Canadian investigators inadvertently allow the tired captain to reverse thrust with one engine after a tired captain turned over after a touchdown, and then the Boeing 737-800 went overrun at Kitchener Waterloo Airport I discovered that I did.
The Flair Airlines aircraft, which was inbound from Vancouver in the early hours of November 25th, 2022, was implementing an ILS approach to Runway 26 at Kitchener.
They were dispatched under minimum equipment regulations using the engine thrust reverser on the left. The inverted was stowed and trapped in place.
According to the Canada Transportation Safety Board, the captain, who had a cloud of this approach, urged the captain to “mentally rehearse” in flight to “mentally rehearse.”
At about 300 feet, the Captain unlocked the Autopilot, but Autorotre became active.
When the aircraft descended to 70 feet, the captain intended to cut the Autothrottle. But instead he pressed the takeoff/go-around switch. Both switches are located on the thrust lever.
The still active Auto Throttle tried to advance the thrust lever to around power, but the captain delayed the lever to “idol” and held them during flare and touchdowns without realizing the force from Auto Rottle.
The aircraft landed 1,400 feet past the runway threshold at 142kt, and speed brakes were deployed.
However, when the captain removes his hand from the left thrust lever, he holds the right lever to activate the available thrust relay, and Autothrottle begins to advance the released left lever towards progression power. Ta.
This led to the withdrawal of SpeedBrakes and deactivated the AutoBrake system with about 5,600 feet of runway remaining.
The captain “did not come true” when the left thrust lever was on the way and he experienced “difficulty in maintaining directional control of the aircraft”.
As a result of the differentiation, the aircraft began to deviate towards the right edge of the runway, and the captain attempted a manual brake.
Approximately 12 seconds after the touchdown, the first mate scanned the instrument and saw the thrust lever on the left advance. He reached under the captain's hand and pulled the lever back to idle, but continued to move forward without being noticed by either pilot when equal officers released it.
The aircraft is still moving at 115kt, so full brakes were applied 16 seconds after the touchdown, leaving the 2,500-foot runway. The captain stowed the thrust reflector on the right hand, bringing both thrust levers back to idle and stayed there.
The aircraft slowed down and the Autothrottle was automatically released at 80kt, but the aircraft covered the runway, first moved to a paved surface, then continued on the grass, then stopped at the edge of the runway for 500 feet I did.
Neither of the 134 passengers nor six crew members were injured, and the aircraft (C-FFLC) was not seriously damaged, but some landing gear pins were replaced and fragments of foreign objects I had to clean up.
The captain had over 24,000 hours of flight experience, but he received a type rating at 737 just seven months before the incident and joined Flair in May 2022.
The first mate received a rating of 737 in August of the same year and had accumulated 182H in the type.
Investigators determined that the captain had “earned a significant sleep debt” the week before the incident, and that he was driving the aircraft after a wake period of nearly 18 hours, and at the end of the low point of the circadian rhythm. I decided it was on my way.
Not only was the entire flight in the dark, but the passenger medical situation during the cruise was a significant portion of the crew's time.
“The captain's level of fatigue reduced his attention and vigilance and increased the likelihood of slipping,” the investigation says.
Rather than the captain's aggressive cutting, the captain's careless press is a combination of fatigue, and is “primed” because of a previously “primed” approach.
Flair's procedure requires simultaneous cutting of the autopilot and autorottle, but the carrier's flight data monitoring program showed “many instances” in which the pilot continued to use the autorottle “a long after” the autopilot .
Other airlines may allow this long-term use of Autothrottle, and the 737 captain had “important experience” with other operators, “this was a common practice.” Ta.
Flair reminded the pilots of the requirement to release Autothrottle at the same time as the Autopilot after the Kitchener incident.
