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ASN Wikibase Occurrence # 211870
Last updated: 23 June 2018
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Date:07-MAR-2017
Time:15:34 LT
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8CT (WL)
Owner/operator:WestJet
Registration: C-GWSV
C/n / msn: 37158/2841
Fatalities:Fatalities: 0 / Occupants: 164
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Sint Maarten-Juliana Airport (SXM/TNCM) -   Sint Maarten
Phase: Approach
Nature:International Scheduled Passenger
Departure airport:Toronto-Lester B. Pearson International Airport, ON (YYZ/CYYZ)
Destination airport:Sint Maarten-Juliana Airport (SXM/TNCM)
Investigating agency: TSB Canada
Narrative:
A WestJet Boeing 737-800 was operating as flight 2652 from Toronto/Lester B. Pearson International Airport, Canada, to Princess Juliana International Airport in Sint Maarten with 158 passengers and six crew members on board. It entered a significant rain shower shortly after crossing the MAPON (missed approach point) waypoint. The crew initiated a missed approach 0.30 nautical miles from the runway threshold at an altitude of 40 feet (12 m) above water. Once visibility improved, the crew conducted a second approach and landed without incident.

Findings as to causes and contributing factors:
- Significant changes in visibility were not communicated to the crew, which allowed them to continue the approach when the visibility was below the minimum required to do so.
- The reduction in the pitch attitude led to an increase in airspeed, which resulted in a reduction in engine thrust and a higher rate of descent than that required by the 3 angle of descent.
- The occurrence of a moderate to heavy rain shower, after the aircraft crossed the missed approach point, led to a significant reduction in visibility. The low-intensity setting of the runway lights and precision approach path indicator lights limited the visual references that were available to the crew to properly identify the runway.
- The features of a hotel located to the left of the runway, such as its colour, shape, and location, made it more conspicuous than the runway environment and led the crew to misidentify it as the runway.
- The reduced visibility and conspicuity of the runway environment diminished the crew's ability to detect that they had misidentified the runway.
- The lack of visual texture and other visual cues available over water contributed to the crew's inability to detect the aircraft's height above the water.
- An increase in visual workload led to inadequate altitude monitoring, which reduced the crew's situational awareness. As a result, the crew did not notice that the aircraft had descended below the normal 3 angle of descent to the runway threshold.

Findings as to risk:
- If the International Civil Aviation Organization Procedures for Air Navigation Services: Air Traffic Management are not implemented in the management of aerodrome light intensity, there is a risk that the optimal light intensity settings for prevailing weather conditions will not be selected.
- If crews do not identify and manage threats, there is an increased risk of crew errors, which could lead to undesired aircraft states.

After the occurrence, WestJet developed a corrective action plan, including information for pilots regarding possible challenges and threats on approaching and landing at Princess Juliana International Airport. WestJet also revised its Route & Aerodrome Qualification for TNCM with additional information. In addition, guidance on airport lighting system management will be added to the Air Traffic Services operations manual in TNCM by September 2018.

Sources:

TSB

Accident investigation:
cover
  
Investigating agency: TSB Canada
Status: Investigation completed
Duration: 1 year and 2 months
Download report: Final report


Images:


Standard 3 angle of descent versus the aircraft vertical approach path (TSB)


Visual references as seen in a flight simulator at approximately 500 feet AGL in poor visibility (TSB)

Revision history:

Date/timeContributorUpdates
04-Jun-2018 20:22 harro Added
04-Jun-2018 20:23 harro Updated [Photo, ]

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