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Air Accident Investigation Sector

Serious Incident

̶ Final Report ̶

AAIS Case N

: AIFN/0010/2018

Runway Confusion

Takeoff from Wrong Runway

Operator:

Air Arabia

Make and Model:

Airbus A320-214

Nationality and Registration:

The United Arab Emirates, A6-ANV

Place of Occurrence:

Sharjah International Airport

State of Occurrence:

The United Arab Emirates

Date of Occurrence:

18 September 2018

Содержание Airbus A320-214

Страница 1: ...018 Runway Confusion Takeoff from Wrong Runway Operator Air Arabia Make and Model Airbus A320 214 Nationality and Registration The United Arab Emirates A6 ANV Place of Occurrence Sharjah International Airport State of Occurrence The United Arab Emirates Date of Occurrence 18 September 2018 ...

Страница 2: ...is to prevent future aircraft accidents and incidents It is not the purpose of this activity to apportion blame or liability The Air Accident Investigation Sector issued this Final Report in accordance with national and international standards and best practice Consultation with applicable stakeholders and consideration of their comments took place prior to the publication of this Report The Final...

Страница 3: ...he Air Accident Investigation Sector of the United Arab Emirates AAIS was notified about the occurrence by a phone call from the operator to the Duty Investigator DI Hotline number 971 50 641 4667 After the assessment the AAIS classified the occurrence as a serious incident Accredited representative was assigned by the Bureau d Enquêtes et d Analyses pour la Sécurité de l Aviation civile BEA of Fr...

Страница 4: ...port this investigation Final Report 2 Photos and figures used in this Report are taken from different sources and are adjusted from the original for the sole purpose of improving the clarity of the Report Modifications to images used in this Report are limited to cropping magnification file compression or enhancement of color brightness contrast or insertion of text boxes arrows or lines 3 Unless...

Страница 5: ...isibility okay CRM Crew resource management EFIS Electronic flight instrument system E WD Engine warning display FCOM Flight crew operating manual FCTM Flight crew technique manual FCU Flight control unit FDR Flight data recorder FFS Full flight simulator FLX MCT Flexible temperature maximum continuous thrust FMA Flight mode annunciator hPa hectopascal IOE Initial online experience LTC Line traini...

Страница 6: ...RWY Runway mode in FMA OMSJ Sharjah International Airport OOSL Salalah International Airport SO Second officer SOP Standard operating procedure TRE Type rating examiner TRI Type rating instructor TOGA Takeoff go around UAE The United Arab Emirates UTC Universal time coordinated ...

Страница 7: ...klist below the line items were completed by the flight crew Instead of steering the Aircraft left following runway 30 lead on lines from Bravo 14 intersection the Copilot steered the Aircraft right for runway 12 The Copilot called out that RWY was not showing on the flight mode annunciation FMA after the thrust levers were moved to the FLX MCT detent As the Aircraft accelerated through 57 knots t...

Страница 8: ...mation 6 1 6 1 Aircraft data 6 1 6 2 Engines data 7 1 6 3 Flight mode annunciator 7 1 6 4 Autobrake system 7 1 6 5 Thrust lever detent positions 8 1 6 6 Flaps lever position 8 1 6 7 Side stick priority 8 1 7 Meteorological Information 9 1 8 Aids to Navigation 9 1 9 Communications 9 1 10 Aerodrome Information 10 1 10 1 Runway 12 30 and taxiway signage 10 1 10 2 Air traffic control standby tower 12 ...

Страница 9: ...xecution 22 2 3 Flight Crew Performance 23 2 3 1 Copilot s training progression 23 2 3 2 Flight crew briefing 24 2 3 3 Runway confusion 24 2 3 4 Take off decision 25 2 3 5 Crew performance 26 2 4 Aerodrome Taxiway and Runway 27 2 5 Air Traffic Control 28 2 5 1 Standby tower 28 2 5 2 Controllers communication and movement monitoring 28 3 Conclusions 3 1 General 30 3 2 Findings 30 3 2 1 Findings rel...

Страница 10: ...endix B Sharjah Airport Chart 37 Appendix C Airbus Normal Checklist 38 List of tables Table 1 Injuries to persons Table 2 Crew information Table 3 Aircraft data Table 4 Engine data Table 5 Slats flaps positions in Airbus A320 based on FCOM List of figures Figure 1 Damaged No 3 main wheel tire Figure 2 Damaged runway 30 light Figure 3 Location of the damaged runway 30 approach light on the runway e...

