Accident Boeing 737-476 (SF) HA-FAX,

ASN Wikibase Occurrence # 320034

Date:	Friday 5 August 2016
Time:	04:07
Type:	Boeing 737-476 (SF)
Owner/operator:	ASL Airlines Hungary
Registration:	HA-FAX
MSN:	24437/2162
Year of manufacture:	1991
Total airframe hrs:	65332 hours
Engine model:	CFMI CFM56-3C1
Fatalities:	Fatalities: 0 / Occupants: 2
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	Bergamo-Orio Al Serio Airport (BGY) - Italy
Phase:	Landing
Nature:	Cargo
Departure airport:	Paris-Charles de Gaulle Airport (CDG/LFPG)
Destination airport:	Bergamo-Orio Al Serio Airport (BGY/LIME)
Investigating agency:	ANSV
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
An ASL Airlines Hungary Boeing 737-400 cargo plane, operating flight QY7332 on behalf of DHL, suffered a runway excursion accident after landing at Bergamo-Orio Al Serio Airport (BGY), Italy.
The aircraft departed Paris-Charles de Gaulle Airport, France at 02:54 hours local time with destination Bergamo. The flight was cleared to perform an ILS approach to runway 28. After clearing the flight to land, the tower controller provided the latest weather information (wind 310 degrees at 15 knots) and stated that the runway condition was wet.
About 04:07 hours the flight crossed the runway threshold at 140 feet AGL at a speed of 156 knots. During the flare the aircraft floated for 14 seconds between 30 and 20 feet. The aircraft touched down about 2000 m down the runway.
The runway length starting at the runway 28 threshold is 9209 ft (2807m). Failing to stop at the end of the runway, the aircraft travelled 300 m across two roads, a parking lot and a highway lane before coming to rest with the nose across another highway lane.
The aircraft crossed the airport perimeter fence at a speed of 109 knots.

CAUSE (translated form Italian)
The causes of the accident are mainly due to the human factor.
In particular, the accident was caused by the exit of the runway during the landing phase, caused by the loss of situational awareness relating to the position of the aircraft with respect to the runway itself. This loss of situational awareness on the part of the crew caused a delay in contact with the runway, which occurred, at a still high speed, in a position too far to allow the aircraft to stop within the space still available.
Contributing to the dynamics of the event:
- the commander's prior decision not to carry out the go-ahead procedure (this decision is of crucial importance in the chain of events that characterised the accident);
- inadequate maintenance of flight parameters in the final phase of landing;
- failure of the crew to disconnect the A/T before landing;
- poor lighting conditions and the presence of storm cells with heavy rainfall at the time of the event (environmental factor), which may have contributed to the loss of situation awareness;
- the attention paid by the crew to the final phase of the flight, where both pilots were intent on acquiring external visual reference and did not realise that the aircraft had flown over the runway at a high speed for 18 seconds before the touchdown;
- the lack of assertiveness of the first officer in questioning the commander's decisions.
Finally, it cannot be excluded that a condition of tiredness and fatigue may have contributed to the accident, even if not perceived by the crew, which may have influenced the cognitive processes, in particular those of the captain, interfering with his correct decision making process.

METAR:

01:50 UTC / 03:50 local time:
LIME 050150Z 26011G23KT 220V310 9999 VCTS FEW040CB BKN080 23/16 Q1010
Wind 260 degrees at 11 knots, gusting to 23 knots and varying between 220 and 310 degrees; Visibility 10+ km; thunderstorm in vicinity; few cumulonimbus clouds at 4000 feet AGL, broken clouds at 8000 feet AGL; Temperature: 23°C, Dew point 16°C; Pressure 1010 mb

02:20 UTC / 04:20 local time:
LIME 050220Z 34011KT 9999 SHRA TS FEW015 SCT030CB BKN050 18/17 Q1011
Wind 340 degrees at 11 knots; Visibility 10+ km; rain showers, thunderstorm; few clouds at 1500 feet AGL, scattered cumulonimbus clouds at 3000 feet AGL, broken clouds at 5000 feet AGL; Temperature: 18°C, Dew point 17°C; Pressure 1011 mb

Accident investigation: