SYNOPSIS
On 17 September 2017, the Jordanian Airline Fly Jordan Solitaire Air, “Boeing 737-300, JY-SOA”, departed from Queen Alia International Airport (OJAI) to King Hussein Airport (OJAQ) at 04: 47:58 UTC with flight number RYW6888 Amman - Aqaba - Dubai, on behalf of Royal Wings Company on a Wet Lease bases (ACMI).The flight departed OJAI with a delay of 47 minutes from the scheduled departure time due to late boarding of passengers.
The Copilot was the pilot flying and the Captain was the pilot monitoring until the controls were transferred to the Captain before touchdown as the Copilot was unable to land the Aircraft on the runway.
During cruise the crew realized that the delay before departure will negatively affect their duty time and consequently asked for straight approach on runway 19 to save time. The ATC Controller informed the crew that the wind is varying with speeds between 10 - 12 knots and another traffic was expected to depart runway 01 within short time. The Captain of the flight accepted the prevailing wind condition at runway 19, however, no agreement was made yet to land runway 19.
At 35 miles from AQB VOR the ATC contacted the crew and asked them if they there are able to maintain their speed to continue landing on runway 19, the crew accepted and continued to a straight in approach.
During final and after dropping the landing gear, the Aircraft was not configured to the correct landing configuration, the flaps were set to configuration one at height of 650 ft AGL, multiple GPWS aural warning were triggered but disregarded by the crew. the high speed approach was not corrected by the crew efficiently and the aircraft continued to landing runway. the Aircraft passed the threshold at 115 ft radio altitude at flaps 5 and continued along the runway to the point when the flaps were selected to 30 at 90 ft radio altitude.
The Aircraft floated over the runway and pilot flying was unable to land it. The Captain took the controls over and managed to put the Aircraft on the runway but with relatively higher than normal speed. The Aircraft touched down at 7400 ft beyond the runway threshold. The airplane came to a stop 10,600 feet beyond the runway threshold (600 feet inside the soft area), and around 200 feet right of the extended runway centerline.
A notification was passed to CARC investigation department immediately from AQJ airport and an investigation was performed based on CARC CEO letter 31/01/508/3756, dated 17/09/2017,since the occurrence is categorized as a serious incident.
HISTORY OF THE FLIGHT
On 17 September 2017, the Jordanian Airline FlyJordan - Solitaire Air “Boeing 737-300, JY-SOA” departed from Queen Alia International Airport (OJAI) to King Hussein Airport (OJAQ) at 04:47:58 with flight number RYW6888 Amman - Aqaba - Dubai, on behalf of Royal Wings Company on a Wet Lease bases (ACMI). With a delay of flight scheduled according to the “Flight Plan” about 47 minutes.
There were 126 persons onboard the Aircraft consisting of two Flight Crewmembers and 4 Cabin Crew. The flight crew consisted of the Commander and the Copilot. The Commander was the pilot monitoring (PM) and the Copilot was the pilot flying (PF).
At 04:44:00 clearance for taxi after pushback and engine start was requested by the crew . The air traffic controller gave clearance to the pilot of the Airplane for taxi to the Runway in use RWY 26R. During the Aircraft taxi the CVR reflect the checklist performed by the Flight Crew and received a call from air traffic controller requested Flight Crew to speed up the taxi in order to allow the Aircraft departure as an another aircraft was expected to land.
At 04:45:12 the Captain informed by chief of Cabin Crew that Cabin secured and Captain instructed them to be seated for takeoff . At 04:45:55 the Captain informed the air traffic controller that Royal Wings 6888 ready for departure. After takeoff
At 04:47:04 the ATC clearance was given to Flight Crew: Royal Wings 6888 to maintain Runway heading until passing 5000feet and the read back done by the Captain.
At 04:48:24 After establishing contact with Amman radar frequency 128.9, the flight was cleared to FL180 and to maintain RWY heading. And Auto pilot engaged at 04:48:50
At 04:49:35 the takeoff check list was completed.
At 04:49:52 the flight RYW 6888 was cleared to proceed BAKIR point and the read back confirmed by the Captain.
