Serious incident Boeing 737-8Q8 5B-DBV, Monday 9 November 2009
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Date:Monday 9 November 2009
Time:19:36 UTC
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8Q8
Registration: 5B-DBV
MSN: 30654/1295
Year of manufacture:2003
Fatalities:Fatalities: 0 / Occupants: 80
Other fatalities:0
Aircraft damage: Minor
Category:Serious incident
Location:Katowice (EPKT) -   Poland
Phase: Landing
Nature:Passenger - Scheduled
Departure airport:Fuerteventura (GCFV)
Destination airport:Katowice (EPKT)
Investigating agency: SCAAI
Confidence Rating: Information verified through data from accident investigation authorities
The crew had performed a Category I ILS approach to Katowice's runway 27 at night conditions and poor visibility. Atmospheric conditions at the airport at 19.30 UTC: wind 210 °/2 KT, RVR for runway 27 was 350 m by the presence of fog, and the lower level of clouds was determined to 100 FT.

Minima for airport and crew for the approach in CAT I are: RVR - 550m and cloud base 200 FT. After touch down to the left of the centre line the aircraft left main and nose gear went off the runway and then for approximately 373 m remained outside of the runway damaging part of the two runway edge lamps. The right main landing gear wheel during this time remained on the asphalt of the runway. The aircraft returned to the runway and has eventually stopped. In a post flight interview the landing captain stated, that he probably mistook the left runway edge lights for the (non-existing) runway centre line lighting. The crew did not report any incident after landing and handed the airplane to a new flight crew, who was to take the airplane from Katowice to Warsaw

F/O of the landing crew provided the information for the crew from Katowice to Warsaw, that he will do the PDI (pre departure inspection) and CPT of amending crew accepted this.
As a result, F/O of the previous crew checked only left main landing gear without performing properly throughout the PDI. When doing this F/O did not have a flash-light for lighting of aircraft elements contained in the PDI procedure. As a result, he skipped checking the front landing gear, the right main landing gear and other items subject to PDI.
This prevented him from detecting broken landing lights, damaged tyres of the front gear, damaged right rim of nose gear, headlamp on the protectors of the gears, undetected remained corruption of the tyres of the right main landing gear wheels.
Each of these faults should have resulted in the inability of the aircraft for further flight until Exchange all damaged items. After returning to the aircraft F/O reported to the CPT for the crew to Warsaw, aircraft is OK. During the push back person monitoring this process on the ground, reported broken landing headlamp to CPT. CPT asked F/O of the previous flight (previous crew was returning to Warsaw on board of the aircraft) if he noticed (when executing PDI) any damaged headlamp, F/O reported "negative". Therefore, the minimum equipment list (MEL) allows the flying CPT to complete the flight to Warsaw and has no objection to the efficiency of the aircraft. After landing in Warsaw and checking the status and tyres of the front gear, CPT wrote an ASR report entry, has filed it to the logbook, handed over the aircraft to the technical personnel, and then both crews proceeded to the hotel.

Accident investigation:
Investigating agency: SCAAI
Report number: 
Status: Investigation completed
Download report: Final report

Sources: preliminary report

Revision history:

12-Dec-2009 07:07 p_k Added
04-Nov-2020 08:22 KagurazakaHanayo Updated [Source, Narrative]
04-Nov-2020 08:24 harro Updated [Operator, Location, Narrative, Accident report]

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