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04 Nov 2020 - 12 years after the event, the Nigerian AIB have published their final report into the runway excursion involving 737-200, 5N-BIG at Port-Harcourt International Airport on 14th July, 2008.

Synopsis

On 14th July, 2008 at 16:49 h, a Boeing 737–282 aircraft with nationality and registration marks 5N-BIG, operated by Chanchangi Airlines Ltd, commenced a scheduled domestic flight from Murtala Muhammed International Airport, (DNMM) with call sign NCH138 for Port Harcourt International Airport (DNPO).

Instrument Flight Rules (IFR) flight plan was filed for the flight. There were 47 persons on board (41 passengers, 2 flight crew and 4 flight attendants) and 3 hours fuel endurance. The Captain was the Pilot Flying (PF) and the First Officer (FO) was the Pilot Monitoring (PM).

At 18:45 h, NCH138 reported five miles to touchdown. Approach Control acknowledged and instructed NCH138 to report field in sight and subsequently handed over to Tower on 119.2 MHz. When contacting the Tower, NCH138 was cleared to land on RWY 21, wind 0100 /10 kt and was advised to exercise caution due to wet runway. NCH138 acknowledged the clearance.

NCH138 landed hard and bounced three times on the runway. According to the ATC controller, after touch down the aircraft rolled in an s-pattern before it overran the runway. NCH138 made a 180° turn with the right engine hitting the ground. The aircraft came to a final stop on the left side and 10 m beyond the stopway.

The accident occurred at night in Instrument Meteorological Conditions (IMC). The Aeroderome Rescue and Fire Fighting Service (ARFFS) arrived the scene and commenced rescue operations immediately. All occupants on board were evacuated; one passenger sustaining a minor injury.

The investigation identified the following causal and contributory factors:

Causal Factor The decision to land following an unstabilized approach (high rate of descent and high approach speed). A go-around was not initiated.

Contributory Factors

  1. The deteriorating weather conditions with a line squall prevented a diversion to the alternates.
  2. The runway was wet with significant patches of standing water..

No safety recommendations were made.

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Final position of the aircraft relative to the runway

1.0 FACTUAL INFORMATION

1.1 History of Flight:

On 14th July, 2008 at 16:49 h, a Boeing 737–282 aircraft with nationality and registration marks 5N-BIG, operated by Chanchangi Airlines Ltd, commenced a scheduled domestic flight from Murtala Muhammed International Airport, (DNMM) with call sign NCH138 for Port Harcourt International Airport (DNPO). Instrument Flight Rules (IFR) flight plan was filed for the flight. There were 47 persons on board (41 passengers, 2 flight crew and 4 flight attendants) and 3 hours fuel endurance. The Captain was the Pilot Flying (PF) and The First Officer (FO) was the Pilot Monitoring (PM).
The FO stated that NCH138 was initially scheduled to depart at 15:30 h, but the flight was delayed due to loading of passenger baggage.
The Captain stated that NCH138 was cleared to FL290 and the flight continued normally.
According to the DNPO Air Traffic Control (ATC) watch supervisor on duty, NCH138 contacted DNPO Approach Control (APP) at 17:05 h with flight information estimating POT at 17:50 h. NCH138 was issued an inbound clearance to POT1 VOR2 with the following weather information for 17:00 h as: Wind calm, Visibility 10 km, Broken clouds 270 m, Scattered clouds 600 m, Cumulonimbus clouds scattered, temperature 25/24°C, Thunderstorms, Temporarily Variable 8 kt, gusting 18 kt, Visibility 3000 m, Thunderstorms and rain, and expect runway (RWY) 21 for landing.

