Cause & Circumstance: A (Bad) Landing Surprise
When a Bombardier Global Express struck objects on the runway while landing at a Montreal airport, no one was more surprised than the business jet’s captain. The fact that half the runway was closed longitudinally and that temporary runway edge lights were installed along the centerline of the full-width runway was unknown to him. How that came to happen is a tale of serial miscommunication involving the NOTAMs (Notice to Airmen), the ATIS (Automated Terminal Information Service) and the unquestioning acceptance of an unusual landing clearance by both pilots. I think it is also an example of how the dysfunctional NOTAM system can start a chain of errors that results in an accident.
The BD-700-1A10 Global Express departed New Jersey’s Teterboro Airport (KTEB) on May 15, 2017, destined for Montreal/Saint-Hubert Airport, Quebec (CYHU) with three crewmembers and one passenger aboard. The flight was operated by Zetta Jet USA under the provisions of FAR Part 135. The aircraft lifted off at 0958 EDT, climbed to FL 330 and cruised at that altitude for about 25 minutes. Before commencing descent, the captain, who was the pilot flying (PF), briefed the approach. It was to be the RNAV (GNSS) Runway 06L approach, and the briefed decision altitude (DA) was 400 ft. AGL. After the briefing, the first officer (FO) tuned the ATIS frequency, listened to it, and then briefed the captain.
The ATIS information for 1000 EDT was an automated observation, wind, 360 deg. at 12 kt. gusting to 17 kt.; visibility, 9 sm; sky, 11,000 ft. AGL overcast; temperature, 14C; dew point, 9C; altimeter, 29.68; RNAV Runway 06L approach in use; departing and landing Runways 06L and 06R. The ATIS stated that the first 2,801 ft. of Runway 24R were closed, and that the available takeoff run, takeoff, accelerate-stop and landing distances were 5,000 feet. The ATIS also indicated that 75 ft. of the south side of Runway 06L/24R were open over a distance of 5,000 feet from the Runway 06L threshold, and that 75 ft. of the north side were closed along the entire length of the runway.
When the FO briefed the captain, he omitted the information about the dimensions of the available runway.
Approaching the initial approach fix LOBDO at 1049:45, the crew checked in with the tower controller, who replied that the winds were 010 deg. at 16 kt. gusting to 22 kt. Tower then asked the crew if they had read the NOTAMs about the construction work on Runway 06L. The FO replied that they had. Tower cleared the flight to land on the south side of Runway 06L at 1050:51, and the FO read back the clearance except for the part about the south side.
The captain then questioned the FO about the NOTAMs. The FO explained that the runway length was reduced to 5,000 ft. but said nothing about the width of the runway or the fact that the entire north side of the runway was closed.
The captain disengaged the autopilot at 500 ft. AGL, lined up with the runway’s normal full width and touched down at 1054:38. The touchdown point was 850 ft. beyond the runway threshold. The nosewheel was 36 ft. to the left of the temporary runway centerline and 1.5 ft. to the right of the temporary left edge of the runway; the left main landing gear was 5.2 ft. outside the confines of the temporary runway. Once on the ground, the captain realized they had struck something and moved the aircraft to the right, stopping 300 ft. from the end of the runway and slightly to the right of the temporary centerline.
No one was injured. The passenger exited the airplane and was escorted to the terminal, while the crew remained at the aircraft until investigators could arrive. The runway was closed until temporary repairs could be made to the airplane, which was late on the night of the incident.
The Transportation Safety Board (TSB) of Canada conducted the investigation. Upon arrival at the aircraft, investigators discovered that the two tires of the left main landing gear (MLG) had burst on contact with the temporary runway edge lights, and there was substantial damage to the left MLG wheels, the gear door, the trailing edge of the wing, the left inboard flap, the left engine nacelle and the center rear fuselage. Tire debris was ingested into the left engine and there were punctures to the inlet area acoustic panel. In addition, five of the temporary runway lights were damaged and had to be replaced.
