Air Accidents Investigation Branch Department For Transport
AIRCRAFT ACCIDENT REPORT 1/2009Air Accidents Investigation BranchDepartment for TransportReport on the serious incidents toBoeing 737-81Q, registration G-XLACon 29 December 2006Avions de Transport Regional ATR-72-202,registration G-BWDA on 29 December 2006Embraer EMB-145EU, registration G-EMBOon 29 December 2006 andBoeing 737-81Q, registration G-XLACon 3 January 2007at Runway 27, Bristol International AirportThis investigation was carried out in accordance withThe Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996The sole objective of the investigation of an accident or incident under these Regulationsshall be the prevention of accidents and incidents. It shall not be the purpose of such aninvestigation to apportion blame or liablility.
Crown Copyright 2009Published with the permission of the Department for Transport (Air Accidents Investigation Branch).This report contains facts which have been determined up to the time of publication. This informationis published to inform the aviation industry and the public of the general circumstances of accidents andserious incidents.Extracts can be published without specific permission providing that the source is duly acknowledged.Published 9 January 2009Printed in the United Kingdom for the Air Accidents Investigation Branchii
RECENT FORMAL AIRCRAFT ACCIDENT AND INCIDENT REPORTSISSUED BY THE AIR ACCIDENTS INVESTIGATION BRANCHTHE FOLLOWING REPORTS ARE AVAILABLE ON THE INTERNET AThttp://www.aaib.gov.uk6/2007Airbus A320-211, JY-JARat Leeds Bradford Airporton 18 May 2005.December 20077/2007Airbus A310-304, F-OJHIon approach to Birmingham International Airporton 23 February 2006.December 20071/2008Bombardier CL600-2B16 Challenger 604, VP-BJM8 nm west of Midhurst VOR, West Sussexon 11 November 2005.2/2008Airbus A319-131, G-EUOBJanuary 2008during the climb after departure from London Heathrow Airporton 22 October 2005.3/2008British Aerospace Jetstream 3202, G-BUVCat Wick Aerodrome, Caithness, Scotlandon 3 October 2006.February 20084/2008Airbus A320-214, G-BXKDat Runway 09, Bristol Airporton 15 November 2006.February 20085/2008Boeing 737-300, OO-TNDat Nottingham East Midlands Airporton 15 June 2006.6/2008Hawker Siddeley HS 748 Series 2A, G-BVOVat Guernsey Airport, Channel Islandson 8 March 2006.7/2008Aerospatiale SA365N, G-BLUNnear the North Morecambe gas platform, Morecambe Bayon 27 December 2006.iiiJanuary 2008April 2008August 2008October 2008
Department for TransportAir Accidents Investigation BranchFarnborough HouseBerkshire Copse RoadAldershotHampshire GU11 2HHDecember 2008The Right Honourable Geoff HoonSecretary of State for TransportDear Secretary of StateI have the honour to submit the report by Mr K Conradi, an Inspector of Air Accidents,on the circumstances of the serious incidents to Boeing 737-81Q, registration G-XLAC,Avions de Transport Regional ATR-72-202, registration G-BWDA and EmbraerEMB‑145EU, registration G-EMBO at Runway 27, Bristol International Airport on29 December 2006 and 3 January 2007.Yours sincerelyDavid KingChief Inspector of Air Accidentsiv
ContentsSynopsis. 21Factual Information. 4Events prior to 29 December 2006. 41.1History of the flights. 51.1.1G-XLAC (Boeing 737-800) 29 December 2006 at 1150 hrs. 51.1.2G-BWDA (ATR-72) 29 December 2006 at 1215 hrs. 61.1.3G-EMBT (Embraer 145) 29 December 2006 at 2001 hrs. 81.1.4G-EMBO (Embraer 145) on 29 December 2006 at 2133 hrs. 91.1.5Events between 29 December 2006 and 3 January 2007. 111.1.6G-XLAC (Boeing 737-800) 3 January 2007. 121.2Injuries to persons . 131.2.1Injuries to persons – G-XLAC 29 December 2006. 131.2.2Injuries to persons – G-BWDA 29 December 2006. 131.2.3Injuries to persons – G-EMBO 29 December 2007. 131.2.4Injuries to persons – G-XLAC 3 January 2007. 131.3Damage to the aircraft. 131.4Other damage. 141.5Personnel information. 141.6Aircraft information. 141.6.1G-XLAC aircraft information. 141.6.1.1Boeing 737-800 general description. 141.6.1.2Boeing 737-800 control system description. 151.6.1.3Boeing 737-800 brake system description. 151.6.1.3.1 Boeing 737-800 antiskid system- normal brakes. 151.6.1.3.2 Boeing 737-800 autobrake system. 161.6.1.4Boeing 737-800 tyre pressures. 161.6.1.5Boeing 737-800 performance. 171.6.2G-BWDA aircraft information. 171.6.2.1ATR 72 general description. 171.6.2.2ATR 72 control system description. 181.6.2.3ATR 72 brake system description. 191.6.2.4ATR 72 reverse thrust description. 191.6.2.5ATR 72 performance . . 191.6.2.6ATR 72 operations in strong crosswinds. 20v
