Dartmouth, Nova Scotia, 29 June 2021 – In its investigation report (A18A0085) released today, the Transportation Safety Board of Canada (TSB) identified multiple contributing factors that led to a 2018 runway overrun.
On 7 November 2018, a Sky Lease Cargo Boeing 747-412F aircraft was conducting a flight from Chicago/O’Hare International Airport (KORD), Illinois, U.S., to Halifax/Stanfield International Airport (CYHZ), Nova Scotia, with three crew members and one passenger on board. The aircraft touched down firmly on Runway 14 at approximately 5:06 Atlantic Standard Time, during the hours of darkness, and subsequently overran the runway. It came to rest 270 m (885 feet) past the end of the runway. Aircraft rescue and firefighting personnel responded. All three crew members received minor injuries and were taken to the hospital. The passenger, a deadheading pilot, was not injured.
The investigation determined that, as part of the pre-departure planning at KORD, the crew and flight dispatch reviewed the Notices to Airmen (NOTAMs) for the intended flight. However, the ineffective presentation style and sequence of the NOTAMs led them to interpret that Runway 23 was not available for landing at CYHZ. Therefore, the crew planned to land on Runway 14.
During the approach to this shorter runway, new information regarding a change of active runway was not communicated by air traffic control directly to the crew, although broadcasted through an automated information system. As a result, the crew continued to believe that the approach and landing on Runway 14 was the only option available. Less than 90 seconds from the threshold, the crew realized that there was a tailwind component; however, they did not recalculate the performance data to confirm that the landing distance available was still acceptable, likely because of the limited amount of time available before landing. The unexpected tailwind resulted in a greater landing distance required, but this distance did not exceed the length of the runway.
Upon landing, a series of events prevented the aircraft from decelerating as expected and caused the aircraft to drift to the right of the runway. The pilot monitoring’s attention was focused on the lateral drift and, as a result, the required callouts regarding the position of the deceleration devices were not made.
Although manual brake application began 8 seconds after touchdown, maximum braking effort did not occur until 15 seconds later, when the aircraft was 800 feet from the end of the runway. From this position, it was not possible for the aircraft to stop on the runway and the aircraft departed the end of the runway and came to a stop 270 m (885 feet) past the end.
During the overrun, the aircraft crossed a significant drop past the end of the runway and was damaged beyond repair. While this uneven terrain was beyond the 150 m (492 feet) runway end safety area (RESA) proposed by Transport Canada, it was within the recommended International Civil Aviation Organization RESA of 300 m (984 feet). In 2007, the TSB issued Recommendation A07-06 stating that the Department of Transport require all Code 4 (1800 m or longer) runways to have a 300 m RESA or a means of stopping aircraft that provides an equivalent level of safety. The issue of Runway overruns has been on the TSB’s Watchlist since 2010.
The investigation included a thorough fatigue analysis, which identified the presence of 2 fatigue risk factors that would have degraded the crew’s performance during the approach and landing: the timing of the flight and insufficient restorative sleep in the 24-hour period leading up to the occurrence. Fatigue management is also a TSB 2020 Watchlist item.
See the investigation page for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.