Crew resource management needs improvement — investigation into July 11, 2017, airliner overrun at Helsinki-Vantaa airport completed

A serious incident occurred at Helsinki-Vantaa airport on July 11, 2017, when a Boeing 737-800 airliner operated by Norwegian Air Shuttle overran the runway after landing. The aircraft carried six crew members and 168 passengers. The incident did not result in injuries. The aircraft and runway end lights sustained damage.

Based on the investigation, the Safety Investigation Authority (SIA) issues two safety recommendations to the European Aviation Safety Agency (EASA) with the aim of improving aviation safety and preventing similar incidents. In a worst case scenario, a runway excursion may have extremely serious consequences.

SIA recommends that EASA investigates how crew resource management (CRM) training for ground operations can be enhanced. Deficiencies in CRM-related communication during the landing roll were noted during the investigation, and these affected the flight crew’s vigilance and situational awareness.

Good CRM is an essential contributor to flight safety. Pilots’ basic training and recurrent CRM training emphasize, among other matters, the importance of standardized communication and a preparedness to interfere with situations that are felt to involve a potential safety hazard. Most serious incidents occur on runways and taxiways.

SIA also recommends that EASA investigates whether the current airline schedules are realistic and whether they affect the procedures of airline industry in a way that would degrade safety. Competition and financial reasons have led airlines to set stringent schedule adherence goals. Balancing in between the schedule adherence goals and the safety goals may lead to the adoption of procedures that undermine safety.

In this particular incident, braking was initiated too late, and the effects of the wet runway and stowed speedbrakes (spoilers) on braking distance were not anticipated. A contributing factor in the incident was an attempt to catch up with the schedule and expedite vacating of the runway. The flight departed Stockholm 53 min behind schedule. It had already been delayed during the departure from Helsinki to Stockholm, and the delay had since accumulated. Aircraft turnaround times at airports are short. During the short time available, the passengers disembark and new ones board, and the aircraft is fueled, loaded, and cleaned, and a delay in any one of these operations may easily result in a late departure.

Flight crews find themselves in a problematic situation if flights are frequently delayed for reasons beyond their control and feel pressed to minimize the delays to the maximum possible extent. A strive for punctuality or the minimizing of of delays may contradict with safety aspects.

Investigation report

Further information:
Chief Investigator Ismo Aaltonen, tel. +358 295 150 703
Executive Director Veli-Pekka Nurmi, tel. +358 295 150 701