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ASN Wikibase Occurrence # 192942
Last updated: 20 November 2018
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Date:19-JAN-2017
Time:11:58 LT
Type:Silhouette image of generic DH8D model; specific model in this crash may look slightly different
de Havilland Canada DHC-8-402Q Dash 8
Owner/operator:ANA Wings
Registration: JA461A
C/n / msn: 4430
Fatalities:Fatalities: 0 / Occupants: 25
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:New Chitose Airport (CTS/RJCC) -   Japan
Phase: Landing
Nature:Domestic Scheduled Passenger
Departure airport:Akita Airport (AXT/RJSK)
Destination airport:New Chitose Airport (CTS/RJCC)
Investigating agency: JTSB
Narrative:
A DHC-8-Q400 of ANA Wings, operating flight ANA/NH1831 from Akita to New Chitose overran on the runway 01R while landing at New Chitose. No injuries were reported among 21 passengers and 4 crew.
The departure of the aircraft from Akita Airport was delayed for 15 minutes because one of two runways at New Chitose Airport were closed due to a snow removal. The captain had particularly checked the snow conditions at New Chitose Airport prior to his departure.
The aircraft, after holding at NAVER (a waypoint at 35 NM south-southwest of New Chitose Airport), was vectored by the radar controller to an ILS final approach course for runway 01R of New Chitose Airport. Runway 01L/19R of the airport was closed due to a snow removal, and the aircraft was instructed to vacate the runway via taxiway B2 connecting to the end of the runway.
At 11:56:34, the aircraft touched down near the touchdown zone marking at approximately 300 m from the threshold at an airspeed of about 122 kt (107 kts groundspeed).
As ground spoilers were automatically deployed right after the main gear touched down, the power lever transited to a position of 42ļ and remained there for about 50 seconds. However, the captain thought he had set the power lever in the flight idle position.
The captain judged that the aircraft would stop based on the runway condition. He attempted to vacate the runway quickly by delaying the braking of the aircraft considering that the landing roll distance to taxiway B2 was long, braking action was Good and only one runway was in use.
The normal operations of the aircraft after touchdown are setting the power lever in the flight idle position, then setting the power lever in Disc range (als known as Beta mode) position and stepping on the brake. According to the FDR records, the power lever moved slowly to flight idle for five seconds from 11:57:23 at about 56 kt groundspeed near where the aircraft passed taxiway B3. The copilot was mainly watching the instrument panel and the heading direction on the runway, and did not notice the power lever positions.
When calling for 60 kt, the co-pilot thought that the airplane could stop without overrunning.
The captain started to step on the brake near taxiway B4 considering the remaining distance, but the braking pressure actually started to rise when passing taxiway B3. The captain did not feel the effect of braking, so he applied maximum braking pressure but still he did not feel the deceleration. Therefore he thought that the braking action was not good.
Because the co-pilot felt the braking of the aircraft, he judged that the power lever was in the Disc position and brakes operated normally. He thought that the weak deceleration was caused by the anti-skid system not working.
Due to the snow-ice condition, the reverse-pitch of the propellers should be used with care, therefore, the captain did not use the reverse-pitch in order to avoid a rapid deviation or lateral slip.
The captain, judging that the aircraft was not decelerating enough to turn, used the pedal and hand-control steering to move to the left to avoid the overrun zone edge light. The aircraft gradually decelerated, but passed through the end of the runway at about 20 kt groundspeed and came to a stop in the snow-covered grassland at 11:58:07. The right main landing gear was about 72 m from the runway end (about 12 m from the overrun zone north end).

The runway 01R/19L was subsequently closed for 6 hours.

PROBABLE CAUSES: "In this serious incident, it is highly probable that the aircraft overran the runway because the aircraft could not obtain the braking force due to the delay of braking operation start by the PIC and PL (Power Lever) was not set at the Disc position. Moreover, it is somewhat likely that the bad conditions with snowfall around the end of the runway and the overrunning zone contributed to the aircraft overrunning.
Regarding the delay of braking operation start by the PIC, it is highly probable that because the PIC instructed from ATC to vacate from Taxiway B2 at the end of the runway tried to vacate the runway in a short time by delaying the braking operation start. Furthermore, it is probable that the PICís misconceiving Taxiway B3 where he just started to vacate as Taxiway B4 contributed to it.
Regarding why the PL was not set to Disc position, it is probable that because the PIC mistook the PL was already Disc position. Furthermore, it is somewhat likely that it was contributed that the co-pilot did not notice PL in different position than normal."

Weather data at the time of the accident (11:58 local/02:58 UTC):
RJCC 190300Z 35013KT 9999 -SHSN FEW006 BKN050 M02/M04 Q1016 RMK 2ST006 7CU050 A3002
(12:00 local/03:00 UTC, wind 350 degrees at 13 knots, visibility 10km+, light shower of snow, clouds 2 oktas 600 feet, 7 oktas 5000 feet, temperature -02 degree Celsius, dew-point -04 degree Celsius, QNH 1016hPa/3002INS)

Sources:

http://jtsb.mlit.go.jp/jtsb/aircraft/detail2.php?id=2170
[LINK NOT WORKING ANYMORE:http://www3.nhk.or.jp/news/html/20170119/k10010845021000.html]

Accident investigation:
cover
  
Investigating agency: JTSB
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report


Images:


Photo: JTSB

Revision history:

Date/timeContributorUpdates
19-Jan-2017 04:55 isamuel Added
19-Jan-2017 06:46 isamuel Updated [Source, Narrative]
19-Jan-2017 13:48 isamuel Updated [Registration, Cn, Source, Narrative]
22-Jan-2017 19:02 harro Updated [Aircraft type, Source]
25-Feb-2018 20:56 harro Updated [Time, Narrative]
28-Feb-2018 15:22 harro Updated [Narrative]
28-Feb-2018 15:23 harro Updated [Damage]
28-Feb-2018 18:25 harro Updated [Source, Narrative, Photo, ]

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