1.6.3G-EMBO aircraft information. 201.6.3.1Embraer 145 general description. 211.6.3.2Embraer 145 control system description. 211.6.3.3Embraer 145 brake system description. 221.6.3.4Embraer 145 performance. 221.7Meteorological information . 221.7.1Meteorological information relating to 29 December 2006. 221.7.2Meteorological information relating to 3 January 2007. 231.7.3Reported runway conditions for 29 December 2006and 3 January 2007. 241.8Aids to navigation. 241.9Communications. 241.9.1Runway state reporting means and methods. 241.9.2Braking Action. 261.9.3UK AIP. 271.9.4‘Slippery when wet’. 281.9.5Notice to Aerodrome Licence Holders (NOTAL) 9/2006. 281.9.6Operational advice and information to flight crews. 291.9.7RFFS Communication. 301.10 Aerodrome information . 311.10.1 General . . 311.10.2 Runway resurfacing . 311.10.2.1 Requirements for runway surfaces. 311.10.2.2 Runway resurfacing work at BIA . 321.10.2.3 Runway rectification work following incidentson 29 December 2006 and 3 January 2007. 351.10.2.5 Independent runway surface inspectionon 7 January 2007. 371.11 Flight Recorders. 371.11.1 Longitudinal Effects on G-XLAC. 371.11.1.1Deceleration vs. Runway Position. 381.11.1.2Deceleration Components. 381.11.1.3Braking Coefficient. 411.11.2 Lateral Effects. 431.11.2.1G-BWDA. 431.11.2.2G-EMBO. 44vi
1.12 Aircraft examinations . 451.12.1 G-BWDA examination. 451.12.2 G-EMBO examination. 461.12.3 G-XLAC examination. 461.13 Medical and pathological information. 461.14 Fire. 461.15 Survival aspects. 461.16 Tests and research. 461.17 Organisational and management information. 461.17.1 ICAO and CAA action. 471.18 Additional information. 481.18.1 Friction Measuring Equipment. 501.18.1.1 Douglas Mu-meter Mk6 CFME . . 501.18.2 Friction Measurement Data from BIA. 511.18.3 Previous runway resurfacing works at Luton Airport. 561.18.4 Previous runway resurfacing works at Belfast City Airport . 571.18.5 Risk assessment carried out by BIA prior to runwayresurfacing works. 571.18.6 Hydroplaning. 581.18.6.1 Estimated dynamic hydroplaning speeds forthe incident aircraft. 591.18.7 National Transportation Safety Board (NTSB) (USA)N471WN Chicago Midway International Airport investigation. 601.18.8 Previous incidents and AAIB Safety Recommendations. 612Analysis. 622.1Runway resurfacing. 622.1.1Planning of resurfacing works. 622.2Hydroplaning. 642.3Operation of the aircraft. 652.3.1G-XLAC. 652.3.2G-BWDA. 662.3.2.1Aircraft loading. 662.3.2.2Crosswind component. 662.3.2.3Runway condition. 662.3.2.4Effects of aileron handling and reverse thrust . 672.3.2.5NOTAMs. 672.3.3G-EMBO. 67vii
342.4Runway state reporting . 682.5FODCOMs as a means of promulgating operational safety information. 692.6CFME and wet runways. 702.7ATC. 712.8Braking coefficient. 722.9Communications. 732.9.1Safety action. 73Conclusions. 743.1Findings. 743.1.1The aircraft. 743.1.2The runway. 743.1.3Flight operations. 753.1.4Air traffic control. 763.2Causal Factors. 773.3Contributory Factors. 77Safety Recommendations. 78AppendicesAppendix ABIA Runway Condition at 29 December 2006Appendix BAdditional Mu-meter Friction MeasurementsAppendix CAdditional Figures from FDR DataAppendix DDiagrams of G-BWDA and G-EMBO Runway ExcursionsAppendix EFlight crew detailsAppendix FThe ‘Snow and Ice Table’viii
GLOSSARY OF ABBREVIATIONS USED IN THIS REPORTAAIBAir Accidents InvestigationBranchaalabove airfield levelAICAeronautical InformationCircularAIPAeronautical InformationPublicationamslabove mean sea levelAOSWGAerodrome Operations andServices Working GroupASUAerodrome Safety UnitATCAir Traffic ControlATISAutomatic Terminal InformationSystemBIABristol International AirportCAACivil Aviation AuthorityCAPCivil air PublicationCFMEContinuous Friction MeasuringEquipmentCVRCockpit Voice Recorder Cdegrees CelsiusDOLDesign Objective LevelEASAEuropean Aviation Safety AgencyFCOMFlight Crew Operating ManualFDMFlight Data MonitoringFDRFlight Data RecorderFLflight levelFMCFlight Management ComputerFODForeign Object DamageFODCOM Flight Operations DepartmentCommunicationftfeetft/s2feet per second squaredgnormal accelerationHDMHeavy Duty Macadamhrshours (clock time as in 12:00 hrs)hzhertzICAOInternational Civil AviationOrganizationILSInstrument landing systemkgkilogram(s)KIASknots indicated anding Distance sipsigPSVRFFSRHPSrpmTAFUTCixmetre(s)Manual of Air Traffic Servicesa timed aerodromemeteorological reportMinimum Friction Levelmegahertzminutesmillimetre(s)Mandatory Occurrence ReportNotice to Aerodrome LicenceHoldersNotice to AirmenPower Control Unitspounds per square inchpounds per square inch gaugePolished Stone ValueRescue and Fire Fighting ServiceRudder Hardover ProtectionSystemrevolutions per minuteTerminal Aerodrome ForecastCo-ordinated Universal Time(GMT)
