Pilot fatigue and fast approach lead to Boeing 737 runway overrun

Edmonton – The Transportation Safety Board of Canada (TSB) released its investigation report (A12W0004) into the January 9th, 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 six crew members on board. ENJ401 overran the runway end by about 230 feet. There were no injuries to the passengers or crew members and no damage to the aircraft.
The flight was being operated under Canadian Aviation Regulations (CARs) Subpart 705. The flight was sub-chartered through North Cariboo Flying Service Ltd. for Worley Parsons’ employees commuting to Fort Nelson for work. ENJ401 made stops in Edmonton, Alberta, and Fort St. John, British Columbia, to pick up passengers.
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. 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. The main landing gear was on frozen soil and the nose gear was in approximately 18 inches of snow.
The aircraft engines remained running for approximately 70 seconds as the flight crew determined the level of damage and possible injuries. The engines were shut down and the shutdown checklist was completed.
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Initially, Fort Nelson Fire Rescue responded with one 1,500 gallon water pump truck, a rescue truck, and a pickup truck from town, 9 kilometres from the airport. They were turned back when the flight crew identified that they did not need emergency assistance as there were no indications of fire, damage, or injuries to passengers or crew.
The Fort Nelson Airport is certified by Transport Canada and operated by the Northern Rockies Regional District. It has 2 runways, the primary being 03/21. Runway 03/21 is designated a Code 4 runway as per Transport Canada’s Aerodromes Standards and Recommended Practices (TP312), and is 6,402 feet long, 200 feet wide, and features no slope. The elevation of the runway is 1,253 feet asl. A variety of instrument approaches serve the airport including an ILS to Runway 03.
Although no formal runway end safety area was designed into Runway 0,3 as recommended in Section 3.1.7 of TP312, the terrain up to 150 metres beyond the runway end is free of obstacles and is graded such that rescue vehicles can manoeuver effectively around an aircraft in that area.
Aircraft rescue and fire-fighting (ARFF) services are not available at the airport, nor are they required by regulation.
CARs 303 stipulates that an airport has to handle more than 180 000 passengers per year to require ARFF. In 2011, Fort Nelson handled 34,206 passengers, and there were 22,050 aircraft movements.
Emergency response for the airport is handled by Fort Nelson Fire and Rescue. Response time from the town to the airport is estimated to be 7 minutes. Additional emergency resources may be available from the oil and gas industry located in and around Fort Nelson.
Flight crew
Records indicate that the flight crew was certified and qualified for the flight in accordance with existing regulations.
The captain had approximately 7,500 hours total flight time with 2,000 hours on type and 50 hours as pilot-in-command. The occurrence flight was the first flight for the captain as a captain with a line first officer. Line indoctrination and flight evaluation reports indicated that his recent upgrade to a captain had gone well and he had been described by his peers and management as a conscientious and knowledgeable pilot. The captain had been off work for 14 days prior to the occurrence.
The captain’s residence was not conducive to attaining good quality sleep as the bedroom, located above the boiler room of the apartment complex, was noisy and warm. The captain had had little to no sleep in the 24-hours prior to the flight and considered calling in sick, but due to the time off felt it would not be viewed in a favourable light. There were no indications that the culture at Enerjet was punative towards crew calling in sick for fatigue.
The first officer had approximately 5,600 hours total flight time with about 700 hours on type as second-in-command. The first officer had been off for 38 days prior to the occurrence. He had achieved 6.5 hours of sleep prior to checking in at 6:00 am
The Enerjet Employee Policy Manual states that all employees are responsible for their attendance and punctuality, and for arriving at work fit for duty. This policy is consistent with CARs 602.02 – Fitness of Flight Crew Members. The policy is silent on matters specifically related to fatigue. Fatigue
Fatigue often results from the combination of and the interaction between a person’s work schedule and the social and domestic pressures that reduce the opportunity for and quality of sleep.

Initially, Fort Nelson Fire Rescue responded with one 1,500 gallon water pump truck, a rescue truck, and a pickup truck from town, nine kilometres from the airport. They were turned back when the flight crew identified that they did not need emergency assistance as there were no indications of fire, damage, or injuries to passengers or crew.
The Fort Nelson Airport is certified by Transport Canada and operated by the Northern Rockies Regional District. It has two runways, the primary being 03/21. Runway 03/21 is designated a Code 4 runway as per Transport Canada’s Aerodromes Standards and Recommended Practices (TP312), and is 6,402 feet long, 200 feet wide, and features no slope. The elevation of the runway is 1,253 feet above sea level (asl). A variety of instrument approaches serve the airport including an instrument landing system (ILS) to Runway 03.