At 04:50:23 the Captain established a call with OCC and reported the departure and estimated arrival times with the total number of passengers on board.
At 04:55:10,( 08 minutes after departure) Flight RYW6888 has established radio contact with Aqaba approach and advised that estimated time of arrival (ETA) will be at 05:20 UTC. Landing information was copied by the crew at 04:55:50 UTC with a wind report 010/11 and eight kilometers haze weather, QNH1012, temperature twenty six and dew point seventeen and the RWY in use 01. The crew were discussing the planned RWY in use and elected to as for RWY 19 with a straight in approach instead of inbound procedure to RWY 01. Shortly after , The flight has been released to Aqaba approach and has established full radio contact with Aqaba approach , while maintaining FL180 The flight crew has reported a release to Aqaba approach ( from Amman approach) at time 04:59:00 while maintaining FL180 and asked for the possibility to use RWY for landing if traffic permit. Aqaba ATC has confirmed the wind speed to the flight crew and reported a variable wind of ten to twelve knots and reported that an expected flight will depart runway 01 within 15 minutes. The flight crew acknowledged and accepted the prevailing condition on runway 19 and confirmed proceeding to BAKIR with a clearance to descent to 8000 feet. The controller told the flying crew of the incident flight that he will check the possibility to grant them a permission to land runway 19. The controller did not report to the flying crew of the incident flight that they can use runway 19 until after 7 minutes from crew request. meanwhile the Flight crew came to agree to prepare for a landing on Runway 01 and the COPILOT. transferred the control to the Captain in order to inter the data for landing runway 01.
At 05:06:04 and at about 35 N.M from AQB Aqaba approach asked the crew if they can maintain high speed to give them a permission to land runway19 , the Captain confirmed that while Aircraft altitude at that time was FL160.
At 05:06:33 Aqaba has cleared the flying crew to descent to 7000 feet and proceed to AQC.
At 05:06:37 Aqaba approach has cleared RYW6888 for a straight in approach to runway 19. Aqaba approach asked about flight position advising confirmed AQC and replied by the Crew affirmative and confirming the straight in approach for runway 19 . After that the Copilot. transferred control to the Captain in order to enter the new approach data for the selected runway, The Copilot. reported that the ILS at runway19 is Inoperative , the Captain advised him to keep VNAV. Then the Copilot. Took the control again . the crew reported at AQC point and established on final.
At 05:10:00 The flight crew has confirmed establishing the final approach to the ATC controller who in turn asked the crew to change to tower frequency 118.1MHZ. Tower frequency was established assuring that the aircraft is in sight and confirming that runway19 is in use for landing while the wind is 10 to 12 knots. At approximately 1600 feet radio altitude ATC contacted the crew and subsequently cleared them to land. During the remainder of the approach, the GPWS was activated several times due high rate of descent and incorrect landing configuration , the Captain told the copilot to reduce speed, disregard the aural warnings and to continue the landing The Aircraft passed the threshold at 115 ft radio altitude at flaps 5 and continued along the runway to the point when the flaps was selected to 30 at 90 ft radio altitude. The aircraft has touchdown the runway at time 05:12:43 UTC around 7400 feet beyond RWY 19 threshold; (2650) feet prior to the end of the paved surface of RWY 0, and went off the runway few seconds after landing the aircraft stopped at 890 feet beyond the end of runway 01 threshold. Figure 1.1 (represent the ground track of the aircraft along the runway and the final position) No passengers or crew were injured, Passengers were advised to remain seated until disembarked The RFF team at AQJ reported to the site and transported the passengers to the terminal by buses. The Incident scene was secured by airport management unit the arrival of CARC investigators. The necessary medical examinations for drugs and alcohol was made to the incident flight crew after a request by the investigation committee. The runway was closed as the aircraft was obstructing the safe operation of the runway and affecting runway instruments performance and safety to other operations and for that purpose, an announcement in the form of a NOTAM was issued for the closure of the airportto13:00UTC.The NOTAM was amended two times and closing the runway has extended to04:00 on Monday 18/9/2017 until the aircraft was removed.
