Pilot fatigue and faster approach led to January 2012 runway overrun in Fort Nelson, British Columbia
Edmonton, Alberta, 25 April 2013 — The Transportation Safety Board of Canada (TSB) today released its investigation report (A12W0004) into the 9 January 2012 runway overrun of a Boeing 737-700 operated by Enerjet in Fort Nelson, British Columbia.
The Boeing 737 was flying from Fort St. John to Fort Nelson, British Columbia, with 112 passengers and 6 crew members on board. The crew flew a visual approach backed up by the instrument landing system to land at Fort Nelson. The approach speed was slightly faster than normal, resulting in the touchdown occurring beyond the recommended touchdown point on the runway, thus reducing the distance available to stop the aircraft. The autothrottle system, which automatically controls engine power during flight, was not disengaged. The system increased engine power slightly after touchdown. This led to the late application of the thrust reversers and speed brakes, which are used to help stop the aircraft along with the brakes. The aircraft overran the runway by 230 feet. There were no injuries or damage to the aircraft.
The crew was not following the descent path indicated by the instrument landing system, which led to a faster approach. The faster approach and the autothrottle being left on for the touchdown contributed to the overrun. In addition, the investigation uncovered that the captain did not get sufficient sleep in the 24 hours before the flight. Fatigue adversely affects judgement and the ability to adequately evaluate and manage operational risks.
Since the occurrence, Enerjet has taken measures to increase awareness of the fatigue self-awareness tool in its company operations manual. The company has also reiterated the importance of making honest self-assessments of fitness for duty, and that booking off duty in cases of illness, stress or fatigue is non-punitive.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation 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.
For more information, contact:
Transportation Safety Board of Canada
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