Страница 11: ...t FLX MCT Flex temperature of 67 degrees Celsius The OFP take off data speeds were 122 knots V1 127 knots VR and 129 knots V2 The flight crew entered all relevant flight performance data including the runway in use runway 30 in the Aircraft flight management system FMS through the multipurpose control and display unit MCDU According to the Operator s procedure the flight crew were provided with OF...

Страница 12: ...e Aircraft had turned right onto runway 12 instead of runway 30 He shortly realized that the Aircraft was on the wrong runway but decided to continue the takeoff believing that the remaining take off runway available was insufficient to reject the takeoff The Commander stated I saw the end of runway coming He immediately advanced both engine thrust levers to the takeoff go around TOGA position The...

Страница 13: ...d returning to OMSJ in a scheduled flight He also added that he did not observe Aircraft structural damage or marks on the wheels during the walk around in OOSA Accordingly he decided to return to OMSJ The return flight was uneventful with the Commander as the pilot flying 1 2 Injuries to Persons There were no injuries to the flight crew cabin crew or the passengers because of the Incident Table 1...

Страница 14: ...he Incident Besides his simulator sessions for rejected takeoffs the Investigation was unable to confirm if the Commander had performed any A320 rejected takeoff during his career The Copilot joined the Operator as a second officer trainee pilot under a designated training program called initial online experience IOE The Copilot held a valid multi crew pilot license MPL a valid class 1 medical cer...

Страница 15: ...ation did not find negative observations or comments about the Copilot s performance by previous instructors Table 2 illustrates the flight crew information Table 2 Crew information Commander Copilot Age 51 34 Type of license ATPL A MPL Valid to 24 Aug 2021 24 June 2026 Rating IR MPA A320 IR MPA A320 Total flying time hours 22184 159 88 Total on this type hours 15536 159 88 Total last 90 days hour...

Страница 16: ... 20 holding point visually scanning runway 30 approach path and the departure end of runway 30 and checking the strip markings on the flight progress strips The controller was relieved from duty after the Incident in accordance with Sharjah Air Navigation Services policy contained in the operations manual of air traffic services 1 6 Aircraft Information The Airbus A320 is a medium range civil tran...

Страница 17: ...rovided the following conditions are fulfilled The conditions required for SRS mode engagement are V2 is inserted in the MCDU PERF TAKEOFF page Slats are extended The aircraft has been on ground for 30 seconds The aircraft is receiving a LOC signal and LOC deviation is less than dot The aircraft heading is within 20 degrees of the ILS related course and The ILS course is identical to the runway he...

Страница 18: ...osition and the phase of flight for each of the flap lever position The positions of the flaps and slats are displayed on the engine warning displays E WD which are centrally located in the cockpit 1 6 7 Side stick priority The two sidesticks on the A320 are not mechanically linked Therefore both sidesticks may be operated independently of each other When both sticks moving simultaneously the syst...

Страница 19: ...dent Tower and Ground control positions were managed by one controller There were two aircraft each on the Tower and Ground frequency The following was the communication between the flights and the OMSJ air traffic controller At 1216 41 the ground gave clearance for pushback stating Arabia triple one push and start approved from stand six face to the east The Commander read back the Ground instruc...

Страница 20: ...estricted to 2 000 ft until further instructions are received from Dubai Departure 1 10 Aerodrome Information 1 10 1 Runway 12 30 and taxiway signage Sharjah International Airport has one concrete runway 12 30 with a length of 4060 meters long 60 meters wide and 7 5 meters hard surface shoulder on each side Runway 12 and runway 30 has a displaced threshold of 300 meters Appendix B of this Report i...

Страница 21: ...30 touchdown zone white bar markings as well as the aiming point with start of runway 30 threshold white markings approximately 650 meters from Bravo 14 runway intersection Figure 7 Taxiway Bravo 14 runway 12 30 holding point information signage Figure 6 Taxiway Bravo 14 to runway 12 30 taxi lines ...

Страница 22: ...way holding point From the assigned Tower and Ground positions an A320 aircraft holding short of Bravo 14 stop bar was not visible from the controller s seat The controller s line of sight for taxiway Bravo 14 intersection with runway 12 30 extends approximately 1 kilometer The height and location of the standby tower reduced the controller s visibility of runways taxiways and maneuvering areas Ho...