At 3:30 am on Monday 18/9/2017, the Airplane was transferred to the maintenance tarmac and a NOTAM declaring the runway availability was issued after making the necessary inspections for the Runway by the ground operations at the airport.
DAMAGE TO AIRCRAFT
Aircraft sustained substantial damage while moving over uneven and unpaved surface and was grounded for necessary repairs and maintenance.
also No. 2 engine S/No. 860151 had ingested some sand due to the very close proximity to the ground and the dust generated while the aircraft was rolling on the ground. Some leakage and damage were sustained by the R/H Main Landing Gear damper which Boeing company recommended changing it, Minor damages to the lower structure of the aircraft were observed which had to be evaluated by Solitaires approved AMO (JORAMCO) and repaired as required. Solitaire Air were ordered to consult the Boeing Company regarding the damages sustained by the aircraft and take all necessary repairs as required.
PILOT IN COMMAND
The PIC has graduated from the Royal Jordanian Air Academy on 6 Sep1999 and obtained a CPL / IR license, then obtained the type rating on B737 in one of the Jordanian airlines. The PIC occupied management positions in flight operations in his previous company. He joined Solitaire air on 1 May 2017 and he was accepted by CARC as hold Flight Operations PH for Solitaire air in addition to his duties as a captain on line. The training records of the PIC shows that he made the required conversion course in accordance to JCAR OPS1 regulations. However, during the course of investigation and the oversight activity carried out by CARC Flight Operations Inspectors that one of the courses required in the conversion was not completed properly as the course instructor who was the accountable manager for Solitaire air falsified the training record of the PIC and signed the related attendance sheet while the PIC was attending another course.
The copilot of the incident flight graduated from the Middle East Aviation Academy in 2009 where he obtained his CPL / IR license. He started his career in airlines since April 2010 to August 2010 where he worked in Ground Operations then on 8 April 2012 till 14 August 2012 he was flying as a First Officer Assistant until he obtained his B737-300 Type rating. He Joined Solitaire Air on 22 June 2017 and flew as a copilot with an ATPL license. No observation were made on the copilot raining and conversion requirements.
ANALYSIS
DFDR ANALYSIS:
Time history plots of the pertinent longitudinal and lateral-directional parameters are attached as Figures 1.15 through 1.18. Figures 1.15 and 1.16focus on the approach, and Figures 1.17 and1.18 focus on the touchdown and rollout. In addition to an evaluation of the FDR recorded parameters provided to Boeing, a kinematic analysis was conducted on the provided FDR data, to correct inherent inconsistencies often present in recorded data. Such inconsistencies may be due to sample rate differences, multiple independent data sources, and the presence of instrumentation biases. The kinematic analysis utilized integrated acceleration data to ensure basic inertial parameters such as altitude, ground speed, and drift angle are compatible and comparable. The analysis‟ output is a kinematically consistent set of data with acceleration biases removed, allowing calculations of wind data and other parameters information.
The FDR data show the airplane configured with flaps up and gear down (Figure 1.15). The speedbrake handle was extended to 43 degrees (maximum speedbrake handle deflection is48 degrees). As a result, the flight spoilers were deflected to approximately 32 degrees (not plotted). Note that the expected spoiler deflection at flight detent is 26 degrees, and maximum deflection is 40 degrees.
The autopilot was engaged in level change (LVL CHG) and lateral navigation (LNAV) modes (Figures 1.15and 1.16). The autothrottle was engaged, and the throttle levers were at idle. The airplane was descending through 4350 feet pressure altitude on approach to Runway 19 (verified by latitude/longitude data [not shown] and magnetic heading) at Aqaba. The airplane was at a computed airspeed of 266 knots, and the calculated sink rate (negative vertical speed) was approximately 4240 feet per minute (fpm) (Figure 1.15). The calculated wind components indicate a tailwind of around 12 knots relative to the runway and a negligible crosswind (Figure 1.16). The calculated winds were consistent with those recorded on the FDR. Around time 2362 seconds the tailwind increased to approximately 16 knots, where it remained fairly steady until touchdown.
