Back to home pageAP-BJO 737-400 Runway excursion on landing

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03 Nov 2015 - Shaheen Air 737-400 AP-BJO (27166/2410) runway excursion on landing at Lahore, Pakistan.

Shaheen Air flight NL142 from Karach to Lahore (OPLA) with 112 passengers and 7 crew landed to the left of runway 36L in 1500m visibility. Both main landing gear were torn off as the aircraft crossed a taxyway. The aircraft settled down onto the grass and stopped about 2500m from the runway threshold and about 200m from the end of the runway.

The aircraft was substantially damaged and 10 passengers received minor injuries. The blood alcohol level of the Captain was 83 gm/dl.

Runway 36L is 3,360 meters long and the primary runway at Lahore but at the time of the accident the ILS was NOTAMed not available due to CAT IIIB upgrade works in progress. There are VOR/DME, NDB and RNAV non-precision approaches available for all four runways. The VOR approach has a 5 degree offset.

OPLA 030455Z 00000KT 2000 FU SCT100 23/16 Q1018 BECMG 3000

A video of the landing and evacuation taken by one of the passengers is available on YouTube here

 

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The final report makes chilling reading. Both crew members reported late for the flight and only planned for one alternate even though the destination was below minimums. The Captain was PF and was later found to be over the legal alcohol limit. The crew planed to follow ILS procedure for runway 36R with intention to break off after acquiring visual with the runway and landing at runway 36L (in 1200m met vis). This was a non standard procedure. The Captain told the F/O to request an RNAV approach. The aircraft was not equipped with mandatory navigation equipment (GNSS) required for carrying out RNAV approach. The Captain was having difficulty concentrating throughout the flight and the FO was continuously found to be prompting him for decision making. The crew changed to an RNAV procedure from a VOR DME without informing ATC who only picked up on this when the aircraft went off track. The aircraft became high on profile and used flap but not speedbrake to try to correct the situation. ATC gave several prompts to the crew about being high on the approach but the crew continued. At 9nm from the runway whilst still IMC the Captain disconnected the A/P and increased the RoD to 2000-3500fpm whilst turning to acquire the runway, which exceeded the flap limit speed. The aircraft ended up low on approach with high speed whilst still not visual with the runway. The crew became visual at MDA (below 500RA) but were left of the centreline. The F/O took over control and manouvred towards the runway but this included levelling off for 7 secs at 400AGL. At 150ft AGL the Captain also saw the runway and retook control back from the F/O but he was still unable to correctly align the aircraft with the runway.

"soon after this the system sounded “One Hundred”, FO made an effort to take over the controls from the captain in order to land the aircraft. The captain was heard uttering “Haye...Ok...Haye...Oh...” indicating total exhaustion and inability to cope up with the difficult situation. The Captain was unaware that he was still holding the controls despite handing over to FO. The FO was heard urging the Captain to leave the controls by saying, “Chorain...aap chorain...chorain...” {Leave it...you...Leave it...Leave it}. The Captain again voiced, “Haye...Oh”. The FO was busy in landing the aircraft while Captain kept uttering exhausting voices besides being hyperventilated."

The aircraft touched down on the left side of the runway with 8deg RH bank and both pilots holding the controls 32kts above Vref. When the left gear touched down it shimmied and detached. The aircraft rested on the cowling and departed the left side of runway edge causing the RH MLG to detach.

According to the laboratory investigation reports in respect of Captain, the blood alcohol level was 83 gm/dl. The impairment of Central Nervous System starts at 50 mg/dl or above that may result in judgmental errors as evident in this case. Moreover, the blood lactate level of 70 gm/dl interprets fatigue due to increased stress as the normal level ranges from 4.5 to 23 mg/dl.

Shaheen Air 737-400 AP-BJO runway excursion on landing at Lahore, Pakistan

Cause of Occurrence.

The accident took place due to:

  1. Cockpit crew landing the aircraft through unstabilized approach (high ground speed and incorrect flight path).
  2. Low sink rate of left main landing gear (LMLG) as it touched down and probable presence of (more than the specified limits) play in the linkages of shimmy damper mechanism. This situation led to torsional vibrations / breakage of shimmy damper after touchdown. The resultant torsional excitation experienced by the LMLG due to free pivoting of wheels (along vertical axis) caused collapse of LMLG.
  3. The RMLG collapsed due to overload as the aircraft moved on unprepared surface.

2.1. Operational Analysis

2.1.1 The mishap flight was a scheduled passenger flight from Karachi to Lahore. The scheduled departure time from Karachi was 0300 UTC and it was to arrive at Lahore at 0445 UTC.

2.1.2 The FO reported at Flight Operations at 0200 UTC and the Captain arrived at 0215 UTC. Whereas, both were required to be in Flight Operations at 0130 UTC and on the aircraft at 0215 UTC as per SAI Ops Manual (Part A) Edition II Ch.7 P.10 para 7.7.1. Due to their late arrival, short time was available to them for detailed pre flight brief and preparation.