Air Accidents Investigation BranchAircraft Incident Report No:1/2009(EW/C2006/12/05)Three aircraft were involved in the principal events described in this report:(i)Aircraft No 1 (This aircraft was involved in two events)Registered Owner and Operator:XL Airways UK LtdAircraft Type and Model:Boeing 737-81QRegistration:G-XLACPlace of Incident:Runway 27, Bristol International AirportLatitude:51 22' NLongitude:002 43' WDate and Time:(i) 29 December 2006 at 1150 hrs(ii) 3 January 2007 at 1832 hrs(ii)Aircraft No 2Registered Owner and Operator:Aurigny Air Services LtdAircraft Type and Model:Avions de Transport Regional ATR-72-202Registration:G-BWDAPlace of Incident:Runway 27, Bristol International AirportDate and Time:29 December 2006 at 1215 hrs(iii) Aircraft No 3Registered Owner and Operator:British Airways CitiExpress PLCAircraft Type and Model:Embraer EMB-145EU1
Registration:G-EMBOPlace of Incident:Runway 27, Bristol International AirportDate and Time:29 December 2006 at 2133 hrsAll times in this report are UTC unless otherwisestated.SynopsisThe serious incidents involving G-BWDA and G-EMBO were notified to the Air AccidentsInvestigation Branch (AAIB) on 29 December 2006. An investigation into the two seriousincidents began on 2 January 2007. During this investigation, the events involving G-XLAC,and others, were identified. All events took place during landings at Bristol InternationalAirport, hereafter referred to as BIA.The AAIB investigation team comprised:Mr K ConradiMr T J AtkinsonMr S J HawkinsMr C J ing)(Flight Recorders)Resurfacing and re-profiling work was taking place on parts of the runway at BIA as part ofa major project to resurface the manoeuvring area pavements, and sections of the runwaysurface were ungrooved ‘base course’ asphalt. From 14 November 2006, there werereports from flight crew of a variety of problems related to the friction characteristics of thetemporary runway surface, though no serious incidents occurred until 29 December 2006.On that day, the flight crew of G-XLAC experienced poor stopping performance duringlanding. Later that day, the flight crew of G-BWDA experienced stopping and lateral controldifficulties during landing, and the aircraft departed the runway surface and came to rest onthe grass area at the side of the runway. Later still, the flight crew of G-EMBO experiencedlateral control difficulties during landing, and the aircraft partially left and then regained therunway. On 3 January 2007, another flight crew, also operating G-XLAC, experienced poorstopping performance. The airport was subsequently closed whilst grooves were cut in thebase course. After it re-opened there were no further incidents.2
The investigation identified the following causal factors:1.Reduced friction on the wet ungrooved base course sections of therunway caused flight crews to experience reduced braking action andreduced lateral controllability on landing in strong crosswinds.2.The Flight Operations Department Communication (FODCOM)advice published by the CAA regarding operations on runways notified‘slippery when wet’, in wet conditions, was not communicated byoperators to flight crews.3.The passing, by ATC, of braking action reports based on Mu-meterfriction assessments, gave flight crews a false confidence in the brakingaction available on the wet runway.The investigation identified the following contributory factor:1.G-BWDA landed in a crosswind outside the operator’s published limitsand the subsequent use of reverse thrust was contrary to the advicecontained in the company’s Operations Manual.The AAIB has made five Safety Recommendations.3
1Factual InformationEvents prior to 29 December 2006On 1 November 2006, the aerodrome authority began a programme of runwayresurfacing and re-profiling as part of a majo
Air Accidents Investigation Branch Department for Transport Report on the serious incidents to Boeing 737-81Q, registration G-XLAC on 29 December 2006 Avions de Transport Regional ATR-72-202, registration G-BWDA on 29 December 2006 Embraer EMB-145EU, registration G-EMBO on 29 December 2006 and Boeing 737-81Q, registration G-XLAC on 3 January 2007
Memorandum on the investigation of civil air accidents 3 4 The Accidents Investigation Branch The Accidents Investigation Br (nch (AlB) is part of the Department of Trade (not part of the Civil Aviation Authority) and the Chief Tnspector of Accidents is responsible directly to the Secretary of State for Trade. The offices of the Branch arc .
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