Although no formal runway end safety area was designed into Runway 03, as recommended in Section 3.1.7 of TP312, the terrain up to 150 metres beyond the runway end is free of obstacles and is graded such that rescue vehicles can manoeuvre effectively around an aircraft in that area.
Aircraft rescue and fire-fighting (ARFF) services are not available at the airport, nor are they required by regulation.
CARs 303 stipulates that an airport has to handle more than 180,000 passengers per year to require ARFF. In 2011, Fort Nelson handled 34,206 passengers, and there were 22,050 aircraft movements.
Emergency response for the airport is handled by Fort Nelson Fire and Rescue. Response time from the town to the airport is estimated to be seven minutes. Additional emergency resources may be available from the oil and gas industry located in and around Fort Nelson.
Flight crew
Records indicate that the flight crew was certified and qualified for the flight in accordance with existing regulations.
The captain had approximately 7,500 hours total flight time with 2,000 hours ‘on type’ and 50 hours as pilot-in-command. The occurrence flight was the first flight for the captain as a captain with a line first officer. Line indoctrination and flight evaluation reports indicated that his recent upgrade to a captain had gone well and he had been described by his peers and management as a conscientious and knowledgeable pilot. The captain had been off work for 14 days prior to the occurrence.
The captain’s residence was not conducive to attaining good quality sleep as the bedroom, located above the boiler room of the apartment complex, was noisy and warm. The captain had had little to no sleep in the 24-hours prior to the flight and considered calling in sick, but due to the time off felt it would not be viewed in a favourable light. There were no indications that the culture at Enerjet was punative towards crew calling in sick for fatigue.
The first officer had approximately 5,600 hours total flight time with about 700 hours on type as second-in-command. The first officer had been off for 38 days prior to the occurrence. He had achieved 6.5 hours of sleep prior to checking in at 6:00 am
The Enerjet Employee Policy Manual states that all employees are responsible for their attendance and punctuality, and for arriving at work fit for duty. This policy is consistent with CARs 602.02 – Fitness of Flight Crew Members. The policy is silent on matters specifically related to fatigue.
Fatigue
Fatigue often results from the combination of and the interaction between a person’s work schedule and the social and domestic pressures that reduce the opportunity for and quality of sleep.
Meteorological information
The hourly weather report for Fort Nelson airport taken 17 minutes before the occurrence indicated that the winds were calm, visibility was 30 statute miles, and there were a few clouds at 6,000 feet above ground level (agl), a scattered layer at 14,000 feet agl, and a broken layer at 21,000 feet agl. The temperature was -10 °C and dewpoint -14 °C. The altimeter setting was 29.42 inches of mercury.
The upper-level wind forecast at the time of the occurrence indicated winds at 3,000 feet asl to be 290° true (T) at 25 knots and at 6,000 feet asl, 280°T at 27 knots with a temperature of -7 °C.
Runway surface condition
The captain obtained an operational flight plan, weather, and notice to airmen (NOTAM) package that was generated at 04:11 by a third-party flight planning company. This package contained a runway surface condition report for Fort Nelson that was taken on January 8th, 2012 at 15:35. It was as follows: 120 feet centre line, 70% frost, 30% ice patches, remaining width 100% dry snow ¼ inch. The Canadian Runway Friction Index (CRFI) at -6 °C was 0.46; both observations taken at 15:35.
The captain briefed the first officer on these conditions prior to the day’s flying and communicated that there would be sufficient runway at maximum landing weight with a CRFI of 0.46. The flight crew did not obtain an updated runway surface condition report or CRFI report at any time prior to the approach into Fort Nelson.
The following CRFI reports were generated by the Fort Nelson Airport on January 9th, 2012:
Canadian Runway Friction Index
07:56 – 0.21 (runway was swept to remove frost)
08:41 – 0.420913 (runway surface condition report given to flight service specialist verbally)
10:30 – 0.43 (runway surface condition report given to flight service specialist verbally)
11:30 – 0.45 (taken 10 minutes after ENJ401 departed runway; lowest of the 12 readings was 0.33)
The method of obtaining runways surface condition reports and CRFI reports was in compliance with existing standards and practices. The last annual inspection for the decelerometer used for CRFI measurement at the Fort Nelson Airport was on 22 May 2011. The TSB Laboratory examination of the flight data recorder longitudinal deceleration on roll-out was consistent with good braking action.
The investigation determined that the deceleration forces were equivalent to that of a bare and dry runway.