By Simon Hradecky, created Friday, Dec 22nd 2017 17:11Z, last updated Friday, Dec 22nd 2017 17:11Z An Air Europa Boeing 737-800, registration EC-HBM performing charter flight UX-911 from Beirut (Lebanon) to Katowice (Poland) with 114 passengers and 8 crew, was on an ILS approach to Katowice's runway 27 at 03:05L (02:05Z) when the aircraft touched down about 870 meters/2850 feet before the runway threshold, collided with approach lights, bounced and touched down again for a total of four touch downs before the aircraft slowed to taxi speed now on the runway and taxied to the apron. There were no injuries, the aircraft sustained substantial damage to engines, fuselage, flaps and horizontal stabilizer and took out most of the approach lights runway 27.



Poland's PKBWL rated the occurrence an accident and stated, that the investigation can still not be considered complete (10 years after the occurrence). The PKBWL however released their final report annotating that the investigation could be reopened any time should new evidence surface and concluding the probable causes of the accident were:



Cause of the accident and contributing factors



The cause of the accident was failure to execute a missed approach procedure even if the criteria of a stabilized approach were not met during an attempt to intercept G/S "from above" at excessive descent rate, under meteorological conditions below the minimum for the aerodrome.



Factors contributing to the occurrence



1. Errors in flight crew co-operation (inadequate CRM).



2. The failure of the crew to perform the approach in accordance with the published procedure.



3. No response of the crew to the warning signals generated by GPWS.



4. Landing on aerodrome equipped with ILS CAT I with autopilot engaged.



The PKBWL reported the aircraft was flown by a captain (59, ATPL, about 15,000 hours total, about 5,000 hours on type, certified CATII/CATIII operations) acting as pilot monitoring, a first officer (37, ATPL, about 5000 hours total, about 2000 hours on type, certified CATII/CATIII operations) acting as pilot flying and an instructor (54, ATPL, more than 15,000 hours total) acting as pilot in command. The captain was expected to take controls at decision height and become pilot flying, the first officer was expected to hand controls to the captain at decision height and assume the role as pilot monitoring.



While descending towards Katowice the instructor and captain discussed the weather situation, both concluded the weather was "just enough" and decided to go ahead with the approach. While contacting Katowice tower the crew received the present weather conditions: "wind 230, 1kt, visibility 300m, RVR 250m, fog, clouds broken 100ft, second layer 600ft, temp.+8, dewpoint +8, QHH 1027.", about 3.5 minutes later ATC reported: "wind var. 2kt, visibility 300m, fog, clouds broken 100ft, temp.+8, dewpoint +8, QNH 1027, expect approach to RWY 27, trans level 80, RWY wet, braking action medium, and copy RVR from treshold 27, 450m, 450m, 650m."



The aircraft was cleared to descend to 4000 feet and to report when over KTC NDB. The first officer suggested they should use the published procedure due to poor visibility, the captain however decided to fly a straight in approach to reduce fuel consumption.



About 6.4nm before the runway threshold, already established on the localizer, the aircraft was still descending at 1560 fpm above the glide slope (deviation according to FDR 5.62 dots fly down) at radar altitude 3072 feet, engines idle at 152 KIAS, when the crew configured the aircraft for landing (gear down, flaps 41 degrees).



At 2:03:24Z the crew received landing clearance on runway 27, tower reported: "wind 240 deg., 2kt, RVR from threshold 27 500m, 500m, 900m. " The crew requested the runway lights at maximum intensity, tower confirmed the lights were set to maximum intensity.



The crew discussed for more than 12 seconds that they were flying too high, the autopilot in LVL CHG mode adopted a vertical rate of descent of 1720 fpm. The autopilot was briefly selected to V/S which reduced the rate of descent, the captain urged "go down", the mode was returned to level change, the rate of descent increased again.



Passing over KTC NDB the aircraft was at 1274 feet radar altitude, 2200 feet MSL descending at 1848 fpm, the aircraft should have passed KTC at 1790 feet MSL, the first officer stated they had passed KTC about 300 feet above target. 15 seconds the captain stated: "OK, entering in slope", 9 seconds later the captain announced: "approaching minimum".



One second later, 02:05:01Z and 17 seconds before first touchdown, the aircraft crossed the glideslope descending at 1664 fpm at radar altitude 388 feet, the GPWS sounded "SINK RATE", the autopilot changed from Level Change to GlideSlope.



12 seconds before touchdown the automatic call out "APPROACHING MINIMUMS" occurred, the captain shouted twice "keep that slope". Descending through 198 feet AGL another GPWS "SINK RATE" call occurred at 1624 fpm rate of descent.



9 seconds before touchdown the GPWS sounded "PULL UP!", rate of descent 1760 fpm, RA (radar altitude) 163 feet.



8 seconds before touchdown the control column was pulled, the engines accelerated, the GPWS "PULL UP" warning ceased 6 seconds before first touchdown.