The computed airspeed was steadily decreasing, and at time 2399 seconds the autopilot and autothrottle disconnected as the airplane descended through 1215 feet radio altitude (Figure 1.15). The cause of the autopilot and autothrottle disconnects could not be definitively determined from the available data. Following autopilot disengagement there was a notable increase in the magnitude of control column fluctuations, resulting in normal load factor variations of +/- 0.2 g‟s. At time 2407 seconds the flight mode annunciator (FMA) pitch mode transitioned from LVL CHG to altitude acquire (ALT ACQ).
The data indicate the occurrence of a Ground Proximity Warning System (GPWS) activation at time 2409 seconds (Figure 1.15). Note that the FDR combines multiple alerts into general warning and caution discretes, and does not record all of the individual alerts. The flaps began to extend to flaps 1 at time 2417 seconds (650 feet radio altitude), and from flaps 1 to flaps 2 shortly afterward at time 2425 seconds (460 feet radio altitude). Only the trailing edge flap deflections were recorded on the FDR, the flap handle position was not recorded.
At time 2435 seconds the GPWS was activated again, along with the TOO LOW TERRAIN discrete. Immediately afterwards, at time 2436 seconds (220 feet radio altitude), the flaps began to extend from flaps 2 to flaps 5.
At time 2442 seconds (90 feet radio altitude) the flaps began to extend from flaps 5 towards flaps 30 (Figure 1.17). The speedbrake handle was also retracted at this time. As the flaps extended, the calculated sink rate began to decrease, until stabilizing at approximately 0 fpm at time 2448 seconds (25 feet radio altitude). The airplane then proceeded to float down the runway, with the radio altitude and computed airspeed gradually decreasing. The airplane descended through 20 feet radio altitude at time 2450 seconds. The flaps remained in transition until they arrived at flaps 30 at time 2452 seconds, by which time the pitch attitude had decreased to approximately 0 degrees. Beginning at time 2454 seconds (16 feet radio altitude), numerous momentary airplane nose-up control column inputs were recorded.
The airplane descended through 10 feet radio altitude at time 2457 seconds. There was no discernable flare, and the pitch attitude remained relatively constant at approximately 0degrees until touchdown.
The airplane touched down at time 2463 seconds, as evidenced by a decrease in longitudinal acceleration, in combination with the transition of the AIR/GROUND discrete to GROUND(Figure 1.17). The landing reference speed (VREF) was not recorded; however, at flaps 30 and a weight of approximately 108,000 pounds (not shown), VREF would have been approximately 133 knots. Touchdown occurred at a computed airspeed of 158 knots(VREF+25), at a groundspeed of 176 knots, and with a maximum normal load factor of 1.5g‟s. Note that the airplane did not exceed the flap placard speed (identified by the upper barber pole), the landing gear operation speed, or the landing gear extended speed at any point during the approach (Figures 1.15 and 1.17).
Promptly after touchdown the thrust reversers deployed, the speedbrake handle extended, and brake pressure was applied (Figure 1.17). At time 2466 seconds, 3 seconds after touchdown, the flaps began to extend from flaps 30 to flaps 40. The commanded brake pressures had increased to the maximum of 3000 pounds per square inch (PSI) by time 2469 seconds, and by time 2473 seconds the engine N1s had stabilized at 80%, which is approximately equivalent to detent 2 reverse thrust. The airplane likely departed the paved surface around time 2477 seconds at a groundspeed of 50 knots, as evidenced by an increase in the perturbations in normal load factor, and a decrease in magnitude of longitudinal acceleration. Right control wheel and right pedal were also commanded at this time (Figure 1.18). The thrust reversers were stowed at time 2484 seconds at 25 knots ground speed, and the airplane came to a rest at time 2491 seconds (not plotted).
GROUND TRACK ANALYSIS
A ground track was generated to show the airplane‟s path during the end of the approach and the landing rollout (Figure 1.19). Longitudinal and lateral distances were calculated using a combination of inertial data (ground speed, drift angle, heading) and airport information (runway and pavement dimensions). As a final airplane location was unavailable, the distances were referenced to the runway longitudinally by aligning the change in normal load factor and longitudinal acceleration characteristics with the end of the paved surface.