Страница 23: ...assengers or crew were injured 1 16 Tests and Research 1 16 1 Rejecting take off scenarios calculations For flight ABY111 taking into consideration the dry runway surface Aircraft take off weight Aircraft configuration and performance and take off wind conditions the Investigation requested the Aircraft manufacturer to calculate if the Commander could have safely rejected the takeoff based on the ...

Страница 24: ...d according to the Aircraft flight crew techniques manual FCTM represents the high speed regime of the takeoff Rejecting a takeoff at this speed as per the FCOM is a more serious matter and a decision needs to be executed carefully The simulator session determined that the Aircraft would have stopped close to runway 30 threshold using maximum engine reverse thrust and maximum autobrake 1 17 Organi...

Страница 25: ...ed to familiarize with so called Hotspots as indicated on the airport ground charts AGC Adequate communication and CRM crew resource management during taxi proper knowledge of airport surface markings lights and signs proper preparation of expected taxi out in routing adequate taxi technique adequate aircraft lighting and continuous area screening will mitigate this risk of runway incursion 1 17 1...

Страница 26: ...ILS signal If the runway is ILS equipped the flight crew can press the ILS pb or LS pb The LOC deviation should be centered after line up The runway symbol on the ND The Runway Awareness and Advisory System In accordance with the FCOM Takeoff procedure the pilot flying is required to announce Takeoff and advance the thrust levers to 50 N1 The FCOM stated To counter the nose up effect of setting en...

Страница 27: ...uming PF duties 1 17 1 6 Rejected takeoff The OM A policy gives the responsibility to the Commander to decide whether a takeoff is continued or rejected The OM A stated Rejected takeoff can be hazardous even if correct procedures are followed The OM A listed several reasons why a takeoff may be rejected which included Incorrect runway line up technique In addition the OM A Control of Aircraft stat...

Страница 28: ...on Instructions under the heading of Take off stated when determining the maximum permitted take off weight that The accelerate stop distance must not exceed the accelerate stop distance available and defines Accelerate stop Distance Available as The length of the take off run available plus the length of stop way if such stop way is declared available by the appropriate Authority and is capable o...

Страница 29: ...fety hazard that must be mitigated prior to transfer of operations to the ATC ST In summary the following hazards were identified ATC ST Artificial lighting during nighttime operations ATC ST Movement area surveillance ATC ST Maneuvering area surveillance ATC ST Maneuvering area surveillance Taxiway Bravo As part of mitigating risks of the identified hazards a remote surface management system RSMS...

Страница 30: ...with view of Bravo 6 and Bravo 7 the main apron with view of stands 4 to 8 and the approach end of runway 30 with view of holding point Bravo 20 However this Incident requires SANS to explore the risk associated with intersection takeoff post this Incident and prepare a safety case study if needed to prevent similar incidents from occurring 1 18 Additional Information 1 18 1 Runway awareness and a...

Страница 31: ...aft lined up on the wrong runway 12 and b The ECAM red warning T O RUNWAY TOO SHORT as the take off runway available was 1 000 m after the Aircraft lined up on runway 12 The Aircraft manufacturer calculated that with the hypothesis of VR at 127 knots the take off runway required was 1 145 m for the original Aircraft configuration of FLX MCT engine thrust at flap 1 F position 1 19 Useful or Effecti...

Страница 32: ...nder s and Copilot s statements was planned and briefed The Copilot stated that she called for the before takeoff checklist below the line after Tower issued clearance for takeoff from runway 30 The Investigation was unable to confirm if the checklist below the line was completed prior to the Aircraft parking brakes being selected OFF or after the Aircraft started moving from runway holding point ...

Страница 33: ...to maintain situational awareness during taxi and takeoff These awareness augmentation systems such as runway awareness and advisory system RAAS and take off surveillance TOS2 system provide aural and or visual alerts in detecting and mitigating taxiway and runway confusion risks 2 3 Flight Crew Performance 2 3 1 Copilot s training progression Considering that this was a training flight with the t...

Страница 34: ... out a briefing about the expected taxi route taxi time runway in use and runway alignment directions and the scenario of a rejected takeoff During the flight and as an intersection rolling takeoff was planned from Bravo 14 more effective briefing was an opportunity for the flight crew to discuss the difference between a full length takeoff and an intersection takeoff Especially that there would n...

