Runway Overrun Onur Air Runway Overrun After Rejected Take-Off of the Onur Air MD-88, Registration TC-ONP, at Groningen Airport Eelde on 17 June 2003
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Runway overrun Onur Air Runway overrun after rejected take-off of the Onur Air MD-88, registration TC-ONP, at Groningen Airport Eelde on 17 June 2003 The Hague, 6 April 2006 (investigation number 2003071) The reports of the Dutch Safety Board are public. All reports are also available on the website of the Dutch Safety Board www.safetyboard.nl 1 THE DUTCH SAFETY BOARD The Dutch Safety Board is an independent administrative body and individual legal entity instituted in Dutch law and tasked with investigating and determining the causes or probable causes of individual incidents or categories of incidents in all sectors. The sole objective of such investigations is to prevent future accidents or incidents, and if considered meaningful based on the results, to duly issue recommendations. The organization consists of a Board with five permanent members and ten permanent committees. For specific investigations, special Supervisory Committees are appointed. The Board is supported by an office consisting of researchers, secretary-safety specialists and support staff. The Dutch Safety Board is the legal successor to the Transport Safety Board. The present investigation was carried out by the Transport Safety Board but is being published under the auspices of the Dutch Safety Board. Board Aviation Committee Chairman: prof. Pieter van Vollenhoven Chairman: dr. J.P. Visser J.A. Hulsenbek J.A. Hulsenbek mrs. A. van den Berg J.T. Bakker prof. dr. F.J.H. Mertens B.M. van Balen1 dr. J.P. Visser J. Marijnen H. Munniks de Jongh Luchsinger J.G.W. van Ruitenbeek Secretary: K.E. Beumkes Office management Projectteam General Secretary: mrs. M. Visser Project leader: G.J. Vogelaar G.J.M. Oomen A. Samplonius Head of J.H. Pongers recommendations department: Head of research H.J. Klumper department: Visitors address: Anna van Saksenlaan 50 Correspondence Postbus 95404 2593 HT Den Haag address: 2509 CK Den Haag Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077 Internet: www.safetyboard.nl 1 Untill 1st February 2006. 2 CONTENTS CONSIDERATION…………………………………………………………………………………… 6 SUMMARY………………………………………………………………………………………………. 12 RECOMMENDATIONS……………………………………………………………………………….. 13 SYNOPSIS……………………………………………………………………………………………….14 LIST OF ABBREVIATIONS………………………………………………….……………………… 15 1 FACTUAL INFORMATION......................................................................... 17 1.1 HISTORY OF THE FLIGHT ................................................................................. 17 1.2 INJURIES TO PERSONS ................................................................................... 19 1.3 DAMAGE TO AIRCRAFT ................................................................................... 19 1.4 OTHER DAMAGE .......................................................................................... 19 1.5 PERSONNEL INFORMATION............................................................................... 19 1.6 AIRCRAFT INFORMATION ................................................................................. 20 1.6.1 General ...............................................................................................20 1.6.2 Relevant thrust settings, speeds and flap settings......................................21 1.6.3 Take–off performance data.....................................................................22 1.6.4 Take-off mass, centre of gravity and stabilizer setting ................................23 1.6.5 Investigation of aircraft systems .............................................................25 1.7 METEOROLOGICAL INFORMATION ....................................................................... 26 1.8 AIDS TO NAVIGATION .................................................................................... 26 1.9 COMMUNICATIONS AND RECORDINGS .................................................................. 26 1.10 AIRPORT INFORMATION .................................................................................. 26 1.11 FLIGHT RECORDERS ...................................................................................... 27 1.11.1 Cockpit Voice Recorder ..........................................................................27 1.11.2 Flight Data Recorder..............................................................................27 1.12 DESCRIPTION OF DAMAGE ............................................................................... 27 1.12.1 General ...............................................................................................27 1.12.2 Aircraft damage....................................................................................27 1.13 MEDICAL AND PATHOLOGICAL INFORMATION .......................................................... 27 1.14 FIRE ........................................................................................................ 28 1.15 SURVIVAL ASPECTS ...................................................................................... 28 1.15.1 Flight safety briefing and evacuation........................................................28 1.15.2 Aircraft Exits ........................................................................................29 1.15.3 Airport fire brigade................................................................................30 1.15.4 Overrun area........................................................................................30 1.16 TESTS AND RESEARCH.................................................................................... 31 1.17 ORGANIZATIONAL AND MANAGEMENT INFORMATION.................................................. 31 1.18 ADDITIONAL INFORMATION .............................................................................. 32 1.18.1 Passenger questionnaire ........................................................................32 3 1.18.2 Aircraft technical investigation ................................................................32 1.18.3 Oversight.............................................................................................32 1.18.4 Other comparable events .......................................................................34 1.19 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES ................................................. 35 2 ANALYSIS............................................................................................... 36 2.1 MISSED APPROACH ....................................................................................... 36 2.2 GENERAL NOTE............................................................................................ 36 2.3 LOAD AND TRIM ........................................................................................... 36 2.3.1 Take-off mass ......................................................................................36 2.3.2 Centre of gravity...................................................................................36 2.4 TAKE-OFF.................................................................................................. 37 2.4.1 Take-off runway ...................................................................................37 2.4.2 Take-off thrust .....................................................................................37 2.4.3 Stabilizer warning .................................................................................38 2.4.4 Stabilizer setting...................................................................................39 2.4.5 Flaps...................................................................................................39 2.4.6 Speeds................................................................................................39 2.4.7 Elevator control force ............................................................................39 2.4.8 Rejected take-off ..................................................................................40 2.4.9 Factors affecting the remaining stop distance............................................40 2.4.10 Consequences ......................................................................................41 2.5 SURVIVAL ASPECTS ....................................................................................... 41 2.5.1 Overrun area........................................................................................41 2.5.2 Evacuation...........................................................................................42 2.5.3 Emergency response .............................................................................42 2.6 ORGANIZATIONAL AND MANAGEMENT FACTORS ....................................................... 42 2.7 HUMAN FACTORS.......................................................................................... 43 2.8 CREW RESOURCE MANAGEMENT ......................................................................... 44 2.9 OVERSIGHT................................................................................................ 44 3 CONCLUSIONS ........................................................................................ 46 4 RECOMMENDATIONS .............................................................................. 50 4 APPENDICES A RTOLW table runway 23 B part A : Aircraft performances part B :TC-ONP take-off performance at Groningen Airport Eelde C part A : Load and trim sheet part B : Actual load and trim calculation D part A : Description longitudinal control system part B : Functional checks E part A : Stabilizer warning system in more detail part B : Stabilizer warning conditions F Transcript