Additionally, the distances were referenced to the runway laterally by aligning the touchdown and beginning of the rollout with the runway centerline. The assumptions relied on to generate this ground track are potential sources of error. The calculated ground track is representative; however, the absolute position may be inexact. In order to validate this calculation, the airplane‟s final position would be required.
The ground track analysis results indicate the airplane crossed the threshold at approximately 115 feet radio altitude and with a computed airspeed of around 195 knots (VREF+62) [not plotted]. The airplane touched down around 7400 feet beyond the runway threshold (2650feet prior to the end of the paved surface) [Figure 1.19]. The commanded brake pressures had reached the maximum of 3000 PSI around 1040 feet prior to the end of the paved surface, and the engine N1 stabilized at 80% around 490 feet prior to the end. As the airplane neared the end of the pavement, it began to deviate right of the centerline. The airplane came to a stop 10,600 feet beyond the runway threshold (600 feet beyond the end of the paved surface),and around 200 feet right of the extended runway centerline.
PRECONDITIONS FOR UNSAFE ACTS
The captain of the flight also stated that on 15 Sep 2017 he was operating a four sectors flight before the incident flight and arrived from it at midnight and until he reached his house it was approaching 2:30 am LT. the captain added that he slept at 4:30 am till 3:00 pm at which he received a phone call from company crew scheduling informing him that he has to report to a flight at 2:00 am next day 17 Sep 2017 (the incident flight). The captain stated that he could not sleep after the call. The aviation medicine doctor analyzed that the captain has to act against the natural body clock to modify his sleeping disorder. At the time of the departure the captain of the incident flight had been awake for 11 hours before the departure. Personal readiness of the captain was not observed as he did not manage his off duty activities and rest requirements. The captain of the incident flight did not make an optimum use of the opportunity for rest provided. The investigation committee concluded that the personnel readiness of the captain was not observed as he was not able to manage his off-duty and rest time before the commencement of that flight, in addition to what has been discussed earlier in subsection 1.13 regarding the captain physical status after using the medicines and acting against his natural body clock. Hence, it is believed that the captain personnel readiness was not utilized properly to ensure that he is able to perform his duties optimally.
Additionally; the CRM conversion training that should be provided by the operator for crew when changing operators is well defined by regulations and shall emphasize in depth on areas related to the organisation safety culture, SOPs, organisational factors and the importance of reporting. these requirements are outlined in OPS 1 Subpart Q with CRM requirements summarized as in the following table
The CRM course required for the captain when he joined solitaire air was not conducted as discussed earlier in 1.17.6 Flight Crew Training subsection, and this believed to be attributed to the insufficient and ineffective CRM skills shown by the crew during the incident flight.
UNSAFE SUPERVISION
Within the course of investigation it was evidenced that there was no adequate planning for this operation in terms of operational risk assessments and duty time planning. The lease operation was not introduced to flight operations department according to the captain of the incident flight who was the flight operations post holder at the time of the incident. Planning of such operations requires an operational assessments to identify the organisation limitations and preparedness in order to conduct a safe operation. That was not exercised systematically by the solitaire air departments.
The unsafe supervision was also evident when the management of the operator did not react with the identified deficiencies reported by the captain of the incident flight regarding safety related issues, such as the flight safety manuals that were found not relevant for the operated airplanes as in 1.17.4 and the duty time issues described in 1.17.5. these unsolved problems created an atmosphere in the company in which reporting is believed to be discouraged in contrary to the safety policy of the company, and that in turn created mistrust problems between the operating crew and their management.
Accountable managers and nominated post holders should take a leading role in developing an active safety culture within their organisation, so that SMS becomes an integral part of the management and work practices of the organization. Senior management commitment is crucial and this needs to be demonstrated on a regular basis. The investigation committee found that the safety culture in solitaire air was impaired with the company management attitude that was prioritizing the commercial and production interests over the safety requirements.
Safety Culture is the way safety is perceived, valued and prioritized in an organisation. It reflects the real commitment to safety at all levels in the organisation. It can have a direct impact on safe performance. If safety culture is not considered and evaluated properly in an organisation then workarounds, cutting corners, or making unsafe decisions or judgments will be the result, especially when there is a small perceived risk rather than an obvious danger.
