Airport (less than 10 km from airport)

Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. The ineffective presentation style and sequence of the NOTAMs available to the crew and flight dispatch led them to interpret that Runway 23 was not available for landing at Halifax/Stanfield International Airport.
2. The crew was unaware that the aircraft did not meet the pre-departure landing weight requirements using flaps 25 for Runway 14.
3. Due to the timing of the flight during the nighttime circadian trough and because the crew had had insufficient restorative sleep in the previous 24 hours, the crew was experiencing sleep-related fatigue that degraded their performance and cognitive functioning during the approach and landing.
4. Using unfactored (actual) landing distance charts may have given the crew the impression that landing on Runway 14 would have had a considerable runway safety margin, influencing their decision to continue the landing in the presence of a tailwind.
5. When planning the approach, the crew calculated a faster approach speed of reference speed + 10 knots instead of the recommended reference speed + 5 knots, because they misinterpreted that a wind additive was required for the existing conditions.
6. New information regarding a change of active runway was not communicated by air traffic control directly to the crew, although it was contained within the automatic terminal information service broadcast; as a result, the crew continued to believe that the approach and landing to Runway 14 was the only option available.
7. For the approach, the crew selected the typical flap setting of flaps 25 rather than flaps 30, because they believed they had a sufficient safety margin. This setting increased the landing distance required by 494 feet.
8. The crew were operating in a cognitive context of fatigue and biases that encouraged anchoring to and confirming information that aligned with continuing the initial plan, increasing the likelihood that they would continue the approach.
9. The crew recognized the presence of a tailwind on approach 1 minute and 21 seconds from the threshold; likely due to this limited amount of time, the crew did not recalculate the performance data to confirm that the runway safety margin was still acceptable.
10. An elevated level of stress and workload on short final approach likely exacerbated the performance-impairing effects of fatigue to limit the crew’s ability to determine the effect of the tailwind, influencing their decision to continue the approach.
11. The higher aircraft approach speed, the presence of a tailwind component, and the slight deviation above the glideslope increased the landing distance required to a distance greater than the runway length available.
12. After the firm touchdown, for undetermined reasons, the engine No. 1 thrust lever was moved forward of the idle position, causing the speed brakes to retract and the autobrake system to disengage, increasing the distance required to bring the aircraft to a stop.
13. The right crab angle (4.5°) on initial touchdown, combined with the crosswind component and asymmetric reverser selection, caused the aircraft to deviate to the right of the runway centreline.
14. During the landing roll, the pilot monitoring’s attention was focused on the lateral drift and, as a result, the required callouts regarding the position of the deceleration devices were not made.
15. The pilot flying focused on controlling the lateral deviation and, without the benefit of the landing rollout callouts, did not recognize that all of the deceleration devices were not fully deployed and that the autobrake was disengaged.
16. Although manual brake application began 8 seconds after touchdown, maximum braking effort did not occur until 15 seconds later, when the aircraft was 800 feet from the end of the runway. At this position, it was not possible for the aircraft to stop on the runway and, 5 seconds later, the aircraft departed the end of the runway at a speed of 77 knots and came to a stop 270 m (885 feet) past the end of the runway.
17. During the overrun, the aircraft crossed a significant drop of 2.8 m (9 feet) approximately 166 m (544 feet) past the end of the runway and was damaged beyond repair. While this uneven terrain was beyond the 150 m (492 feet) runway end safety area proposed by Transport Canada, it was within the recommended International Civil Aviation Organization runway end safety area of 300 m (984 feet).

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If the pilot monitoring does not call out approach conditions or approach speed increases, the pilot flying might not make corrections, increasing the risk of a runway overrun.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. The investigation concluded that there was no reverted rubber hydroplaning and almost certainly no dynamic hydroplaning during this occurrence.
2. Although viscous hydroplaning can be expected on all wet runways, the investigation found that when maximum braking effort was applied, the aircraft braking was consistent with the expected braking on Runway 14 under the existing wet runway conditions.

The mechanic's failure to properly align the engine exhaust crossover pipe during replacement, and his supervisor's failure to properly inspect the installation, which resulted in an in-flight fire and the loss of engine power.