The flight crew held the necessary certificates and qualifications for the flight. Both pilots held ATP certificates and type ratings for the BD-700, and they had a similar amount of total flying time, 3,485 hr. for the captain and 3,305 hr. for the FO. The captain had more time in type, 1,172 hr. vs. 382 hr. for the FO, but in other measures they were alike: Both had 15 hr. in type in the last seven days; both had 2.9 hr. on duty the day of incident and 11.5 hr. off duty the night prior; and both had almost the same amount of flight time in type in the previous six months, 271 hr. for the captain and 258 hr. for the FO. The captain was due for recurrent training soon and the FO had just completed his recurrent training less than two months before the incident.
The tower controller had more than seven years of experience in his present unit, was rated as an expert speaker of both English and French, and was well rested.
The Global Express aircraft was manufactured in 2002 and was properly certified, equipped and maintained. Weight and CG were within limits. Designed for long-range flight, the airplane’s maximum takeoff wight was 93,500 lb. and its wingspan was 93.5 ft. The actual landing weight, approach speed and expected landing distance were not given in the report.
Due to the construction being done on and near the runway, the only instrument approach in use was the RNAV approach flown by the crew. A NOTAM was issued limiting the approach to an LNAV minimum descent altitude of 600 ft. AGL, rather than the lower 400-ft. AGL LPV minimums used by the crew. Since ceiling and visibility were VFR, the crew’s choice was not consequential except as an indication of not complying with the NOTAM.
The TSB found that the communications between the tower controller and the crew were clear and not interfered with. When the FO failed to read back the part of the landing clearance pertaining to the south side of the runway, the controller did not challenge him.
The airport was operated by a non-profit corporation known as Développement Aéroport Saint-Hubert de Longueuil (DASH-L). The airport had three runways, only one of which, 06L/24R, was suitable for business or commercial jets such as the Global Express. [Nearby Trudeau Airport (CYUL) had three suitable runways: 7,000, 9,600 and 11,000 ft. in length.)
The repairs that were being performed on Runway 06L/24R and three nearby taxiways were part of a plan developed by DASH-L and approved by Transport Canada. Work on Phase 2 of the repairs had begun on April 15, 2017, a month before the incident, and were scheduled to end on July 15, 2017. The repair plan identified 11 risks and provided 13 mitigations. The mitigations included temporary lighting, threshold markings and lights, illuminated Xs and Xs on the ground, and a temporary PAPI relocated to the threshold of Runway 06L. The “06L” white paint marking on the approach end of the runway was moved and centered on the active, south side of the runway, and two arrows pointed to the runway markings. A thin white line was painted around the useable 75-by5,000-ft. rectangle of the runway.
One additional mitigation was implemented. Temporary runway edge lights were installed along the old centerline. They were not illuminated during the day, and were difficult to see by a crew on final approach. The incident crew never noticed them. The TSB found that the lights were not secured so as to be frangible, allowing them to move and damage the airplane.
From the date construction started in 2016 until one month after the incident, CYHU had experienced 10 reported incidents related to the temporary runway modifications. These included four aircraft that struck the temporary lights but did not experience major damage, two aircraft that had inadvertently landed on the parallel taxiway and two aircraft that had traveled on the closed portion of the runway.
The TSB also cited a similar landing accident at another Canadian airport in 2015 in which a NOTAM had been issued for a similar longitudinal runway width reduction and yet another landing aircraft had struck temporary lights.
According to the TSB report, the operator of the Global Express in the incident at CYHU, Zetta Jet USA, offered personalized, on-demand, worldwide service. The company was based in Singapore, had another location in Burbank, California, and had a fleet of 21 aircraft, including 13 BD-700s and six Gulfstreams. Zetta Jet ceased operations six months after this incident amidst published concerns about financial irregularities.
A subsequent article will further explore the investigation and the problem with NOTAMs.