During CARCs investigation and the following oversight activities conducted on solitaire air as discussed in 1.17.7 it was found that the under-reporting of hazards is evidenced in the company, the finding was discussed with different personnel working in solitaire air and found that this impairment in reporting culture was due to fears of recrimination or adding hardship to them from their management; and in some occasion risks may be under estimated because they came to believe that doing so, is what they are supposed to do.
The investigation committee has classified these findings as failure of solitaire air management to correct known problems by not developing corrective actions in response to the limited amount of available safety reports. Additionally, the investigation revealed that the management of the company was showing a pattern of supervisory violations as discussed earlier in this report.
3. CONCLUSIONS
3.1 FINDINGS
FINDINGS RELEVANT TO THE AIRCRAFT
a) The aircraft was certified, equipped, and maintained in accordance with the existing requirements of the Jordan Civil Aviation Regulations.
b) The aircraft was airworthy prior to Incident. There was no evidence of any defect or malfunction in the aircraft that could have contributed to the Incident
FINDINGS RELEVANT TO THE FLIGHT CREW
a) The crew had valid license and medical certificate. There was no evidence of crew incapacitation.
b) The PIC in this flight acted as PM and Copilot acted as PF;
c) The PIC accepted to land RWY19, while setup was made to land RWY01, according to this data, the arrival time was expected 05:20 UTC. The aircraft ALT was 15200 feet at GS of 378 knots;
d) The PIC took over the control second time during the flight ,when he accepted to change landing RWY from RWY01 to RWY19;
e) Copilot setup FMS for RWY19 and turned ILS frequency 110.9 at time 05:07:23UTC at ALT 12500 with IAS was 305knots and GS 362knots, were both pilots confirmed that ILS frequency inoperative;
f) The flight crew did not conduct descent checklist, approach checklist and landing checklist they changed the landing runway from RWY01 to RWY19;
g) The sink rate of descent recorded vary and up to 4240 feet per minute and below 500 feet radio altitude the sink rate was approximately 1200 fpm ;
h) There were several GPWS warning of „ SINK RATE, TOO LOW TERRAIN„ activated during approach and landing Phase ,were ignored by flight crew ;
i) The aircraft touched down at a computed airspeed of 158 knots ( VREF+25), at groundspeed of 176 knots; exceeding the SOP limitations set by aircraft manufacturer.
FINDINGS RELEVANT TO THE AIRCRAFT OPERATIONS
a) The wind conditions in which the pilot landed the aircraft were outside the limits detailed in the Flight Manual and the Operations Manual.
b) The continuation of the landing with airspeed above the calculated threshold speed resulted in touchdown beyond the normal touchdown point.
FINDINGS RELEVANT TO THE AIRCRAFT OPERATOR
a) The crew Resource management training arranged by the operator did not promote robust flight deck communication.
b) The flight duty period planned for this specific flight to DWC was 11:30 hrs and the maximum FDP is 12:00 hours, which shows a legal duty time planning; however; the planning was not realistically reflected on the actual and real conduct of the flights.
c) The onboard aircraft flight safety documents represented in the FCOM and QRH were not customized for the specific aircraft MSN and tail registration
d) The operation was not assessed properly in a way that the management of the organisation would be able to capture the hazards encountered or the deviation from regulations, standards and rules.
e) The company was not providing sufficiently the required crew resource and threat error management courses that helps in the effective use of all available resources for flight crew personnel to assure a safe and efficient operation, reducing error, avoiding stress and increasing efficiency.
f) The solitaire air management responsibility in developing and maintain the required standards of safety and quality management systems were not effectively observed in which it altered the organisational safety culture.
g) The Flight Data Monitoring was not utilized properly as a tool that support an effective monitoring of the flights conducted by the company.
