India B738 at Mumbai on Jul 10th 2018, overran runway on landing
Last Update: June 26, 2019 / 16:16:06 GMT/Zulu time
Incident Facts
Date of incident
Jul 10, 2018
Classification
Incident
Airline
Air India
Flight number
IX-213
Departure
Vijayawada, India
Destination
Mumbai, India
Aircraft Registration
VT-AXT
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Airport ICAO Code
VABB
The airport reported the aircraft touched down normally within the landing zone, however could not stop due to the slippery conditions. The longer main runway was out of service due to maintenance.
On Jun 26th 2019 India's DGCA released their final report concluding the probable causes of the incident were:
- The incident was caused due to prolonged flare wherein nearly 40% of the available landing distance was consumed followed by failure of Engine # 1 thrust reverser due to defective thrust reverser middle & lower actuator.
- Dynamic aquaplaning and prevalent weather conditions were contributory factors to the incident.
The DGCA provided following synopsis of the sequence of events:
The flight was uneventful till 50 ft of approach at Mumbai where the aircraft was slightly high on threshold. Runway in use at CSIA, Mumbai was Runway 14. Moderate rain was forecasted in the Meteorological report. Wind was reported as 270 degrees 12 knots and visibility was reported as 2200 meters at Mumbai. Considering the runway length available and the prevailing weather conditions the auto brakes were selected on maximum braking. Landing distance calculations were made well in time. The aircraft profile in approach was normal. The flare started at threshold and continued for 14 seconds as the aircraft was slightly high on power and there was a tail wind component of approximately 08 knots. Aircraft touched down approximately 962 meters from runway 14 threshold at 09:20 hrs. The runway was contaminated with water patches due prevailing moderate rain. After 03 seconds of touchdown, Engine # 2 thrust reversers were deployed but the Engine # 1 thrust reversers remained in transit since touchdown and did not deploy. First Officer immediately called out about failure of thrust reverser and not to use full reverser & use maximum Manual braking. Realizing that there could be controllability issue, PIC put the Engine # 2 thrust reversers to IDLE by lowering engine power. Power of both the engines was immediately reduced. Simultaneously recognizing that the braking action was not sufficient and the aircraft was not decelerating enough as expected, crew decided to apply manual braking. Auto brakes were disconnected and crew applied manual brakes. PIC also asked First Officer to assist him in applying maximum manual brakes to decelerate the aircraft. The rudder was utilized to effectively maintain the directional control of the aircraft. Aircraft crossed the end of Runway 14 in the landing roll by approximately 5 meters before coming to a halt on the paved surface. Later, aircraft vacated Runway via Taxiway E1 on its own power under guidance of Follow Me vehicle and parked on stand V29 at 09:40 hrs (chocks on). No human injury was reported in the incident.
The aircraft sustained damage to the left hand main tyres, that were worn out due to excessive braking.
The captain (44, ATPL, 3,491 hours total, 3,208 hours on type) was pilot flying, the first officer (62, ATPL, 8,140 hours total, 5,354 hours on type) was pilot monitoring. The DGCA annotated that the first officer had undergone command upgradation training but had failed and continued to fly as first officer.
The DGCA described the weather conditions at the time of landing: "During landing moderate rain was prevailing at the airport. Crew observed that the runway surface was contaminated with water patches due presence of moderate rains. First Officer submitted that the water available on runway was felt, after landing, to be having depth of more than 3mm."
The DGCA analysed that the landing distance required, no reversers, approach speed 5 knots above Vref, temperature 26 degrees C, tail wind of approximaltey 8 knots, 1000 feet MSL and 58,000kg landing mass was 7874 feet. The actual distance, the aircraft travelled from touchdown to coming to a stop was 4965.8 feet (editorial note: not including the flare and travel from threshold to touchdown). The DGCA wrote: "Landing distance required in prevailing weather conditions for the landing aircraft configuration without thrust reverser was calculated to be 7874 ft. However, the aircraft stopped after travelling 4965.8 ft from touchdown which substantiate that the brakes were effective enough. Therefore, serviceability of the brakes was not considered as a factor to the incident."
The DGCA continued analysis: "As the Engine # 1 thrust reverser failed to deploy, crew were constrained to put the Engine # 2 thrust reverser to IDLE in order to maintain the directional control of the aircraft. This resulted in non-availability of thrust reversers after landing in the prevailing weather conditions wherein tail winds of approximately 08 knots & moderate rains were present. The failure of deployment of Engine # 1 thrust reverser resulted in increase in landing distance required and hence contributed to the incident."
