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|
Attributes | |
ACN | 263547 |
Time | |
Date | 199402 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dca |
State Reference | DC |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | Marginal |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tower : bos |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 190 flight time total : 6300 flight time type : 2900 |
ASRS Report | 263547 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | inflight encounter other other anomaly other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : unable |
Consequence | Other |
Supplementary | |
Primary Problem | Weather |
Air Traffic Incident | other |
Narrative:
We anticipated deteriorating WX all day. By preflight time, I was surprised that current WX report did not reflect this. I asked first officer to test autolands on preflight, and called dispatch to verify current and forecast WX and alternates. Fuel planning was more than sufficient for holding and/or diversion, alternates were excellent. En route I asked first officer to request alternate WX from ACARS and we discussed the need for braking action reports. I anticipated icing conditions close to the ground, and turned on engine and airfoil anti-ice in the descent even though not as yet required. We were vectored to intercept the final some 30 mi out and cleared for the ILS 36 approach approximately 20 mi out. I briefed the approach and planned to fly it at vref plus 10 KTS, 5 KTS faster than normal due to: forecast possible LLWS, frontal related rough ride/LLWS 1 hour earlier at rdu, report from tower of moderate turbulence on final below 2500 ft. Tower reported braking action good by a 737 and did not indicate a wet runway. I elected to use minimum autobrakes in accordance with company policy. The last 1000 ft was flown on course and on GS at approach speed. Touchdown was right on the 1000 ft stripe and normal reversing initiated immediately with approximately 1.5 EPR. Initial deceleration appeared normal. Approximately abeam taxiway M and 90 KTS, I began a transition to manual braking and appeared to be in position to turn off at runway 33. At this point I felt no braking action and pressed the brake pedals further, with no response. Nearing the runway 33 intersection, I applied maximum brake pressure and said aloud that I did not think we would stop, as the braking action was nil. To my knowledge, the first officer made all standard callouts throughout the approach and landing. In the last 1000 ft of runway we gradually slowed from a fast taxi speed to a slow taxi speed as we entered the overrun. I was cognizant of maintaining reverse thrust throughout in order to depart the pavement at as slow a speed as possible to prevent damage. I also attempted to steer slightly right of centerline to avoid the approach lights from runway 18. We came to rest approximately 50 ft from pavement end, whereupon I stowed spoilers, checked flaps at land, and considered evacuate/evacuation. I was aware that the first officer called the tower and requested assistance prior to stopping. With no apparent fire or damage and after checking for the same with the tower, I informed the tower that we would wait for the crash crew to check us out and did not anticipate evacuating. I confirmed this with the first officer, then made a PA to let passenger and crew know of my plan. Jumpseat rider volunteered to check cabin for problems, and he and the flight attendants reported none. First officer called company to coordinate tug crew/passenger buses. We started the APU, shut the engines down, and completed the parking checklist. After aircraft movement proved impossible, I directed an orderly deplaning via the aft airstairs. Flight attendants, crash crew personnel and the jumpseat rider monitored from the rear and outside the aircraft. There were no reported injuries nor damage to aircraft or runway. I then completed an aircraft logbook entry to inspect for gear and flap contamination and reported to the flight office for debriefing. Critical in this episode is timely dissemination of pertinent information. In the rapidly changing WX environment that afternoon, I was expecting things to be worse than actually reported. Exactly when was the braking action report of 'good?' why was there no report of runway contamination? Does the PIC have to ask for a long list of suspected problems in a busy ATC/flight environment? Once in the landing phase, it is clear that any early deceleration is better, such as maximum reverse thrust immediately and/or medium setting on autobrakes. This would ensure maximum aerodynamic braking and some wheel braking in the touchdown zone, if available friction permits. These measures would be overkill in many sits, such as long runways, but welcome on shorter runways (8000 ft or less?) where, even with only light rain, braking action can be poor to nil (not for past the midpoint) from opposite direction landing rubber deposits. The final element is to consciously ensure maximum reverse once you've begun to slide, as brakes will be completely ineffective on ice. This is not something currently in our training, however, and may need to be emphasized. The single biggest preventive measure in this case is communication, especially regarding actual conditions versus forecast and reported.