3.2 CAUSE(S)
The cause of this Incident was Flight Crew failure to discontinue the Unstabilized Approach and their persistence in continuing with the landing despite 8 numbers of warning from EGWPS
3.3. CONTRIBUTING FACTORS
The following factors are believed to be the main causal factors of the occurrence:
a) The delay on ground OJAI for 47 minutes influenced crew decision to land on RWY19 at OJAQ to save time.
b) The straight in, unstabilized approach was the main result of the Aircraft high energy for the consecutive phases out from 1000 ft down to the touchdown point.
c) The higher than allowed tailwind component that recorded an average of 16 knots during final approach and landing phases.
d) Incorrect landing configuration was a contributing factor for Aircraft high speed and explain pilot flying inability to control the prolonged float of the Aircraft and the ability to roll it out.
e) The pilot monitoring (Captain) was aware of the tailwind, however he accepted the prevailing conditions without discussing the operational limitations of the Aircraft with the pilot flying.
f) Crew inaction to discontinue the unstabilized approach and make a go around helped in the developed situation.
g) Crew poor situational awareness and lack of coordination.
h) Deliberate Disregard of the aural warnings without correcting the Aircraft attitude.
i) Lack of cockpit management (CRM) for task sharing and decision making. Crew resource management (CRM) was not evident during the approach phase of flight
j) Failure of the airline to provide its pilots with clear and consistent guidance and training regarding company policies and procedures related to stabilization criteria and the necessary actions to be followed including the conduct of go around.
k) inability to recognize the two critical elements, namely fixation and complacency that affected pilot decision to land the aircraft while the approach was not meeting the stabilization criteria
l) Negative organizational factors were evidenced in terms of operational pressure that was exerted by the management of Solitaire air.
m) Inadequate risk management by the operator as the repeated reports of duty time exceedances were not known or observed by the operational safety management
n) Noncompliance to state regulations regarding the proper training of crews was found a contributing factor as the PIC CRM conversion training was not completed in a correct way.
o) Non availability of customized flight safety documents (FCOM, FCTM and QRH) which includes the manufacture recommended standard operating procedures.
4. RECOMMENDATIONS
4.1 SOLITAIRE AIR
It is recommended that solitaire air:
1. review the crew resource management and threat error management training and refreshers for all flight crew and incorporate the threat and error management on both classrooms and simulator sessions.
2. Emphasize on go around maneuvers whenever required and specially when the approach is found unstabilized on both instrument and visual metrological conditions and encouraging company pilots to report unstabilized approaches whenever they happen.
3. Provide copilots with necessary training related to assertiveness.
4. Review the reporting policy and monitor the effectiveness implementation of it in terms maintaining the confidentiality of the reporters and developing the required management follow ups and controlling measures. The Operator should have a sound and effective non-punitive safety reporting system that shall be implemented throughout the organization in all areas where operations are conducted.
5. Review the safety management system in the company and provide the staff with the required effective SMS training, by emphasizing on the methods required to create a safety culture within the organisation
6. Review crew duty time rules in a way that a more realistic duty time calculations is to be considered, including the factors that may affect the compliance to CARC regulations.
7. Develop a more effective flight data monitoring that enables the management to address the hazards encountered during the ongoing operations and helps in providing corrective actions proactively through trends analysis of the captured operational deviations. This can be made by more frequent data download and analysis.
8. Conduct a more frequent co-ordination meetings between various operational departments to discuss the challenges encountered and provide ongoing follow ups for the corrective actions required.
9. Provide the required arrangements to maintain the consistency of operations and flight safety documents (FCOM, QRH, FCTM, etc.) in order to provide the operating crew with the correct and customized SOPs.
4.2 CARC
1. It is recommended that the Flight Standards Directorate increase surveillance of AOC holders with emphasis on the actions of flight crew and their adherence to SOPs by conducting more frequent flight deck observations.
2. It is recommended that Flight Standards Directorate review the operators flight safety documents to ensure that they are customized to the types and registrations of airplanes operated by each operator.
3. It is recommended that CARC inspectors evaluate the accountable manager and post holders in terms of their responsibilities and authorities to ensure that they are able to demonstrate a commitment to the management of safety and a sound knowledge of safety management system principles and practices within the organisation for which they are responsible including, in particular, knowledge of their own role.
The full final report can be read here. |
JY-SOA 737-300 Unstable approach and overrun