2.1.3 The FO received Flight Plan, obtained latest weather information & NOTAMS. The METAR received by FO when he reported at Flight Operations indicated OPLA visibility 1500 M with a reducing trend to 1000 M which was below the minimum required (1600 M) for landing at OPLA on runway 36L through a VOR DME approach. However, at the time of take off i.e. 0300 UTC from JIAP Karachi, the destination aerodrome had 1500 M visibility with misty outlook and increasing trend to 2000 M.

2.1.4 The Captain was Pilot Flying (PF) and FO was Pilot Monitoring (PM) for the flight. The Captain conducted a short departure brief which included taxi route and Standard Instrument Departure (SID). He did not discuss destination aerodrome weather conditions, diversion to alternate aerodrome and landing on runway 36L through VOR DME which was an uncommon practice requiring attention.

2.1.5 According to Flight Plan the flight was to cruise at FL 330 and total flight time to destination was 1 hour 23 minutes. Only one alternate aerodrome was planned which was Peshawar (OPPS). The weather forecast for OPPS indicated rain.

2.1.6 The Flight took off at 0308 UTC and carried out instrument departure. The flight climbed to its cruising altitude as planned and remained uneventful during cruise. Before initiating descent as per flight plan, the cockpit crew obtained latest weather of destination aerodrome (OPLA) which mentioned visibility 1200 meters. This visibility was below the minimum required (1600m) for carrying out a VOR DME approach and necessitated decision for diversion to alternate aerodrome. The cockpit crew decided to continue for the destination. At this time the flight was with Karachi Area Control Centre (ACC).

2.1.7 At 0359:02 UTC the flight changed over to Lahore ACC. Lahore ACC cleared the mishap flight for arrival to Lahore for VOR DME approach runway 36L. The Captain asked FO to request Lahore ACC for “ten miles finals runway 36R, initially” which was complied. Lahore ACC declined clearance for runway 36R and informed cockpit crew that the requested runway was not available due scheduled maintenance and also passed on latest weather as “ Lahore weather warning for poor visibility due mist up till 0700E and present visibility 1200 meters”. According to FO they were planning to follow ILS procedure for runway 36R with intention to break off after acquiring visual with the runway and landing at runway 36L. This was a non standard procedure.

2.1.8 At 0404:29 the FO tried twice to contact Sialkot International Airport (an airport in near vicinity of AIIAP, Lahore) to obtain her weather (the alternate aerodrome as per flight plan was Peshawar). The radio contact with Sialkot was not established. At this time, the FO discussed with the Captain that in case of diversion their alternate aerodrome was Peshawar and it required additional fifty minutes of flying time.

2.1.9 At 0404:57 the FO asked Captain whether they had to go for RNAV. The Captain told him to request for RNAV approach. The aircraft was not equipped with mandatory navigation equipment (GNSS) required for carrying out RNAV approach and the operator had also issued necessary instructions in this regard, also this decision was contrary to recommended procedure i.e. ICAO Doc 9613 para 3.4.1.1 and 3.4.1.2. At this stage, when the FO was cross checking the arrival procedure on Flight Management Guidance Computer (FMGC) he apprised the captain that by mistake the captain had selected runway 18L instead of runway 36L, which was later on accepted by the Captain and the FO was advised to change the arrival procedure. The conversation between Captain and FO at this time indicates that the Captain had difficulty in identifying / reading and feeding the correct arrival procedure due to inability in concentration.

2.1.10 The FO was continuously found to be prompting the Captain for decision making. In order to calculate RVR for VOR DME approach runway 36L as given in Jeppesen Chart 13-5, the FO calculated RVR as 1800 meters by multiplying visibility (1200m) with 1.5. He lacked the knowledge of RVR calculation procedure and did not consider availability of other services at runway 36L, like high intensity approach lighting system (HIALS) or high intensity runway lights (HIRL) as mentioned in Jeppesen General Airway Manual p.200 appended below. Incorrect calculation of RVR was not corrected by the Captain as well.

2.1.11 As per criteria mentioned in above table, RVR was same (1200m) as the reported visibility due to other type of lighting system (SALS 420M) installed on runway 36L. The required RVR for carrying out a VOR DME approach by Cat C airplane at runway 36L of OPLA as per Jeppesen Chart 13-5 was 1600m.

