Accident Boeing 737-85P EC-HBM,
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Date:Sunday 28 October 2007
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-85P
Owner/operator:Air Europa
Registration: EC-HBM
MSN: 28382/256
Year of manufacture:1999
Engine model:CFMI CFM56-7B26
Fatalities:Fatalities: 0 / Occupants: 122
Aircraft damage: Substantial, repaired
Location:Katowice-Pyrzowice Airport (KTW) -   Poland
Phase: Approach
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Beirut Airport (BEY/OLBA)
Destination airport:Katowice-Pyrzowice Airport (KTW/EPKT)
Investigating agency: SCAAI
Confidence Rating: Accident investigation report completed and information captured
Air Europa flight 911, a Boeing 737-800, sustained substantial damage when it impacted approach lights before landing at Katowice, Poland.
The flight departed from Beirut, Lebanon at 22:40 UTC, bound for Katowice. The first officer was pilot flying, the captain was pilot monitoring and an instructor captain was seated in the jump seat.
At 01:42 UTC, when in Bratislava FIR, the crew began to descend from FL360 to FL120. At that time ATC from Bratislava FIR passed to the crew the meteorological conditions for Katowice Airport: wind variable 2 kt, visibility 400 m, visibility for RWY 27: 650m, 550m, 550m, fog, clouds 500ft and 300ft, QNH 1027, dewpoint +8.
The Captain and the instructor agreed that the conditions were suitable to attempt landing, saying: "it is just enough".
The flight was progressively cleared to descend to FL080 and after contacting the Katowice Tower controller, they were instructed to report their position 16 NM ahead of KTC VOR. Weather was reported being: wind var. 2kt, visibility 300m, fog, clouds broken 100ft, temp.+8, dewpoint +8, QNH 1027, expect approach to RWY 27, trans level 80, RWY wet, braking action medium, and copy RVR from threshold 27, 450m, 450m, 650m.
The weather conditions received were commented by the Captain: "Well, that is a little bit difficult, isn’t it?"
At 01:59:54 UTC the Tower controller cleared the flight to descend to 4000ft and requested the crew to report when over KTC. During the descent the first officer suggested that, due to poor visibility, the approach should be performed according to the published procedure, but the captain decided to perform a straight-in approach to reduce fuel consumption.
At 02:03:18, at a distance of 6.4 NM from the runway 27 threshold, the airplane entered the final leg in the landing configuration (landing gear extended, flaps extended to 41º), which was confirmed by the captain who reported to the Tower controller: "... AE 911 is on the localizer runway 27 ...". At that time the airplane was above the glideslope
The Tower controller subsequently cleared the crew for landing and passed the following meteorological conditions: "AE 911 clear to land RWY 27, wind 240 deg., 2kt, RVR from threshold 27 500m, 500m, 900m.".
The crew then requested full intensity approach lights and five seconds later they received response that the lights had been switched to maximum.
At 02:04:19, at 1610ft radio altitude, the airplane was still above the glideslope and the vertical speed started to increase. The captain urged the first officer saying: "go downwards, go downwards ...".
Ten seconds later the captain radioed passing the KTC navigational aid at 2000ft. According to FDR data, the plane was at a pressure altitude of about 2200ft and according to the ILS procedure KTC should be passed at 1790ft.
At 02:05:01 the aircraft descended through the glideslope at a radio altitude of 388 feet. The captain then twice shouted: "... keep that slope ..". After which the GPWS sounded with an aural "Sink rate... pull up" warning.
The captain spotted approach lights at 02:015:13 and said: "In sight...I have it!", and took over controls from the first officer. Two seconds later the aircraft impacted the second row of lights of the approach light system. After touching down the thrust levers were momentary advanced to the take-off setting. This resulted in activation of TAKE-OFF WARNING due to configuration improper for take-off, followed by activation of the stick shaker. The aircraft touched down four times before thrust reversers were selected, meanwhile destroying the remaining lights at a distance of about 850 meters before the runway threshold.
As a result of the occurrence the aircraft sustained substantial damage to both wings skin, flaps, engines and the landing gear hydraulic system.

Cause of the accident and contributing factors:
The cause of the accident was failure to execute a missed approach procedure even if the criteria of a stabilized approach were not met during an attempt to intercept G/S "from above" at excessive descent rate, under meteorological conditions below the minimum for the aerodrome.
Factors contributing to the occurrence
1. Errors in flight crew co-operation (inadequate CRM).
2. The failure of the crew to perform the approach in accordance with the published procedure.
3. No response of the crew to the warning signals generated by GPWS.
4. Landing on aerodrome equipped with ILS CAT I with autopilot engaged.


02:00 UTC / local time:
EPKT 280200Z VRB02KT 0300 R27/0500 R09/0600 FG BKN001 08/08 Q1027

02:30 UTC / local time:
EPKT 280230Z 00000KT 0300 R27/0500 R09/1000 FG BKN001 08/08 Q1027

03:00 UTC / local time:
EPKT 280300Z VRB02KT 0400 R27/0500 R09/1000 FG SCT002 BKN005 08/08 Q1027

Accident investigation:
Investigating agency: SCAAI
Report number: 466/07
Status: Investigation completed
Duration: 10 years 1 month
Download report: Final report



Revision history:


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