According to the First Officer NCH138 requested descent into POT at about 100 NM. The Captain added that due to ATC delay, the descent commenced at about 80 NM.
The Control Tower Watch Supervisor stated that at 18:00 h, NCH138 requested to hold over POT at 3500 ft for weather improvement, because there was rain overhead the station with build-up closing in at the threshold of RWY 21. At about 15 NM, between radials 180° and 210°, NCH138 reported breaking out of weather.
At 18:19 h, NCH138 requested weather information from the Tower. Tower advised the flight crew that RWY 03 was better for landing. At this time, NCH138 requested RWY 03 for approach and Approach Control cleared NCH138 for the approach to RWY 03.
At 18:27 h, the flight crew reported established on approach to RWY 03, leaving 2000 ft. The Approach Control then transferred NCH138 to DNPO Tower for landing instructions.
At 18:28 h, the Tower instructed NCH138 to report field in sight. The flight crew acknowledged and reported RWY 03 in sight. Tower cleared NCH138 to land on RWY 03 and NCH138 was cautioned that the runway was wet.
At 18:34 h, NCH138 executed and reported a missed approach. NCH138 requested a climb to 3500 ft. NCH138 was cleared to climb and instructed to report overhead POT.
At 18:39 h, NCH138 requested a descent and clearance for an approach to RWY 21. Approach Control cleared NCH138 to descend to 2000 ft and report to Tower when established on the approach and also to report leaving 2000 ft.
At 18:42 h, NCH138 reported inbound maintaining 2000 ft. The Approach Control requested the distance from the runway and sought consent of NCH138 for Arik 514 at the holding point to take off. NCH138 declined, as they were about 10 miles to touchdown.
At 18:45 h, NCH138 reported five miles to touchdown. Approach Control acknowledged and instructed NCH138 to report field in sight and thereafter handed over to Tower on 119.2 MHz. When contacting the Tower, NCH138 was cleared to land on RWY 21, wind 0100/10 kt and was advised to exercise caution due to wet runway. NCH138 acknowledged the clearance.
NCH138 landed hard and bounced three times on the runway. According to the ATC controller, after touch down the aircraft rolled in an s-pattern before it overran the runway. NCH138 made a 180° turn with the right engine hitting the ground. The aircraft came to a final stop on the left side and 10 m beyond the stopway.
The accident occurred at night in Instrument Meteorological Conditions (IMC). The Aeroderome Rescue and Fire Fighting Service (ARFFS) arrived the scene and commenced rescue operations immediately.
All occupants on board were evacuated; one passenger sustaining a minor injury.

1.3 Damage to aircraft

The aircraft was substantially damaged.

1.7 Meteorological Information

At 17:00 UTC Wind: Calm Visibility: 10 km Clouds: Broken at 270 m, scattered at 600 m, cumulonimbus in several directions. Temperature/Dew point: 25/24o C Weather: Thunderstorms Trend: Temporarily variable at 8 kt, gusting 18 kt, visibility 3000 m, thunderstorm and rain. QFE: 1007 hPa QNH: 1010 hPa

1.8 Aids to Navigation

NOTAM was issued showing that ILS Glide Slope was unserviceable

1.9 Communication

There was effective communication between the Tower and the aircraft..

1.10 Aerodrome Information

Port Harcourt International Airport is owned and operated by Federal Airports Authority of Nigeria (FAAN). It is located 32 km west of the city and has a runway with an orientation of 03/21 which is 3000 m long and 60 m wide, located at coordinates latitude 050 00I 56II N and longitude 0060 56I 58II E, and at an elevation of 87 ft (ASL). The runway is equipped with Precision Approach Path Indicator PAPI, approach and edge lighting systems. See Appendix 3 for airport layout plan. The airport hours of operation were limited from sunrise to sunset as per NOTAM Referenced: NTM A0082/0632 dated 8th July, 2008. The pilot mentioned that all the lights were “NIL” (not ON) at the time of the occurrence.

1.12 Wreckage and Impact Information

The aircraft touched down at 1700 m into runway 21, bounced several times, skidded left off the extended centre line, back to the centre and continued to the right at 2100 m. The broken pieces of the nose wheel rim and the damaged tyre were found at 2100 m and 2200 m, respectively.
The aircraft overran the runway, cut an NDB cable, made a 180° turn with the right engine hitting the ground. The aircraft came to a final stop on the left side, 10 m beyond the stopway. Upon observation, the following damage was noticed:
1. Nose wheel sheared off leaving the bolt behind.
2. No. 2 and 4 Main wheel assemblies were damaged.
3. No. 2 and 4 Main wheel tyres were burst.
4. Both engines ingested gravels/sand and debris.
5. No. 2 Engine tail cone and thrust reverser were damaged.1.14 Fire There was no evidence of fire in-flight or post impact fire.