Страница 35: ...lluminating lead on lights towards runway 30 after the stop bar at Bravo 14 holding point Bravo 14 holding point signage Bravo 14 taxiway lead on yellow centerline for runway 30 and The illuminating runway 30 uni directional edge lighting Another cue to the flight crew that they had entered the wrong runway was the runway 30 white double touchdown zone markings and runway 30 aiming points which wo...

Страница 36: ...t during takeoff due to the shift of sight The Investigation believes that the Commander s efforts aimed at liftoff before reaching the end of the runway rather than rejecting takeoff at lower than 100 knots airspeed That judgment and consequent decision were indications of a take off minded situation The Commander was aware of the High Low rejected take off speed criteria and was trained on rejec...

Страница 37: ...e Commander took control In such situation and with a passive Copilot role the Operator s policy required the pilot flying to Land as soon as practicable after considering all pertinent factors Based on his conclusion that the Copilot cannot assume her responsibilities due to her affected mental state after takeoff the Commander decided to continue the flight instead of returning to OMSJ The Comma...

Страница 38: ...ee that the surveillance deficiency at the standby tower was a factor in this Incident because the controller had other aids to monitor ABY111 However the Investigation recommends that SANS perform a safety case assessment and mitigate risks associated with intersection take off hazards 2 5 2 Controllers communication and movement monitoring The Investigation review of the air traffic controller s...

Страница 39: ...roller was unaware that the flight crew had planned a rolling takeoff The controller had a level of confidence that the flight crew were aware that runway 30 would have required a left turn from Bravo 14 intersection and would not have considered any possibility that the flight crew might have runway confusion The Investigation concludes that the controller s visual watching responsibility after g...

Страница 40: ...minal liability 3 2 Findings 3 2 1 Findings relevant to the Aircraft a The Aircraft was certified equipped and maintained in accordance with the existing requirements of the Civil Aviation Regulations of the United Arab Emirates b The Aircraft records indicated that it was airworthy when dispatched for the flight c The No 3 main wheel tire sustained cuts because of impact with an approach light du...

Страница 41: ... the flap configuration to Flaps 2 m The Copilot was applying a nose down attitude on the sidestick up until the Aircraft rotated n The Commander did not attempt to use the sidestick priority o The Commander acted as the pilot flying and the pilot monitoring during take off roll and climb p The Commander stated that the Copilot was frozen and startled q The Aircraft liftoff occurred at about 30 me...

Страница 42: ... Civil Aviation Regulations for the taxiways and runway 12 30 and installed the necessary markings lighting stop bars and signage c The lead on lights were functional and centerline marking was visible from runway holding point Bravo 14 to runway 30 and if followed would avoid runway confusion d The airport was not equipped with ground movement radar GMR system 3 3 Causes The Air Accident Investig...

Страница 43: ...ety Actions taken by Sharjah Air Navigation Service SANS SANS addressed the issues relevant to controllers scanning and monitoring responsibilities and implemented additional training and procedural changes in the operations manual 4 3 Final Report Safety Recommendations 4 3 1 Safety Recommendations addressed to the Operator SR41 2021 Considering that this was a training flight with the trainee Co...

Страница 44: ... runway verification and crosscheck and the before takeoff checklist for both pilots to confirm the correct runway prior to entering as well as prior to takeoff the critical elements were probably missed which resulted in both pilots having degraded situation awareness of the Aircraft position The breach in these barriers allowed the Copilot to continue to steer the Aircraft following the taxi lin...

Страница 45: ... management following degraded not categorized as incapacitation 4 3 2 Safety Recommendations addressed to Sharjah Air Navigation Service SANS SR46 2021 The Investigation noted that sighting the direction of an aircraft holding at Bravo 14 intersection was obstructed by a light pole located at the aircraft parking stand a short distance away from the standby tower As the airport was not equipped w...

Страница 46: ...Final Report AIFN 0010 2018 issued on 10 January 2022 36 Appendix A ABY111 Takeoff Along Runway 12 ...

Страница 47: ...Final Report AIFN 0010 2018 issued on 10 January 2022 37 Appendix B Sharjah Airport Chart ...

Страница 48: ...Final Report AIFN 0010 2018 issued on 10 January 2022 38 Appendix C Airbus Normal Checklist ...

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