A new report from the Transportation Safety Board of Canada (TSB) concludes there were several factors that caused a Flair Airlines plane to overrun the runway at Region of Waterloo International Airport back in 2022, which includes pilot fatigue and an equipment defect.
The Boeing 737-800, which is owned and operated by Flair Airlines, was heading to Kitchener-Waterloo when, upon landing on Nov. 25, 2022 at about 6:25 a.m. ET, it overran runway 26.
A total of 134 passengers and six crew were on board flight F8 501 and while there was visible damage to one wing, no one was injured.
Photos show the plane stopped in a field about 500 feet, or 152 metres, off the end of the runway in Breslau.
The report released Thursday said the plane departed from Vancouver just after 2:30 a.m. ET with an inoperative left engine thrust reverser. It was something that had been detected in May of that year and the report points out there were 22 subsequent reports which “provided an opportunity to troubleshoot the problem.”
“Despite this, the defect did not meet the regulatory definition of a recurring defect, thus, Flair’s maintenance control software did not identify it as such. If the underlying issue behind a persistent maintenance defect is not addressed in a timely manner, there is a risk that it may compound, resulting in a serious consequence,” the report continued.
As well, the captain of the flight “had accrued a significant sleep debt” after conducting two additional overnight flights that week and was “operating the aircraft after a nearly 18-hour wake period, at the end of a circadian low,” the report said.
During the landing, the captain pressed the wrong button —the takeoff/go-around (TO/GA) switch, instead of disengaging the autothrottle — which caused the engine to thrust.
However, the indications from the plane’s system didn’t alert the flight crew to the mistake, partly because they were helping a passenger with a medical issue.
“The investigation found that there were several factors which contributed to the inadvertent press of the TO/GA switch and the undetected flight mode change,” the report concluded.
“These include pilot fatigue, the attention of both pilots focused outside the aircraft during the Flair and landing, and that the aircraft systems did not provide visual and aural cues that were noticeable enough by the flight crew to indicate the inadvertent mode change during that phase of flight.”