 

2.0 ANALYSIS

2.1 Conduct of Flight

NCH138 departed DNMM at 16:49 h enroute to DNPO maintaining FL 290. The aircraft established contact with DNPO Approach Control at 17:05 h and reported estimate POT VOR at 17:50 h. The ATC acknowledged and issued an inbound clearance for a POT VOR approach to runway 21. Weather information for 16:00z was relayed to the flight crew. The weather information indicated thunderstorm activity over the station.
As the flight progressed, the flight crew requested actual weather from Tower observation. The Tower advised that runway 03 was better for landing, as the thunderstorm activity was moving towards runway 21.
At 18:19 h, the flight crew requested approach for runway 03. At 18:25 h, the Approach Control granted the approval. On reaching minimum decision altitude (MDA), the flight crew lost the runway in view, which prompted them to execute a missed approach.
At 18:39 h, NCH138 requested a descent for an approach to runway 21. APP Control cleared NCH138 to descend to 2000 ft on QNH 1012hPa and transferred the aircraft to Tower.
On contact with Tower, NCH138 was cleared to land on runway 21. The aircraft landed hard at about 1700 m into the runway, bounced about 3 times as a result of which the flight crew lost directional control of the aircraft and subsequently overran the runway.

2.3 Weather and environmental conditions

NCH 138 was initially scheduled to depart Lagos (DNMM) to Port Harcourt (DNPO) at 15:30 h, but the flight was delayed until 16:49 h (a one hour 19 minute delay).
The pilots received METAR information of 15:00 and 16:00 for Port Harcourt International Airport as observed: Surface wind direction was 180°, speed 8 kt, visibility 10 km in nil weather, broken cloud at height of 360 m, A few cumulonimbus clouds in several directions at 660 m, temperature 28°C, dew point 24°C and prevailing mean sea level air pressure (MSL) 1011 hPa; the surface wind was from 220° at 6 kt, visibility 5km in thunderstorm and rain showers, broken cloud base 300 m, few cumulonimbus clouds in several directions at 600 m, temperature 28°C, dew point 24°C and prevailing mean sea level air pressure (MSL) of 1010 hPa.
A special meteorological report was issued at DNPO at 16:30 prior to the departure of NCH138 from DNMM. The recorded weather information showed a calm surface wind, visibility 10 km in thunderstorm, broken cloud base 300 m, scattered 600 m cumulonimbus in several directions, and prevailing mean sea level air pressure (MSL) of 1010 hPa.
Furthermore, the 17:00 and 18:00 meteorological reports issued at DNPO prior to the arrival of NCH138 showed calm surface wind, visibility 10 km in thunderstorm, broken cloud base 270 m, scattered 600 m cumulonimbus in several directions, temperature 25°C, dew point 24°C, and prevailing mean sea level air pressure (MSL) of 1010 hPa. The trend forecast was temporary with variable wind 8 kt, gusting 18 kt, visibility 3000 m in thunderstorm with rain. And the surface wind from 010° at 10 kt, visibility 6 km in thunderstorm with rain, broken cloud base 180 m, scattered 600 m cumulonimbus in several directions, temperature 22°C, dew point 20°C, and prevailing mean sea level air pressure (MSL) of 1012 hPa. The trend forecast was temporary visibility expected to be 3000 m in thunderstorm with rain.
It is evident from the above weather deductions that there was adverse weather activity prior to and after the arrival of NCH138 at DNPO on the day of the occurrence. In addition, the satellite weather imagery obtained from NiMeT indicated a line squall over Port Harcourt area from 17:00 to 21:00.
It is the practice of the flight crew to request and receive briefing on updated weather information for the departure, enroute and destination. There were no records available to the Bureau indicating that the flight crew received such weather updates prior to the departure.

