History of the Flight
On 16 July 2011, at 0645 Newfoundland Daylight Time, a Kelowna Flightcraft Air Charter Ltd. Boeing 727-281 (registration C-GKFJ, serial number 21455) operating as KFA228 departed Moncton International Airport, New Brunswick, for St. John's International Airport, Newfoundland and Labrador, on a scheduled cargo flight with 3 crew members. Pre-flight preparations noted gusting winds, light drizzle, and fog at St. John's. During the flight, the crew obtained ATIS information Oscar and consulted landing performance tables, deciding to conduct an ILS approach to Runway 11.
At 0806, the aircraft was established on the ILS glideslope and localizer. About two minutes later, the crew visually acquired the runway through light rain and selected wipers. The aircraft touched down at 0809 approximately 1850 feet beyond the threshold at between 157 and 162 knots.
Landing and Overrun
Approximately one second after touchdown, spoilers were manually deployed. Reverse thrust was applied from about 7 to 16 seconds after touchdown. Maximum wheel braking began about 8 seconds after touchdown; almost immediately the crew noted skidding. The aircraft skidded left of centerline about 9 seconds later, approximately 5500 feet from the threshold. The crew determined the aircraft would not stop within the remaining runway and advised the tower controller, who sounded the crash alarm. The aircraft remained left of centerline for about 2500 feet then crossed to the right about 400 feet before the pavement end. It departed the paved surface with the nose yawed about 13° left at approximately 40 knots, coming to rest in grass and mud about 60 feet left of extended centerline on a heading of 098° magnetic, about 48 seconds after touchdown. Maximum manual wheel braking was maintained throughout. There were no injuries; the aircraft had minor damage.
Hydroplaning
The aircraft touched down about 1850 feet from the threshold at higher than required airspeed, reducing available runway length. About 8 seconds after touchdown, braking was applied and almost immediately the aircraft skidded. Pieces of reverted rubber found on the runway near the touchdown point and along the left side indicated reverted rubber hydroplaning occurred almost immediately after brake application and periodically during the landing roll. Typical recovery from skidding involves momentarily releasing brakes, but the crew held brakes throughout. The wet runway caused hydroplaning, leading to loss of directional control and braking; this was exacerbated by holding brakes on and excessive tire tread wear.
Tire Wear
Three of the four tires were more than 80% worn; the fourth was about 65% worn. On wet runways, once a tire exceeds about 80% wear, wet-runway friction coefficients drop markedly. Using tires more than 80% worn reduces traction and increases hydroplaning risk.
Runway Conditions
TSB investigators found the runway surface smooth, lacking gritty microtexture. Good microtexture combats viscous hydroplaning. While FAA and ICAO recommend friction surveys at 65 km/h and 95 km/h, Transport Canada does not require microtexture testing. Not testing microtexture increases hydroplaning risk due to incomplete friction assessment. The runway was not grooved; grooved runways improve drainage and reduce hydroplaning. The lack of adequate runway end safety areas (RESA) also increases risk of damage and injuries during overruns.
Anti-skid System
Firefighters confirmed all four brakes were hot, indicating brake pressure was applied to all. The anti-skid control unit was serviceable at the time.
Runway Surface Condition Reporting
Runway surface condition (RSC) reporting standards focus on winter conditions and lack clear guidance for heavy rain or standing water. The absence of defined RSC standards for water on runways increases hydroplaning risk.
Safety Management System
The investigation found that the operator's safety management system (SMS) had deficiencies. Employees were not fully clear on reporting obligations; the RMS policy did not explicitly define hazardous situations. The company did not address frequent brake heating and fuse-plug releases through its RMS. Earlier hydroplaning occurrences at St. John's were not formally reviewed. A practice of misting brakes was introduced without RMS review, contrary to the aircraft manufacturer's recommendations. Transport Canada's June 2011 program validation found the company's risk management did not consistently identify hazards or define risk scenarios. The Airport Authority conducted only an informal risk assessment after previous overruns, concluding no further action needed. When SMS is not fully effective, hazards may go unidentified and unmitigated.
Probable Cause
The aircraft touched down about 1850 feet from the threshold, and at a higher than required airspeed, which reduced the available runway length to stop the aircraft. Excessive tread wear and the wet runway caused the aircraft to hydroplane.