ? • Accident analysis showed: – A number of significant active failures and – Significant inadequate defences W037c.13 Qantas Airways Limited
  14. 14. Active Failures • The runway was affected by water • Flight Crew failed to use an appropriate risk management strategy for the approach and landing • The F/O did not fly the aircraft accurately during final approach • The Flight Crew were confused over who had control and did not select appropriate level of reverse thrust W037c.14 Qantas Airways Limited
  15. 15. Inadequate Defences • Company published information, procedures and training for landing on water affected runways was inadequate • Flight Crew training in evaluating the procedural and configuration options for approach and landing was deficient – The crew may have been “pre-conditioned” to the use of Flap 25 and idle reverse thrust W037c.15 Qantas Airways Limited
  16. 16. Change Management • Published the Boeing document “Landing on Slippery Runways” (doc D6-44247) in the Qantas Flying Manual • Provided a flow chart to assist Flight Crew in determining appropriate flap and reverse thrust settings W037c.16 Qantas Airways Limited
  17. 17. Aircraft Weight Environmental Conditions Evaluate Runway Conditions as Reported Runway Contaminated Runway Dry Runway Wet or Slippery Reported Determine F25 Landing Braking Action Field Length Is F25 Landing Field GOOD MEDIUM POOR Length less than No Available Distance? Yes Determine F30 Landing Field Length Do not land unless a greater Use Flap 25 and Full emergency exists. Hold until Reverse Thrust conditions improve or divert Determine F30 Landing Field Length Is F30 Landing Field Is F30 Landing Field Length less Length less than than Available Distance? Available Distance? No Yes Yes No Use Flap 30 and Full Use Flap 30 and Full Use another Runway Reverse Thrust Reverse Thrust W037c.17 Qantas Airways Limited
  18. 18. Change Management (continued) • Flight Crew use max reverse thrust as the “standard” with idle reverse permitted only under stipulated conditions • Flap 25 is the normal landing flap on dry runways • Flap 30 used on wet runways (no credit taken for grooving or PFC overlay) W037c.18 Qantas Airways Limited
  19. 19. Change Management (continued) • Produced CBT package summarising performance on slippery and contaminated runways • Provided detailed stopping distance information for various surface conditions • Highlighted to crew the importance of using correct techniques for landing on wet, slippery and contaminated runways • Included call of “AUTOBRAKES” each time this is annunciated on EICAS W037c.19 Qantas Airways Limited
  20. 20. Change Management (continued) • Monitoring of landing configurations and touchdown points has shown: – Significant trend towards flap 30 irrespective of runway conditions – Max. reverse thrust used on most occasions – Touchdown points are closer to the “desired” point. i.e. less “float” W037c.20 Qantas Airways Limited
  21. 21. Trend in Landing Flap Setting 100% 100% 80% 80% Flap 30 60% 60% Percentage Percentage of landings of landings 40% 40% 20% 20% Flap 25 0% 0% Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Apr-00 Jun-00 Aug-00 Oct-00 Dec-00 Feb-01 Apr-01 Jun-01 Aug-01 Oct-01 Dec-01 Feb-03 Apr-02 Jun-02 Apr-00 Jun-00 Aug-00 Oct-00 Dec-00 Feb-01 Apr-01 Jun-01 Aug-01 Oct-01 Dec-01 Feb-03 Apr-02 Jun-02 W037c.21 Qantas Airways Limited
  22. 22. Trend in Reverse Thrust Use 100% 100% 90% 90% 80% 80% 70% 70% >82%N1 60% 60% Percentage Percentage50% of landings 50% of landings 40% 40% 30% 30% 20% 20% 40 to 81%N1 10% 10% Idle 0% 0% Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Apr-00 Jun-00 Aug-00 Oct-00 Dec-00 Feb-01 Apr-01 Jun-01 Aug-01 Oct-01 Dec-01 Feb-03 Apr-02 Jun-02 Apr-00 Jun-00 Aug-00 Oct-00 Dec-00 Feb-01 Apr-01 Jun-01 Aug-01 Oct-01 Dec-01 Feb-03 Apr-02 Jun-02 W037c.22 Qantas Airways Limited
  23. 23. Trend in Distance From 50’ to TD 3000ft + 3000ft + 100% 100% 2500 - 2999ft 90% 90% 2000 - 2499ft 80% 80% 1500 - 1999ft 70% 70% 60% 60% Percentage Percentage 50% of landings 50% of landings 40% 40% 1000 - 1499ft 30% 30% 20% 20% 10% 10% Under 1000ft 0% 0% Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Apr-00 Jun-00 Aug-00 Oct-00 Dec-00 Feb-01 Apr-01 Jun-01 Aug-01 Oct-01 Dec-01 Feb-03 Apr-02 Jun-02 Apr-00 Jun-00 Aug-00 Oct-00 Dec-00 Feb-01 Apr-01 Jun-01 Aug-01 Oct-01 Dec-01 Feb-03 Apr-02 Jun-02 W037c.23 Qantas Airways Limited
  24. 24. Cabin Communications • Nose gear collapse resulted in loss of all Flight Deck / Cabin communications • Confusion existed as to need for evacuation • Co-location of back-up comms equipment in an area prone to damage is considered undesirable • Provided Flight and Cabin Crew with procedures to use in the event of loss of Cabin Interphone or PA W037c.24 Qantas Airways Limited
  25. 25. Summary • Provide Flight Crew with the appropriate tools to do the job • Train Flight Crew to analyse each landing separately to determine the appropriate landing configuration • Ensure procedures for landing on wet, slippery and contaminated runways are in place and thoroughly understood • ATSB report available at www.atsb.gov.au W037c.25 Qantas Airways Limited

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