Boeing 737 Overruns Runway in Fort Nelson Due to Fatigue and Unstable Approach

Casualties unknown • Fort Nelson, British Columbia, CA

A Boeing 737-700 operated by Enerjet overran the runway at Fort Nelson, British Columbia, after an unstable approach and thrust increases during landing roll.

What happened

On 09 January 2012, an Enerjet Boeing 73 37-700, registration C-GDEJ, overran the end of Runway 03 at Fort Nelson, British Columbia, by approximately 230 feet. The flight, operating as ENJ401, was a sub-chartered commuter service transporting employees for work. The aircraft had traveled from Fort St. John via Edmonton and Calgary.

During the final approach, the aircraft failed to maintain a stabilized configuration, specifically failing to achieve a 3° glideslope. Despite receiving two glideslope warnings from the enhanced ground proximity warning system, the crew elected to continue the approach. During the landing phase, the aircraft touched down 800 feet beyond the recommended touchdown point. Shortly after touchdown, the autothrottle system increased thrust to maintain a selected airspeed, which prevented the deployment of speed brakes and delayed the use of thrust reversers. There were no injuries to the 112 passengers or 6 crew members, and the aircraft sustained no damage.

The investigation

The investigation examined the stability of the approach, the effectiveness of the aircraft's stopping devices, runway conditions, and the role of pilot fatigue. Investigators analyzed the flight management computer data, the pilot's use of the autopilot flight director system, and the crew's adherence to stabilized approach criteria. The investigation also reviewed the captain's sleep patterns and the effectiveness of the airline's fatigue self-assessment tools.

Findings

  • The captain was fatigued due to a lack of appreciable sleep in the 24 hours prior to the flight, which likely led to diminished attention and impaired judgment.
  • The crew continued the approach while the aircraft was in an unstable configuration, focusing on salvaging the flight path rather than executing a missed approach.
  • An attempt to capture the glideslope by pitching the nose down resulted in increased airspeed, leading to a late touchdown and reduced available runway.
  • The autothrottle remained engaged below 50 feet, causing an increase in thrust that hindered the deployment of speed brakes and thrust reversers.
  • The airline's fatigue self-assessment tools were found to be unreliable, as pilots often struggle to recognize their own level of impairment.

Safety action

Following the occurrence, Enerjet implemented a communication to all flight crews involving an examination of the company operations manual. This initiative aimed to increase awareness of fatigue self-assessment tools and reinforce the importance of honest fitness-for-duty reporting, ensuring pilots understood that booking off duty due to fatigue or illness is non-punitive.

Probable cause

The runway overrun was caused by a combination of pilot fatigue, which led to an unstable approach and poor decision-making, and the failure to disengage the autothrottle, which resulted in increased thrust and delayed use of deceleration devices during the landing roll.

All Boeing 737-800 accidents →

Frequently asked questions

What happened in the 2012-01-09 Boeing 737-700, C-GDEJ accident near Fort Nelson, British Columbia, CA?

A Boeing 737-700 operated by Enerjet overran the runway at Fort Nelson, British Columbia, after an unstable approach and thrust increases during landing roll.

What aircraft was involved and where did it happen?

The accident on 2012-01-09 involved a Boeing 737-700, C-GDEJ, operated by 1263343 Alberta Inc. (dba Enerjet), at Fort Nelson, British Columbia, CA.

What was the probable cause of the accident?

The runway overrun was caused by a combination of pilot fatigue, which led to an unstable approach and poor decision-making, and the failure to disengage the autothrottle, which resulted in increased thrust and delayed use of deceleration devices during the landing roll.

Loading the flight search…