The cause of the aviation accident with the RRJ 95B RA-89011 aircraft when landing at night with one deactivated thrust reverser was the transfer to the crew of incorrect information about the value of the friction coefficient, which led to the landing on an icy runway, the average normative friction coefficient which was less than 0.3, which did not allow landing in accordance with current regulations. This led to a significant increase in landing distance, rolling the aircraft out of the runway and collision with the junction of the reconstructed section of the runway with a height of about 0.4 m, which led to the destruction of the main landing gear supports and damage to the engines with fuel leakage without causing a fire.
The contributing factors were the following:
- Absence of a connecting ramp (which was not envisaged by the reconstruction project) between the current and the part of the runway being reconstructed;
- inefficiency of the SMS of Yakutsk Airport JSC in terms of identification and control of risks associated with the possibility of ice formation at the runway, and insufficient control over the implementation of the SMS by aviation authorities;
- erroneous determination of the Xc value at the last measurement;
- inefficiency of ice removal procedure during runway cleaning due to lack of chemical reagents for ice removal and/or thermal machines at the airfield;
- lack of information from the RRJ-95LR-100 RA 89038 aircraft crew about actual rolling out of the runway, which was an aviation incident and was subject to investigation;
- failure by airport and ATC officials to take appropriate action after receiving the RRJ-95LR-100 RA-89038 low friction report from the aircraft crew.

The operator's decision to allow a flight in an airplane with known, unresolved maintenance discrepancies, and the flight crew's failure to properly configure the airplane in a way that would have allowed the emergency or parking brake systems to stop the airplane during landing.

The pilot's descent below minimum descent altitude during the non precision instrument approach for reasons that could not be determined based on the available information.

The following findings were identified:
- The approach was considered stabilized;
- The required landing distance of 6,431t (1,960m) was compatible for the operation, since the LDA of runway 32 at SBFI was 7,201ft (2,195m);
- There was no evidence of malfunction of the aircraft brake system that could have caused the runway excursion;
- At the time of landing, the runway was wet with a significant amount of water on the pavement;
- The estimated deceleration corresponded to what would be expected on a very wet runway (> 3mm of water) with hydroplaning of the tires at higher speeds;
- The friction and macrotexture measurements had normal parameters and did not contribute to the aircraft's poor deceleration;
- The characteristics of the precipitation over threshold 14 associated with the large variations in wind direction and intensity were consistent with the windshear phenomenon, resulting from a microburst;
- The PR-TLZ sensors did not detect the occurrence of windshear during the landing approach;
- A sudden increase in the calibrated speed that peaked at 32kt altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, resulting in poor braking in the parts where the ground speed was lower;
- The speedbrakes were not extended during the run after landing, contrary to what was prevised in the AFM;
- The aircraft ran the full length of the runway, overpassed its limits and crashed into a ravine;
- There was a windshear alert issued about 30 seconds after the landing of the PRTLZ by an aircraft that was at the threshold 32;
- The aircraft had substantial damage; and
- The crewmembers and the passenger left unharmed.
Contributing factors:
- Control skills – undetermined
Despite the low contribution of the speedbrakes to the reduction of the landing distance, this device represents a deceleration resource through aerodynamic drag that should not be neglected, especially during landing on wet runways, and could have contributed to avoiding runway excursion.
- Adverse meteorological conditions – a contributor
The large variation in wind intensity peaked at 32 kt. This variation lasted 13 seconds and raised the indicated speed from 76 kt to 108 kt. Considering that the speed of 108 kt was very close to the VREF (111 KCAS), it can be stated that this phenomenon altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, leading to poor braking.

The pilot's selection of an empty fuel tank for takeoff, which resulted in fuel starvation and the subsequent total loss of engine power.

The pilot's improper fuel management, which resulted in a total loss of right engine power due to fuel starvation; the pilot's inadequate flight planning; the pilot's failure to secure the right engine following the loss of power; and his failure to properly configure the airplane for the go-around, which resulted in the airplane's failure to climb, an exceedance of the critical angle of attack, and an aerodynamic stall.