2.1.12 At 0412:15 UTC, the cockpit crew changed over to Lahore Approach Frequency as cleared by Lahore ACC. As the FO contacted Lahore Approach and informed that the flight was handed over to her and it was descending from FL 240 to FL150. Lahore Approach found the flight being right of track and inquired cockpit crew by asking them, if they were right of track. The Captain quickly asked FO to tell Lahore Approach that they were following RNAV procedure for runway 36L. The FO complied with the Captain’s instructions. Lahore Approach acknowledged that and directed the FO to report position LEMOM while continuing descend to FL 70. Lahore approach acknowledged Captain’s decision to follow RNAV and did not pursue for her previous clearance for VOR DME approach runway 36L and change of procedure to RNAV at this stage.

2.1.13 At 0416:52 UTC Lahore Approach cleared mishap flight for RNAV LEMOM ONE CHARLIE arrival runway36L, “descend down to 3000 ft on QNH 1018 hecta pascal and report position ELAMA”. The FO acknowledged the approach by correctly reading back. The flight turned right from hdg 040° to 070° while descending through 10300ft, with speed reducing through 273 kts and at a distance 27.4 NM from thresholds runway 36L.

2.1.14 At 0420:18 UTC Lahore Approach observed the flight passing through FL85 at 20 track miles which was approx 2000-2500 ft higher than the assigned altitude. At this time, the cockpit crew selected Flaps-1, 2 and 5 in quick succession in order to increase the ROD, however speed brakes were not used here. Lahore Approach contacted cockpit crew to reconfirm whether they will be able to make approach or will discontinue due to being high. The Captain immediately prompted FO to reply by saying “Affirmative”. The FO replied as “affirmative, we can make it”.

2.1.15 At this stage, it is established that the flight was neither following the track (it was right of track) nor the assigned altitudes as per ATC clearance / relevant chart. The cockpit crew lacked desired situational awareness due to stress of poor visibility combined with loss of concentration of Captain probably due to effects of alcohol, yet they wanted to continue for the landing at destination airport.

2.1.16 At 0420:47 UTC the FO suggested the Captain to use the Speed Brake so that the flight can quickly descend to desired altitude. The captain in response voiced “haye...haye...haye” indicating that he was exhausted and unable to cope up with the difficult situation.

2.1.17 At 0422:05 UTC the Captain asked FO to lower Flaps-10 and lower Landing Gears. The FO complied with the instructions and confirmed. The Captain again voiced “haye...haye...haye”. At this stage, they also lowered Flaps-15, Landing Light - On and Flaps-30. The Captain asked FO to complete landing checklist which was successfully done by the FO.

2.1.18 At 0422:50 UTC the flight was approaching over ELAMA at 5400 ft, 9.7NM from thresholds (runway 36L) at speed approx 180kts.

2.1.19 At 0422:53 UTC when the flight reported her position over ELAMA, the Lahore Approach Control observed her to be at 5000 ft altitude instead of already cleared 3000 ft. The duty controller cautioned cockpit crew by telling them that their altitude at ELAMA should have been 3000 ft whereas he had observed it to be 5000 ft. He also advised them to continue at pilot’s own responsibility; if they end up carrying out missed approach, they should continue to maintain runway heading and also advised to contact tower. By these instructions, it appears that the Lahore Approach Controller was quite certain that the flight would end up carrying out missed approach due to being very high on approach.

2.1.20 After reaching over ELAMA, the flight turned left heading 355° and lowered Flaps-30. The speed at this time was 180 kts and flight was descending through 5000 ft.

2.1.21 At 0423:52 UTC the Captain disengaged the autopilot at 9NM from RWT to lose the excess height by increasing ROD also executed turns to acquire the runway. However, the captain’s decision to disengage autopilot at this stage without being visual with the runway increased his workload. Resultantly, the aircraft descended with very high ROD from 2000 – 3500 ft/min. The excessive ROD with Flaps-30 selected resulted in exceeding flap speed limit.

2.1.22 By the time the flight reached 4.6 NM from runway threshold lines, her parameters were hdg 356°, Ht 1211ft, speed 170 kts and ROD 1300 ft/min which were almost correct at this distance from the runway but still not visual with the runway (the cockpit crew was actually carrying out VOR DME approach against their R/T communication of RNAV approach for which the aircraft was not suitably equipped). The Captain kept flying the aircraft with no visual cues due poor visibility, increased stress level, loss of situational awareness and reduced mental ability which led to ending up low on approach with high speed. Important flight parameters on final approach below 1000 ft AFE are tabulated below which indicate that the approach had become unstabilized.

2.1.23 The above mentioned chart clearly depicts that below 1000 ft AFE the MA flew an unstabilized approach keeping in view large variations in speed, heading, and bank angle. This unstablized approach warranted a go around as per criteria given by Boeing Company and, which mentions... “All approaches should be stabilized by 1,000 ft AFE in instrument meteorological conditions (IMC) and by 500 ft AFE in visual meteorological conditions (VMC). An approach is considered stabilized when all of the following criteria are met:

- The airplane is on the correct flight path - Only small changes in heading and pitch are required to maintain the correct flight path - The airplane should be at approach speed. Deviations of + 10 kts to – 5 kts are acceptable if the airspeed is trending toward approach speed - The airplane is in the correct landing configuration - sink rate is no greater than 1,000 fpm; if an approach requires a sink rate greater than 1, 000 fpm, a special briefing should be conducted - Thrust setting is appropriate for the airplane configuration - All briefings and checklists have been conducted. Note: An approach that becomes unstabilized below 1,000 ft AFE in IMC or below 500 ft AFE in VMC requires an immediate go-around.”

