reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2008 B737 runway excursion Jambi Indonesia

Brief account : 

At about 1500 ft and after flaps 15 was selected during the VOR approach, the A hydraulic system failed.  

The Captain as PF asked for the QRH to be actioned but continued with the landing, electing to descend below the glide-slope profile to achieve an early touchdown.  After landing he found it difficult to decelerate and lost control, so the aircraft was severely damaged when it departed the side of the runway. There were multiple serious injuries and one ground fatality.  

Crew-related factors : 

Both pilots were reasonably experienced. The F/O as PM subsequently stated that he would have liked the Captain to have gone around to allow more time to complete the QRH items, which went unconfirmed by the Captain as PF. As a result the Captain was had not refreshed his knowledge of the systems affected by the loss of the A hydraulics, which significantly affected deceleration and directional control - brakes, reversers, spoilers, rudder and nose wheel steering. 

If the crew had been using a PicMA procedure, it would have fallen to the Captain as PM during the approach to action the QRH, which involved only 2 immediate actions. However it would have been followed by reading the list of affected systems. At that stage of the flight it is likely he would have called for a go-around (as was in fact desired by the F/O), while the crew analysed the consequences of the hydraulic loss.

As it was, having indicated that he had already seen the runway, his plan continuation bias towards landing resulted in a fast shallow touchdown, completely unprepared for the reduced control that he was then faced with.   

Type: 
B737-200
Where: 
Jambi Indonesia
Expected weather: 
Visual
Pilot in charge: 
Capt
Early transition: 
Unknown
Go-around : 
No
Damage: 
Serious
PicMA potential: 
Major
Year: 
2008
Time: 
Day
Deterioration: 
No
Vert Guidance: 
None
Both Head Up: 
No
LoC: 
No
Operator: 
Sriwijaya Air
Fully prepared: 
No
Actual Weather: 
None relevant
Autopilot : 
Unknown
CCAG: 
Normal