Enerjet Flight 401 Runway Overrun at Fort Nelson

Incident Overview and Flight Details On January 9, 2012, Enerjet Flight 401, operating a Boeing 737-700 with registration C-GDEJ, overran the end of Runway 03 at Fort Nelson, British Columbia, by approximately 230 feet. The aircraft was on a sub-chartered commuter flight for Worley Parsons employees, having originated in Calgary and stopped in Edmonton and Fort St. John. At the time of the incident, the aircraft carried 112 passengers and 6 crew members. No injuries were reported, and the aircraft sustained no damage. The flight departed Fort St. John at 1042 Mountain Standard Time and overran the runway at 1117 Mountain Standard Time. The aircraft was certified, equipped, and maintained according to regulations, and the crew was qualified for the operation. ## Approach and Operational Factors The captain, who was the pilot flying, briefed the first officer for a visual approach to Runway 03 backed by the instrument landing system. The captain selected a flap setting of 40 and an autobrake setting of 3. The first officer entered the flap setting into the flight management computer and verified a landing weight of 55,967 kg, retrieving a reference speed of 128 knots. The approach was not stabilized according to Enerjet criteria because the aircraft did not achieve a 3-degree glideslope. The crew acknowledged this after two aural glideslope warnings from the enhanced ground proximity warning system but elected to continue, believing the approach was salvageable. On short final, the aircraft was flown at 140 knots, which was 12 knots above the reference speed. This excess speed resulted in a longer flare and a touchdown 800 feet beyond the recommended 1,000-foot touchdown point. ## Contributing Factors and Fatigue The investigation identified fatigue as a significant contributing factor. The captain had not attained appreciable sleep in the 24 hours preceding the flight. This condition likely resulted in attention decrements that affected his judgment and ability to manage operational risks. The captain's decision to continue the approach when the aircraft was not in a stabilized configuration was consistent with a fatigue-induced reduction in forward planning. Additionally, the captain pitched the aircraft nose down on short final to capture the glideslope, which increased airspeed and further delayed the touchdown point. The autothrottle system was not disengaged below 50 feet, causing it to increase thrust to maintain the selected airspeed. This thrust increase delayed the deployment of speed brakes and thrust reversers, leaving insufficient runway to stop the aircraft. The runway length was appropriate for the operation but offered little margin for deviation in speed or touchdown point. The runway surface condition was as issued and may have been better than reported, as the aircraft stopped in 6,632 feet rather than the 7,168 feet predicted by the landing distance chart. ## Safety Actions and Investigation Conclusion The Transportation Safety Board concluded its investigation into the occurrence, authorizing the release of the report on March 6, 2013, with official release on April 25, 2013. In May 2012, Enerjet issued a communication to all flight crew containing an open-book exam on sections of the company operations manual related to fatigue self-assessment. The exams were corrected at an all-pilots meeting in June 2012 to raise awareness of the fatigue self-assessment tool and to emphasize the importance of honest fitness-for-duty assessments. The Board noted that self-assessment of fatigue is unreliable and that a multi-layered approach to managing fatigue risks is required, as reliance on pilots monitoring their own fatigue levels may not always identify unacceptable risks.