Original NASA ASRS Text
Title: RWY EXCURSION AFTER MLG EXPERIENCES LOSS OF ACFT CTL ON RWY CONDITION ICE. AIRLINE MGMNT POLICY OPERATIONAL PROCS FOLLOWED FOR REVERSING TECHNIQUE AND AUTO BRAKE SETTING.
Narrative: WE ANTICIPATED DETERIORATING WX ALL DAY. BY PREFLT TIME, I WAS SURPRISED THAT CURRENT WX RPT DID NOT REFLECT THIS. I ASKED FO TO TEST AUTOLANDS ON PREFLT, AND CALLED DISPATCH TO VERIFY CURRENT AND FORECAST WX AND ALTERNATES. FUEL PLANNING WAS MORE THAN SUFFICIENT FOR HOLDING AND/OR DIVERSION, ALTERNATES WERE EXCELLENT. ENRTE I ASKED FO TO REQUEST ALTERNATE WX FROM ACARS AND WE DISCUSSED THE NEED FOR BRAKING ACTION RPTS. I ANTICIPATED ICING CONDITIONS CLOSE TO THE GND, AND TURNED ON ENG AND AIRFOIL ANTI-ICE IN THE DSCNT EVEN THOUGH NOT AS YET REQUIRED. WE WERE VECTORED TO INTERCEPT THE FINAL SOME 30 MI OUT AND CLRED FOR THE ILS 36 APCH APPROX 20 MI OUT. I BRIEFED THE APCH AND PLANNED TO FLY IT AT VREF PLUS 10 KTS, 5 KTS FASTER THAN NORMAL DUE TO: FORECAST POSSIBLE LLWS, FRONTAL RELATED ROUGH RIDE/LLWS 1 HR EARLIER AT RDU, RPT FROM TWR OF MODERATE TURB ON FINAL BELOW 2500 FT. TWR RPTED BRAKING ACTION GOOD BY A 737 AND DID NOT INDICATE A WET RWY. I ELECTED TO USE MINIMUM AUTOBRAKES IAW COMPANY POLICY. THE LAST 1000 FT WAS FLOWN ON COURSE AND ON GS AT APCH SPD. TOUCHDOWN WAS RIGHT ON THE 1000 FT STRIPE AND NORMAL REVERSING INITIATED IMMEDIATELY WITH APPROX 1.5 EPR. INITIAL DECELERATION APPEARED NORMAL. APPROX ABEAM TXWY M AND 90 KTS, I BEGAN A TRANSITION TO MANUAL BRAKING AND APPEARED TO BE IN POS TO TURN OFF AT RWY 33. AT THIS POINT I FELT NO BRAKING ACTION AND PRESSED THE BRAKE PEDALS FURTHER, WITH NO RESPONSE. NEARING THE RWY 33 INTXN, I APPLIED MAX BRAKE PRESSURE AND SAID ALOUD THAT I DID NOT THINK WE WOULD STOP, AS THE BRAKING ACTION WAS NIL. TO MY KNOWLEDGE, THE FO MADE ALL STANDARD CALLOUTS THROUGHOUT THE APCH AND LNDG. IN THE LAST 1000 FT OF RWY WE GRADUALLY SLOWED FROM A FAST TAXI SPD TO A SLOW TAXI SPD AS WE ENTERED THE OVERRUN. I WAS COGNIZANT OF MAINTAINING REVERSE THRUST THROUGHOUT IN ORDER TO DEPART THE PAVEMENT AT AS SLOW A SPD AS POSSIBLE TO PREVENT DAMAGE. I ALSO ATTEMPTED TO STEER SLIGHTLY R OF CTRLINE TO AVOID THE APCH LIGHTS FROM RWY 18. WE CAME TO REST APPROX 50 FT FROM PAVEMENT END, WHEREUPON I STOWED SPOILERS, CHKED