5 seconds before touchdown the captain spotted the approach lights and called "I have it", the first officer confirmed "your controls". The GPWS sounded SINK RATE twice, rate of descent 1112 fpm at 50 feet AGL.



2 seconds before touchdown a first sound of impact was recorded by the CVR, probably first collision with an approach light post.



1 second prior to touchdown, 3 feet AGL, the captain commented: "Oh, my God".



The aircraft touched down at 6 degrees nose up and 144 KCAS, the thrust levers were momentarily placed into the takeoff position, a takeoff configuration warning occurred. The stick shaker activated, the second touchdown occurred at +1.799G at 5.8 degrees nose up. The thrust levers were retarded. Two more bounced occurred, then the thrust reversers were deployed, autothrottles were disconnected, the autopilot was disengaged, the aircraft reached the runway, taxied off the runway and went to the stand.



The PKBWL wrote:



Five minutes after the first touchdown, during taxiing, the Captain intended to inform the traffic controller about the occurrence, he said:



2:10:34 hrs - "We should say something to the tower, because we have lights broken?"



and:



2:10:42 hrs - ... "it must be a lot of lights broken, and other things"



the instructor responded:



2:10:44 hrs - "......wait, wait, wait".



As a result, the crew did not inform air traffic services about the occurrence.



The PKBWL analysed that the last RVR information provided by tower "RVR RWY27 500m, 500m and 900m" were below the required minima, however, this did not prompt the crew to divert to their alternate with better weather conditions.



The PKBWL analysed the decision by the captain to proceed with the straight in approach probably was triggered by concerns over an excessivefuel consumption during the flight, however, there was still sufficient fuel in the tanks to divert to Warsaw.



The PKBWL analysed:



Both pilots at the controls were aware that they were too high for straight-in approach (G/S was below the airplane), hence it required a greater descent rate (1600-2000 ft/min - more than twice the normal descent rate on G/S) and interception of G/S from above. It caused that 17 seconds before the first contact with the ground the airplane crossed G/S and continued the flight below G/S.



Increase in the aircraft pitch (from -3 deg to +6 deg) to intercept G/S (this time from below) occurred just above the ground, causing that the airplane was close to touchdown attitude. Therefore, the damage to the airplane resulted from the collision with the approach lights rather, and not from the touchdown.



The PKBWL emphasized: "Any significant deviation from planned flight path, airspeed, or descent rate should be announced (by PM). The decision to execute a go-around is no indication of poor performance."



Based on the FDR analysis the PKBWL analysed that the approach was unstabilized contrary to the Flight Crew Training Manual and wrote:



As a result of unstabilized approach, where G/S was intercepted from above at a great descent rate, premature multiple touchdowns of the aircraft and collisions with the ground obstacles occured. Approach to landing and landing were performed with B autopilot engaged, which the crew disengaged only after the landing roll.



The aircraft intercepted the localizer at RA 3800 feet which was 1700 feet above the glideslope and continued the approach reaching more than 2000 fpm rate of descent temporarily and wrote: "Boeing company concluded that AP attempted to capture G/S, but an excessive descent rate caused fast crossing of G/S and triggered BEAM ANOMALY DETECTION."



The PKBWL concluded their analysis with the analysis of flight crew actions:



2.4.1. The crew did not conduct LANDING CHECKLIST.



2.4.2. G/S capturing from above with a high descent rate and G/S crossing at a distance of 1.5NM from the runway threshold in the absence of visual reference to the ground is a HIGHLY DANGEROUS maneuver which led to the accident.



2.4.3. In the existing weather conditions, it was necessary to divert to an alternate aerodrome having better conditions, e.g. EPWR or EPWA.



2.4.4. When attempting to land on EPKT, it was necessary to perform the published approach procedure instead of straight-in approach, which forced the crew to fly at a high vertical speed in the absence of visual reference to the ground.



2.4.5. The briefing prior to the descent was incomplete, omitting STRAIGHT-IN approach, which was actually performed.



2.4.6. The crew did not respond to the SINK RATE and PULL UP messages generated by GPWS over a dozen seconds before the first contact of the airplane with the ground.



2.4.7. PIC, as a commander and also as an instructor should have supervised the correctness of the crews decisions and their correct implementation. In the Commissions opinion, PIC should have seated at controls during take-off, initial climb, approach and landing, especially if those flight phases have taken place in weather conditions close to minima.



2.4.8. Landing with AP engaged led to G/S crossing and the airplane passing below G/S, which resulted in its premature contact with the ground.



All of the above errors indicate that the crew did not apply the CRM principles.



The crews failure to inform the airport services about the touchdown short of RWY threshold and damage to the approach lights system had an adverse impact on safety of subsequent landing aircraft. That failure was a violation of the rules of conduct in the area of aviation safety, and was also contrary to the ethics of a professional pilot.



Some of the aircraft damage (Photo: PKBWL):





The approach lights (Photo: PKBWL):





ILS runway 27 approach chart (Graphics: PKBWL):