2.1.24 At 0424:02 the Captain asked FO whether the runway was visible. The FO replied in negative and advised Captain to engage the autopilot, which could make runway contact easy. However the autopilot was not engaged.

2.1.25 At 0424:16 the cockpit crew reported their position to ATC Tower which was 04 DME runway 36L. The duty controller at ATC Tower replied ,” recheck landing gears down & locked, wind calm, caution for birds and cleared to land runway 36L”. The FO acknowledged by saying, “cleared to land when field in sight, Shaheen 142”.

2.1.26 At 0424:32 the Captain continued to fly the aircraft and FO kept assisting him till they reached 500 ft AGL. The FO rechecked missed approach procedure and reset flight directors for a possible go around.

2.1.27 At 0425:24 when the system sounded “Five Hundred”, the Captain once again asked FO whether runway was visible. The FO replied in negative. As the airplane was descending through 460 ft AGL, constant airspeed of 150 kts was maintained. The calculated airspeed for the weight of the aircraft at landing was 136 kts.

2.1.28 At 0425:41 the FO kept on guiding the captain to turn right, just before the system sounded “Minimums” the FO picked up visual with the runway towards right. The FO also took over the controls and asked Captain to inform ATC that runway was in sight. The aircraft temporarily levelled off at 400 ft AGL for approximately 7 seconds and simultaneously a right turn was initiated. While descending below 400 ft AGL, the vertical speed kept varying between -1100 ft/min to -180 ft/min. At 200 ft AGL, power was advanced to 55%-65% which increased airspeed and temporarily decreased sink rate. Although the FO picked up visual with the runway at Minimum Descend Altitude (MDA) by chance, however since the approach parameters in terms of ”correct flight path” were not attained, a go around should have been initiated instead of efforts to align / land.

2.1.29 At 0425:47 the Captain also sighted the runway (at approximately 150ft AFE) and took over the controls from FO. However, the Captain was still unable to correctly align the aircraft with the runway, as the aircraft had ended up towards right side of the runway and a left turn was required. The FO was found asking the Captain to turn left but not only the Captain was unable to acknowledge the gravity of non normal situation he advised FO to ‘relax’. The FO responded by saying “Ok...you had ended up well towards right of runway”.

2.1.30 At 0426:07 soon after this the system sounded “One Hundred”, FO made an effort to take over the controls from the captain in order to land the aircraft. The captain was heard uttering “Haye...Ok...Haye...Oh...” indicating total exhaustion and inability to cope up with the difficult situation. The Captain was unaware that he was still holding the controls despite handing over to FO. The FO was heard urging the Captain to leave the controls by saying, “Chorain...aap chorain...chorain...” {Leave it...you...Leave it...Leave it}. The Captain again voiced, “Haye...Oh”. The FO was busy in landing the aircraft while Captain kept uttering exhausting voices besides being hyperventilated.

2.1.31 At 0426:13 the aircraft had reached its flare out height and system sounded “Fifty...Forty...Thirty...Twenty...Ten” and both throttles were retarded to idle. The aircraft touched down 1400 ft down form threshold lines in left half of the runway on right wheel in a right bank angle of 8°, a nose up attitude of 1.5° and 4.5° crab angle while the Captain and FO both were holding the controls and FO was making the landing. According to FDR data, the touchdown speed was 174 kts ground speed/166 kts True Airspeed against 134 kts of reference speed (Vref). Auto-speed brake got deployed at touchdown since it was armed. Thereafter, the aircraft slightly bounced and left wheel touched down the runway surface followed by second touching down of right wheel. When the left wheel touched down the left main landing gear broke following a shimmy event. Thrust reversers and brakes were applied, as speed brake was armed before landing.

2.1.32 The mishap aircraft departed runway towards left on fair weather strip due to high drag generated by rubbing of left engine cowling with the runway surface. Soon after MA departed the runway on soft ground, the right main gear also broke. The MA was now resting on both engines and nose wheel which remained intact throughout. The MA continued to skid on fair weather strip for 8000 ft before coming to final stop. Throughout landing roll the Captain and FO remained quiet and did not talk for any action till aircraft stopped. Thereafter since the captain did not ask FO for Engine shutdown checklist and evacuation of passengers. The same was accomplished by the FO. No passenger was injured during the incident or during emergency evacuation.

The full report is available here

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