Casualties unknown

2014-10-15: Embraer EMB-500 Phenom 100 — Pilot liniowy — Bydgoszcz Szwederowo (EPBY), PL

Bydgoszcz Szwederowo (EPBY), PL

On October 15, 2014, an Embraer EMB-500 Phenom 100 operated by Pilot liniowy was involved in an aviation accident near Bydgoszcz Szwederowo (EPBY), PL. Investigators recorded the probable cause as: Failure of the pilot flying (captain) to execute a go-around procedure, combined with crew resource management deficiencies including improper use of SOPs, ineffective monitoring, lack of communication, poor situational awareness, lack of command, and… This summary draws on records from the Polish State Commission on Aircraft Accidents Investigation (PKBWL); 3 related events involving the same aircraft type or operator are linked below.

Sourcesthe Polish State Commission on Aircraft Accidents Investigation (PKBWL)Primary reportUpdated 1785092869Data APIEditorial standards

On 15 October 2014, an Embraer EMB-500 Phenom 100 (SP-AVP) overran runway 08 at Bydgoszcz Szwederowo Airport after an unstabilized approach, stopping 253m beyond the runway end. No injuries occurred.

Incident Overview

On 15 October 2014, an Embraer EMB-500 Phenom 100, registration SP-AVP, performing commercial flight FYJ30 from Geneva (LSGG) to Bydgoszcz (EPBY), overran runway 08 during landing. The aircraft came to rest 253 meters beyond the runway end and 116 meters right of the centerline. All six occupants (passengers and crew) were uninjured and evacuated to the terminal. No injuries were reported.

Flight History

The flight from Geneva was uneventful until the descent into Bydgoszcz. The crew began descent from FL380 before point SUI. During descent, they attempted to contact Bydgoszcz tower but initially could not; communication was established with help from Poznań APP approximately 31 NM from EPBY at FL100. The crew received clearance for an RNAV approach and descent to 6000 ft. However, they inadvertently deleted a waypoint and had to quickly reprogram the FMS, causing time pressure. The approach was flown at an increased speed of about 160 knots, and landing flaps were extended only 0.3 NM from the runway threshold. Despite an unstabilized approach, the crew decided to land. Touchdown occurred at midfield at a groundspeed of 118 knots. Braking was applied on a wet runway with approximately 1250 meters remaining. The EMB-500 is equipped only with main wheel brakes and anti-skid; no aerodynamic brakes, thrust reversers, or autobrake are installed. An attempt to exit the runway onto taxiway A at the end failed, and the aircraft slid sideways at 47 knots groundspeed, departing the runway through threshold 26. It continued across grass and stopped 253 meters from the runway end. The tower controller immediately alerted rescue services, which arrived within 2 minutes and secured the aircraft, crew, and passengers.

Damage

The aircraft sustained damage from collision with a runway end light on runway 08, and the left main landing gear leg exhibited contact marks with a cut tire.

Weather

Weather conditions were considered to have influenced the occurrence.

Cause

The Polish State Commission on Aircraft Accident Investigation (PKBWL) determined the cause of the serious incident to be: 1) Failure of the pilot flying (captain) to execute a go-around procedure. 2) A combination of crew resource management (CRM) aspects that prevented proper decision-making: improper use of standard operating procedures, ineffective monitoring by the pilot not flying, lack of effective communication, poor situational awareness, lack of command by the captain, and inadequate task coordination.

Contributing Factors

Contributing factors identified by the PKBWL included: 1) Ineffective and non-compliant CRM training conducted by the operator. 2) Insufficient oversight by the operator to enforce proper implementation of operational procedures. 3) Illogical provisions in the operator's manual allowing exemption of certain pilots from transition training, which were accepted by the aviation authority.

Safety Actions

The operator suspended its air carrier operations; therefore, no preventive actions were formulated.

Recommendations

The PKBWL issued no safety recommendations.

Probable cause

Failure of the pilot flying (captain) to execute a go-around procedure, combined with crew resource management deficiencies including improper use of SOPs, ineffective monitoring, lack of communication, poor situational awareness, lack of command, and inadequate coordination.

Investigation report by the Polish State Commission on Aircraft Accidents Investigation (PKBWL). Original record: https://pkbwl.gov.pl/raporty/2014-1860/. This page is a structured re-presentation; facts and quotes are in the Panstwowa Komisja Badania Wypadkow Lotniczych (PKBWL), Poland.