GR609 - Incident: Luxwing DH8D at Guernsey on Apr 23rd 2024

A Luxwing de Havilland Dash 8-400 on behalf of Aurigny Air Services, registration 9H-LWB performing flight GR-609 from London Gatwick,EN to Guernsey,CI (UK) with 63 passengers and 5 crew, landed on Guernsey's runway 27 but overran the end of the runway at 18:43L (17:43Z) and came to a stop on soft ground about 30 meters/100 feet past the end of the runway. There were no injuries and no visible damage to the aircraft.

On Jul 2nd 2026 the AAIB released their final report concluding the probable causes of the serious incident were:

The runway excursion occurred because the Commander, while trying to perform a gentle landing, touched down a considerable distance beyond the landing zone with insufficient runway left to arrest the aircraft using normal braking. The application of full braking force was too late to prevent a low-speed departure from the runway. More proactive exploitation of FDM data may have detected how the flights were being conducted in the early stages of the contract as there was evidence available of previous landings beyond the touchdown zone. In response to the serious incident both the Lessee and the Lessor identified and made changes to their safety management systems.

The AAIB analysed:

Operations

Both the available flight data and CCTV demonstrated the aircraft ‘floating’ down the runway for an extended period of time before touching down. The aircraft was flown below 10 feet above the runway surface for some 10 seconds without reducing below Vapp, during which time it consumed nearly half of the landing distance available. The reason given for this was the commander, as handling pilot, wanting a gentle touchdown.

All three pilots occupying the flightdeck stated that the runway slope had contributed to a lack of visual perspective, meaning that none of them was aware how far down the runway the aircraft had travelled by the time it did finally touchdown. They would, however, have been aware of the prolonged period of time the aircraft had been over the runway, in excess of what should have been considered normal. Equally, all three would have known the relatively short landing distance available, not least because this was the reason given for the commander choosing to be the handling pilot. Under the circumstances, having overshot the touchdown zone on a relatively short runway a go-around would have been expected.

The lack of experience of both the co-pilot and safety pilot, and the seniority gradient existing between them and one of the company’s senior managers, would have made their ability to both identify and communicate any concerns to the commander challenging.

Having touched down, the runway remaining was considerably shorter than planned but, judging he had sufficient runway ahead, the commander delayed applying full braking and did not make use of reverse propeller pitch to slow the aircraft. This proved inadequate to stop the aircraft in the remaining distance, although the aircraft left the runway at relatively low speed. There was still, however, the potential for damage to have been caused, without the crew’s knowledge. This, and the potential to cause damage in trying to taxi back to the runway, should have resulted in a quick decision to shut the aircraft down whilst awaiting assistance. Instead, it was some six minutes before the engines were shut down, and then only after two attempts to taxi the aircraft back onto the runway. Despite an apparent lack of urgency to shut the engines down, when this was done it was without adherence to any normal or emergency checklist, leaving potential for items to be missed.

The investigation highlighted the difficulty of finding the appropriate emergency shutdown checklist in the manufacturer’s QRH. It is accepted that the crew did not attempt to find the checklist and so, in this instance, it is unlikely that this contributed to their failure to use them. It is, however, considered that in other circumstances the difficulty in identifying the emergency shutdown and evacuation checklist may have a significant outcome. The manufacturer is of the view that there is not an issue based on many years of operation and that it is for operators to develop and train on the use of the normal and abnormal emergency procedures. The operators will base their QRH on that provided by the manufacturer and are unlikely to deviate. However, at least one major operator has taken it upon themselves to make the checklist more easily identifiable and accessible.

Organisational factors

An imperative to generate capacity through ACMI contracts was due to a lack of aircraft availability primarily caused by unforeseen problems in the transition from a mixed aircraft fleet to a predominately ATR fleet. This particular ACMI contract was required at short notice after a long-planned alternative fell through unexpectedly.

The short notice nature of the ACMI meant that the change management process for both the Lessee and Lessor, whilst compliant, was time pressured. But there was no evidence that required safety activities or due diligence were compromised prior to the letting of the contract.

Once the contract was established the relationship between the parties appears to have been positive although reactive in nature. For example, agreements on the provision of FDM data were in place but no information containing any safety triggers had been provided to the Lessee by the Lessor prior to the serious incident.

Whilst the Lessor identified problems after the event with the FDM data, analysis of the data provided to the investigation showed there were some triggers for minimal braking and excessive speed at touchdown indicated in the data available to the Lessor prior to the incident flight. The braking triggers were of low severity and some of the airspeed triggers may have been spurious due to wind conditions. However, the investigation considered that a more proactive approach to exploiting the FDM data available may have provided indications to the Lessee and Lessor of how the ACMI flights were being flown in the early stages of the contract. Particularly as CCTV footage identified instances prior to the runway excursion where the aircraft had landed beyond the touchdown zone.

Post the serious incident both the Lessee and the Lessor identified and made changes to their safety management systems. These were primarily aimed at improving operational collaboration in ACMI scenarios, eg observational flight check rides and improved liaison between the operational training and flight crews of the contracting parties.

Engineering

No technical reason could be established to explain why the aircraft veered to the right under braking. The differential in tyre wear between the left and right MLG was assessed by the aircraft design authority as being within the capabilities of the Anti-skid system to manage and performance modelling showed that the single broken stator in one brake unit would have a minimal effect on braking performance.

Regulatory

The ACMI activity was conducted in accordance with regulation and this was not considered a factor in this serious incident. However, during the investigation it was agreed by the UK CAA and CIDCA that enhancements to the current sharing of safety information should be expedited and this resulted in an agreement to generate a formal MoU on safety information exchange between the respective regulators.

Related Flight: GR609, Aurigny Air Services News