2.4 Operational considerations

NCH138 was delayed on the ground in Lagos for over an hour. During that time, a SPECI for 16:30 h was issued indicating deteriorating weather at Port Harcourt airport. Additionally, satellite imagery received from NiMeT corroborated the deteriorating conditions. An updated weather report would have assisted the flight crew in evaluating several options in arriving at a decision well ahead of time which would have enhanced their situation awareness.
The Flight Plan for NCH138 showed an endurance of 3 hours and a 50 minutes flight time, however, the actual flight time lasted 1 hour 55 minutes.
NCH138 departed Lagos at 16:49 h and estimated POT VOR at 17:50 h indicating a flight time of about an hour.
On reaching the station and due to weather conditions, NCH138 decided to hold in the vicinity of the airport, considered diverting to the alternates or to Owerri, but were unable to due to line squall. NCH138 carried out a missed approach and then made a second approach to land. This lasted for about 54 minutes.The aircraft had about an hour endurance left and a few minutes remaining before the closure of Port Harcourt airport at sunset.
The delay on the ground in Lagos for over an hour, the time in holding and considered diversions, the missed approach, the limitations on airport operational hours, unavailable runway lighting system and the diminishing fuel endurance remaining were factors that could have pressured the flight crew into landing the aircraft.

 

3.0 CONCLUSIONS

3.1 Findings

1. The flight crew members were properly licensed and qualified under the Nigeria Civil Aviation Regulations in force at that time to conduct the flight.
2. The pilots were medically fit and adequately rested to operate the flight. There was no evidence of flight crew fatigue.
3. The aircraft was properly certificated, equipped, maintained and was structurally intact prior to the flight.
4. NCH138 was initially scheduled to depart at 15:30 h, but the flight was delayed on the ground in Lagos for over an hour (one hour 19 min).
5. The meteorological reports and trends received for 15:00 h and 16:00 h indicated adverse weather in the Port Harcourt area.
6. During the delay, a SPECI for 16:30 h was issued indicating deteriorating weather at Port Harcourt airport.
7. There was no evidence available to the Bureau to indicate the flight crew received updated weather information during the delay or prior to departure to Port Harcourt.
8. NCH138 departed Lagos at 16:49 h, contacted DNPO APP Control and estimated POT VOR at 17:50 h with a fuel endurance of 3 hours.
9. The satellite imagery on the day of the occurrence indicated an adverse weather activity overhead the Port Harcourt area.
10. On reaching the station, NCH138 had to hold at the vicinity of the airport, considered diverting to an alternate or to Owerri but was unable due to a line squall.
11. At 18:34 h, NCH138 carried out a missed approach on runway 03.12. There was a pilot report (PIREP) from Arik flight 514, at the holding point to runway 21, to NCH138 that runway QDM 2110 and visibility was quite good.
13. The crew opted to land on runway 21 on sighting it during the missed approach.
14. A NOTAM issued on 1st May, 2008 stated that the ILS for runway 21 was unserviceable and the airport operational hours were for day light operations only.
15. During approach on the final landing, the PM advised a high rate of descent and approach speed of about 160 kt to the PF. There was also aural warning from the aircraft of an excessive descent rate.
16. The aircraft landed hard at about 1700 m, bounced about 3 times, damaged the nose wheel assembly, overshot the runway, and turned 180° with the right engine hitting the ground. The aircraft came to a stop 10 m beyond the stopway.
17. The ATC activated the Crash Alarm Bell and the information was subsequently passed to all relevant units at 18:44 h.
18. When the aircraft came to a complete stop, there was no command for an evacuation. The flight attendants initiated the evacuation.
19. The Airport Fire and Rescue team arrived the scene at 18:46 h.
20. The forward left evacuation slide separated from the container and could not be deployed during the evacuation.
21. The remaining slides were deployed and used in the evacuation.
22. All the passengers on board were evacuated safely with one passenger sustaining minor injury.
23. The accident occurred at coordinates 05°00'56''N and 006°56'58''E, elevation of 87 ft. The natural light condition at the time was twilight in rain.

3.2 Causal Factor

The decision to land following an unstabilized approach (high rate of descent and high approach speed). A go-around was not initiated.

3.3 Contributory Factors

1. The deteriorating weather conditions with a line squall prevented a diversion to the alternates.
2. The runway was wet with significant patches of standing water.

4.0 RECOMMENDATIONS

In view of the issuance of the Nigeria CAR 2009 and the revision in 2015, which addressed the areas of shortcomings identified in this investigation, no safety recommendations are made.

 

The full report is available here

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