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AVIATION INVESTIGATION REPORT A15Q0075 Runway Overrun

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AVIATION INVESTIGATION REPORT A15Q0075 Runway Overrun AVIATION INVESTIGATION REPORT A15Q0075 Runway overrun WestJet Boeing 737-6CT, C-GWCT Montréal/Pierre Elliott Trudeau International Airport, Quebec 05 June 2015 Transportation Safety Board of Canada Place du Centre 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 2017 Aviation Investigation Report A15Q0075 Cat. No. TU3-5/15-0075E-PDF ISBN 978-0-660-08454-1 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Aviation Investigation Report A15Q0075 Runway overrun WestJet Boeing 737-6CT, C-GWCT Montréal/Pierre Elliott Trudeau International Airport, Quebec 05 June 2015 Summary On 05 June 2015, a WestJet Boeing 737-6CT (registration C-GWCT, serial number 35112) was operating as flight 588 on a scheduled flight from Toronto/Lester B. Pearson International Airport, Ontario, to Montréal/Pierre Elliott Trudeau International Airport, Quebec. At 1457 Eastern Daylight Time, the aircraft touched down in heavy rain showers about 2550 feet beyond the threshold of Runway 24L and did not stop before reaching the end of the runway. The aircraft departed the paved surface at a ground speed of approximately 39 knots and came to rest on the grass, approximately 200 feet past the end of the runway. There were no injuries to the 107 passengers or 5 crew members and no damage to the aircraft. The 406-megahertz emergency locator transmitter did not activate. The incident occurred at 1458, in daylight. Le présent rapport est également disponible en français. Aviation Investigation Report A15Q0075 | i Table of contents 1.0 Factual information.......................................................................... 1 1.1 History of the flight ............................................................................................ 1 1.2 Injuries to persons............................................................................................... 3 1.3 Damage to aircraft .............................................................................................. 3 1.4 Other damage ..................................................................................................... 3 1.5 Personnel information......................................................................................... 3 1.6 Aircraft information............................................................................................ 4 1.6.1 General ......................................................................................................................................4 1.6.2 Deceleration devices ...............................................................................................................5 1.6.3 Antiskid protection .................................................................................................................7 1.6.4 Ma in wheel tires ......................................................................................................................8 1.6.5 Landing performance .............................................................................................................8 1.6.6 Runway condition definitions ........................................................................................... 12 1.6.7 Landing on wet, slippery, or contaminated runways .................................................. 12 1.6.8 Boeing Commercial Aircraft performance calculations............................................... 13 1.7 Meteorological information ............................................................................... 15 1.8 Aids to navigation ............................................................................................ 17 1.9 Communications .............................................................................................. 17 1.9.1 General ................................................................................................................................... 17 1.9.2 Previous landings................................................................................................................. 17 1.10 Aerodrome information .................................................................................... 18 1.10.1 General ................................................................................................................................... 18 1.10.2 Runway 24L physical description .................................................................................... 18 1.10.3 Runway 24L lighting and markings................................................................................. 19 1.10.4 Runway friction .................................................................................................................... 19 1.10.5 Grooving of runway ............................................................................................................ 21 1.10.6 Runway end safety area...................................................................................................... 21 1.11 Flight recorders ................................................................................................ 24 1.12 Wreckage and impact information .................................................................... 24 1.13 Medical and pathological information ............................................................... 24 1.14 Fire................................................................................................................... 24 1.15 Survival aspects ................................................................................................ 24 1.15.1 Aircraft evacuation .............................................................................................................. 24 1.15.2 Aircraft rescue and fire-fighting ....................................................................................... 24 1.16 Tests and research............................................................................................. 25 1.16.1 Turbojet braking performance on wet runways............................................................ 25 1.16.2 Runway overruns................................................................................................................. 26 1.16.3 Studies of factors contributing to runway overruns..................................................... 26 1.16.4 TSB laboratory reports ........................................................................................................ 28 1.17 Organizational and management information ................................................... 28 1.17.1 WestJet flight data monitoring .......................................................................................... 29 ii | Transportation Safety Board of Canada 1.18 Additional information ..................................................................................... 29 1.18.1 Approach and landing ........................................................................................................ 29 1.18.2 Stabilized approach ............................................................................................................. 30 1.18.3 Wet runway operations ...................................................................................................... 31 1.18.4 Runway assessment and condition reporting................................................................ 32 1.18.5 Hydroplaning........................................................................................................................ 33 1.18.6 Threat and error management........................................................................................... 34 1.18.7 Situational awareness, mental models, and decision making .................................... 35 1.18.8 TSB Wa tchlis t ........................................................................................................................ 36 1.19 Useful or effective investigation techniques ....................................................... 36 2.0 Analysis ......................................................................................... 37 2.1 Introduction ..................................................................................................... 37 2.2 Operational threats ........................................................................................... 37 2.2.1 General ................................................................................................................................... 37 2.2.2 Runway condition expectation.......................................................................................... 37 2.2.3 Actual runway condition.................................................................................................... 38 2.2.4 Approach and landing in heavy rain............................................................................... 39 2.2.5 Approach, flare, and touchdown point ........................................................................... 40 2.3 Managing of deceleration devices.....................................................................
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