FLAPS AT LAND, AND CONSIDERED EVAC. I WAS AWARE THAT THE FO CALLED THE TWR AND REQUESTED ASSISTANCE PRIOR TO STOPPING. WITH NO APPARENT FIRE OR DAMAGE AND AFTER CHKING FOR THE SAME WITH THE TWR, I INFORMED THE TWR THAT WE WOULD WAIT FOR THE CRASH CREW TO CHK US OUT AND DID NOT ANTICIPATE EVACUATING. I CONFIRMED THIS WITH THE FO, THEN MADE A PA TO LET PAX AND CREW KNOW OF MY PLAN. JUMPSEAT RIDER VOLUNTEERED TO CHK CABIN FOR PROBS, AND HE AND THE FLT ATTENDANTS RPTED NONE. FO CALLED COMPANY TO COORDINATE TUG CREW/PAX BUSES. WE STARTED THE APU, SHUT THE ENGS DOWN, AND COMPLETED THE PARKING CHKLIST. AFTER ACFT MOVEMENT PROVED IMPOSSIBLE, I DIRECTED AN ORDERLY DEPLANING VIA THE AFT AIRSTAIRS. FLT ATTENDANTS, CRASH CREW PERSONNEL AND THE JUMPSEAT RIDER MONITORED FROM THE REAR AND OUTSIDE THE ACFT. THERE WERE NO RPTED INJURIES NOR DAMAGE TO ACFT OR RWY. I THEN COMPLETED AN ACFT LOGBOOK ENTRY TO INSPECT FOR GEAR AND FLAP CONTAMINATION AND RPTED TO THE FLT OFFICE FOR DEBRIEFING. CRITICAL IN THIS EPISODE IS TIMELY DISSEMINATION OF PERTINENT INFO. IN THE RAPIDLY CHANGING WX ENVIRONMENT THAT AFTERNOON, I WAS EXPECTING THINGS TO BE WORSE THAN ACTUALLY RPTED. EXACTLY WHEN WAS THE BRAKING ACTION RPT OF 'GOOD?' WHY WAS THERE NO RPT OF RWY CONTAMINATION? DOES THE PIC HAVE TO ASK FOR A LONG LIST OF SUSPECTED PROBS IN A BUSY ATC/FLT ENVIRONMENT? ONCE IN THE LNDG PHASE, IT IS CLR THAT ANY EARLY DECELERATION IS BETTER, SUCH AS MAX REVERSE THRUST IMMEDIATELY AND/OR MEDIUM SETTING ON AUTOBRAKES. THIS WOULD ENSURE MAX AERODYNAMIC BRAKING AND SOME WHEEL BRAKING IN THE TOUCHDOWN ZONE, IF AVAILABLE FRICTION PERMITS. THESE MEASURES WOULD BE OVERKILL IN MANY SITS, SUCH AS LONG RWYS, BUT WELCOME ON SHORTER RWYS (8000 FT OR LESS?) WHERE, EVEN WITH ONLY LIGHT RAIN, BRAKING ACTION CAN BE POOR TO NIL (NOT FOR PAST THE MIDPOINT) FROM OPPOSITE DIRECTION LNDG RUBBER DEPOSITS. THE FINAL ELEMENT IS TO CONSCIOUSLY ENSURE MAX REVERSE ONCE YOU'VE BEGUN TO SLIDE, AS BRAKES WILL BE COMPLETELY INEFFECTIVE ON ICE. THIS IS NOT SOMETHING CURRENTLY IN OUR TRAINING, HOWEVER, AND MAY NEED TO BE EMPHASIZED. THE SINGLE BIGGEST PREVENTIVE MEASURE IN THIS CASE IS COM, ESPECIALLY REGARDING ACTUAL CONDITIONS VERSUS FORECAST AND RPTED.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.