Aviation safety investigations & reports

Boeing Co 737-800, VH-VOE

Investigation number:
200202710
Status: Completed
Investigation completed

Summary

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A Boeing 737-800, registered VH-VOE, was being operated on a scheduled flight between Brisbane and Darwin. The crew conducted a VOR/DME arrival to Runway 29 at Darwin International Airport. The runway had a temporarily displaced threshold. The aircraft touched down an estimated 1016 m from the departure end of the runway, at about 23:35 Central Standard Time. During the landing roll, the aircraft overran the runway and came to a stop approximately 44 m into the 90 m runway end safety area. There were no injuries, and the aircraft was not damaged. Air Traffic Control was not aware that the aircraft had overrun the runway. Consequently, emergency response services were not contacted.

Runway overruns feature prominently in accidents involving western-built transport category jet aircraft. Long and/or fast landings were factors in these occurrences. In this occurrence, a high approach speed led to a long landing and overrun situation. The pilot in command continued with an unstabilised approach and did not go around as required by company standard operating procedures. The copilot did not announce that the approach was unstable and instruct the pilot in command to go around. Throughout the approach, there were various cues available to both crewmembers to indicate that the approach was unstable and that a go-around was required.

Overall, there were a number of safety issues identified during the course of the investigation. Those issues included: a non-precision approach at night that was conducive to illusions; a displaced threshold that limited the landing distance available; crew resource management problems; aircraft handling difficulties; an underdeveloped landing approach risk assessment by the crew and a safety management system that had yet to incorporate the flight data monitoring programmes advocated by the International Civil Aviation Organization and industry associations. As part of the relatively new operator's maturation process, the operator has developed a number of measures that are being implemented over the short, medium and longer terms to improve the training of crews, and the capability of the operator's safety management system.

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Download Final Report
[Download  PDF: 679KB]
 
 
 
General details
Date: 11 June 2002   Investigation status: Completed  
Time: 2350 hours CST    
Location   (show map): Darwin, Aero.    
State: Northern Territory   Occurrence type: Runway excursion  
Release date: 16 March 2004   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737  
Aircraft registration VH-VOE  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Brisbane, QLD  
Destination Darwin, NT  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 3688.0 12580
Last update 13 May 2014