On Nov. 25, 2022, a Flair Airlines Boeing 737-800 overran the runway while landing at the Region of Waterloo International Airport in Ontario. The aircraft was arriving from Vancouver, British Columbia, with six crew members and 134 passengers on board. There were no injuries.
In its final report issued on Thursday, the Transportation Safety Board of Canada (TSB) investigation found that several factors contributed to the incident.
During the landing approach, the captain inadvertently pressed the takeoff/go-around (TO/GA) switch instead of disengaging the autothrottle as intended. This caused the autothrottle to increase engine thrust.
Investigators stated that the flight crew did not notice the change, as they were focused on looking outside the cockpit at this point.
After touchdown, the captain removed his hand from the left thrust lever to activate the right engine thrust reverser. With the aircraft still in go-around mode, the right engine produced reverse thrust while the left engine began advancing to maximum forward thrust. This deactivated the automatic braking and speed brake systems.
The captain managed to keep the aircraft on the runway using manual braking, but there was not enough runway remaining to stop. The aircraft overran the runway by approximately 500 feet, coming to rest on a grassy area beyond the runway’s end.
Pilot Fatigue
Investigators determined that pilot fatigue likely played a role in this incident. The captain had accumulated “significant sleep debt” in the days before the flight and had been awake for nearly 18 hours at the time of the incident.
The overrun happened during the nighttime “window of circadian low” when human performance tends to be at its worst.
Maintenance Delays
Investigators also found that a defect with the aircraft’s left thrust reverser had been reported repeatedly over the previous six months, with 23 related defects logged. However, the issue did not meet the regulatory definition of a recurring defect, so it was not flagged in the airline’s maintenance tracking system.
After the incident, Flair updated its procedures to reinforce the existing requirement for pilots to disengage the autopilot and autothrottle simultaneously during an approach.
