Root Cause Analysis of Runway Excursion

Runway Excursion

• Human Error
  • Pilot Fatigue
  • Incorrect automation management (mode confusion)
  • Fatigue degraded monitoring of airspeed/flight path
  • Poor Crew Coordination
  • Failure to call stabilized approach criteria
  • Miscommunication about thrust or landing configuration
  • Pilot Decision Making
  • Late go-around decision
  • Unstable approach continued to land
• Environmental Factors
  • Contaminated runway (water/ice/slush)
  • Hydroplaning or reduced directional control
  • Reduced braking action leading to overrun
  • Crosswind / Wind Shear
  • Sudden wind shear on final approach
  • Loss of directional control on touchdown
• Aircraft Systems
  • Thrust Reverser Failure / Propulsion
  • Engine surge or loss of power on landing roll
  • Reverser asymmetry or no reverse
  • Braking System Malfunction
  • Brake overheating or uneven braking
  • Anti-skid failure or degraded brakes
• Airport Infrastructure
  • Runway Length or Arresting Systems
  • Lack of EMAS or inadequate arrestor beds
  • Runway too short for landing weight/configuration
  • Runway Condition and Maintenance
  • Insufficient runway grooving or friction treatment
  • Poor runway surface condition (potholes, uneven)
• Air Traffic Control
  • Faulty Operational Policies
  • Inadequate SOPs for contaminated-runway operations
  • Dispatch planning with marginal weather or calculated landing performance error
  • Wrong Sequencing of ATC Instructions
  • Runway change or vectoring in adverse conditions
  • Late landing clearance forcing unstable approach
• Technical Support
  • Insufficient Technical Support or Troubleshooting
  • Incomplete records leading to missed inspections
  • Faulty fault-isolation causing repeat failures
  • Poor Maintenance Practices
  • Incorrect maintenance leading to system degradation
  • Deferred defect (brake or thrust reverser) not repaired
• Ground Personnel
  • Adding Third Parties
  • Poor communication dispatch
  • Access to unauthorized or inexperienced personnel
  • Ground Vehicle on Runway or Incursion
  • Insufficient NOTAM or NOTAM misinterpretation
  • Unexpected evasive action leading to collapse of directional control

Suggested Actions Checklist

Here are some corrective actions, preventive actions and investigative actions that organizations may find useful:

• Human Error
  • Pilot Fatigue
    • Corrective Actions:
    • Implement immediate crew schedule adjustments to ensure pilots meet minimum rest requirements before duty.
    • Preventive Actions:
    • Introduce a fatigue risk management system (FRMS) with predictive fatigue modeling in roster planning.
    • Investigative Actions:
    • Review recent duty rosters and flight logs to identify fatigue-inducing scheduling patterns.
  • Poor Crew Coordination
    • Corrective Actions:
    • Conduct targeted CRM (Crew Resource Management) refresher sessions focusing on in-flight communication and coordination.
    • Preventive Actions:
    • Integrate periodic team-simulation exercises to reinforce coordination under stress conditions.
    • Investigative Actions:
    • Analyze cockpit voice recordings to identify specific communication breakdown points during approach or landing.
  • Pilot Decision Making
    • Corrective Actions:
    • Review and retrain pilots on stabilized approach and go-around decision-making criteria.
    • Preventive Actions:
    • Embed decision-making and risk assessment modules into recurrent simulator training.
    • Investigative Actions:
    • Evaluate flight data to determine how frequently unstable approaches are continued to landing.
• Environmental Factors
  • Contaminated Runway (water/ice/slush)
    • Corrective Actions:
    • Enhance runway sweeping and de-icing operations prior to anticipated adverse weather.
    • Preventive Actions:
    • Implement automated runway surface monitoring systems to detect and alert for contamination.
    • Investigative Actions:
    • Review airport weather logs and runway friction test data for the incident period.
  • Crosswind / Wind Shear
    • Corrective Actions:
    • Issue immediate pilot advisories and review approach procedures under crosswind or shear conditions.
    • Preventive Actions:
    • Install advanced wind shear detection and alerting systems near approach zones.
    • Investigative Actions:
    • Analyze meteorological data and pilot reports to confirm the severity and timing of wind shear events.
• Aircraft Systems
  • Thrust Reverser Failure / Propulsion
    • Corrective Actions:
    • Inspect and repair thrust reverser actuators and associated control systems.
    • Preventive Actions:
    • Establish enhanced pre-landing system checks and periodic thrust reverser functional tests.
    • Investigative Actions:
    • Review maintenance logs to identify prior reports or deferred defects related to reverser malfunction.
  • Braking System Malfunction
    • Corrective Actions:
    • Replace or recalibrate faulty brake components and anti-skid control units.
    • Preventive Actions:
    • Revise maintenance inspection intervals for brake assemblies and hydraulic lines.
    • Investigative Actions:
    • Conduct post-event teardown analysis to determine root cause of brake system failure.
• Airport Infrastructure
  • Runway Length or Arresting Systems
    • Corrective Actions:
    • Reassess landing weight limits and revise operational charts for short runways.
    • Preventive Actions:
    • Coordinate with airport authorities to evaluate feasibility of EMAS or arrestor bed installations.
    • Investigative Actions:
    • Analyze performance calculations and compare them against actual landing distances during the event.
  • Runway Condition and Maintenance
    • Corrective Actions:
    • Repair runway surface irregularities and improve grooving or friction levels.
    • Preventive Actions:
    • Schedule periodic runway friction and surface inspections with documented compliance tracking.
    • Investigative Actions:
    • Review runway maintenance logs and last inspection reports for discrepancies or missed actions.
• Air Traffic Control
  • Faulty Operational Policies
    • Corrective Actions:
    • Update contaminated-runway SOPs and dispatch procedures to align with current best practices.
    • Preventive Actions:
    • Conduct policy audits annually to ensure consistency with ICAO and regulatory requirements.
    • Investigative Actions:
    • Review incident reports to assess whether outdated or incomplete policies contributed to the event.
  • Wrong Sequencing of ATC Instructions
    • Corrective Actions:
    • Retrain controllers on standardized sequencing and communication protocols during adverse weather.
    • Preventive Actions:
    • Introduce procedural checklists for runway change and vectoring decisions.
    • Investigative Actions:
    • Examine ATC communication logs to trace timing and sequence of clearances.
• Technical Support
  • Insufficient Technical Support or Troubleshooting
    • Corrective Actions:
    • Provide additional training to maintenance personnel on systematic troubleshooting techniques.
    • Preventive Actions:
    • Implement a standardized fault isolation checklist for recurring aircraft system issues.
    • Investigative Actions:
    • Review maintenance documentation to identify instances of incomplete or erroneous troubleshooting.
  • Poor Maintenance Practices
    • Corrective Actions:
    • Reinspect all recent maintenance work on critical systems such as brakes and propulsion units.
    • Preventive Actions:
    • Introduce quality control audits and certification requirements for maintenance personnel.
    • Investigative Actions:
    • Analyze maintenance error trends and compare with incident data to detect systemic gaps.
• Ground Personnel
  • Adding Third Parties
    • Corrective Actions:
    • Audit and requalify third-party service providers for compliance with safety and training standards.
    • Preventive Actions:
    • Establish a controlled vendor approval process with periodic competency verification.
    • Investigative Actions:
    • Review third-party service records to determine whether procedural deviations occurred.
  • Ground Vehicle on Runway or Incursion
    • Corrective Actions:
    • Implement immediate restriction on airside vehicle movement during active runway operations.
    • Preventive Actions:
    • Install improved signage, lighting, and runway incursion alert systems.
    • Investigative Actions:
    • Review ground movement logs and NOTAM communications to determine authorization lapses.