The DGCA analysed the performance:
At 09:20:16 hrs around 50ft RA the aircraft was at threshold which was slightly higher than normal. The flare started at threshold by increasing the pitch of the aircraft with power of 58.2% N1 and 59.5% N1 available from Engine # 1 & 2 respectively. The application of power was higher than required. The pitch of the aircraft varied between 0.87º at starting of flare to its maximum value 4.04º during flare which was normal. Power of Engine # 1 & 2 was lowered down to IDLE, 32% N1 and 32.75% N1 respectively, at 09:20:25 hrs at 09 ft RA. Subsequent to lowering the power, aircraft made firm touchdown at 09:20:30 hrs. The vertical speed of the aircraft was observed to be normal. Aircraft took 09 seconds from threshold (around 50 ft RA) to reach 09 ft RA and further 05 seconds from 09 ft RA to touchdown. Higher power application during flare combined with varying winds having tail wind component lead to flaring the Threshold 1513.6 m/ 4965.8 ft A/C touchdown A/C Stopped aircraft for 14 seconds. As a result, aircraft touched down at 962.6 m/ 3158 ft from threshold, with vertical acceleration of 1.15g. 962.6 m of runway was covered during flare which is considered as a prime contributory factor to the incident. Lateral deviation of the aircraft was within limits throughout the approach.
Crew action of putting Engine # 2 thrust reverser to IDLE by reducing both the engine powers post identification of Engine # 1 thrust reverser failure upon touchdown was correct in order to maintain the directional control of the aircraft.
Further, crew realized after touchdown that the runway was contaminated with water patches due to rain. Crew felt that the deceleration rate of aircraft was not as desired and took decision of using maximum manual brakes. The decision to use maximum manual brakes was correct in order to get the desired deceleration considering the contaminated runway surface, prevailing tail wind and absence of thrust reverser.
Both PIC and FO applied manual brakes and simultaneously the rudder input was also given to effectively maintain the directional control of the aircraft. With application of maximum manual brakes, the aircraft could be stopped on the paved surface after crossing the Runway 14 end by 5.2 meters and at 12.55 meters right of the center line.
The handing of the aircraft post touchdown with one thrust reverser failed, contaminated runway surface and prevailing tail wind conditions was satisfactory and hence it was not considered as a factor to the incident. Crew showed good CRM throughout the flight.
Total distance travelled from threshold was 2476.2m/ 8123.8 ft and aircraft crossed end of Runway 14 by around 5.2 m/ 17ft.
Surface Friction Test of Runway 14 was conducted on 29/06/2018 and friction coefficient values were found to be within the limits. Two arrivals and two departures operated on Runway14 before arrival of IX- 213 and none of the aircraft reported adverse braking action. Hence, runway surface friction was not considered as a factor to the incident.
The DGCA analysed with respect to dynamic aquaplaning:
It is ascertained that there would have been dynamic aquaplaning occurred on the incident flight till the time the aircraft ground speed was above 128.86 knots.
The ground speed was recorded to be 123 knots after 05 seconds of touchdown, i.e. at 09:20:35 hrs. Therefore, it is assumed that the aircraft had encountered dynamic aquaplaning for around 05 seconds between 09:20:30 hrs to 09:20:35 hrs and probably during this time crew felt that the braking action was poor & deceleration rate of aircraft was not as desired. Subsequently at 09:20:37 hrs Auto brakes were disconnected and manual brakes were applied. Dynamic aquaplaning was considered as a contributory factor to the incident.
With respect to weather the DGCA analysed:
The flaring was initiated at 50 ft RA, i.e. at threshold, and the presence of varying winds having tail wind component adversely contributed in the duration of flaring.
Further, the presence of moderate rains lead the runway to become contaminated with water patches felt to be having more than 3mm depth. During such conditions, if the ground speed of aircraft is higher than the minimum ground speed for initiation of dynamic aquaplaning, then the dynamic aquaplaning occurs. As the ground speed of the aircraft at the time of landing, i.e. 142 knots, was greater than the minimum ground speed for initiation of dynamic aquaplaning, i.e. 128.86 knots, it is assumed that the aircraft had encountered dynamic aquaplaning at touchdown. The aircraft ground speed was more than minimum ground speed for initiation of dynamic aquaplaning for around 05 seconds from touchdown. Hence, it is assumed that the dynamic aquaplaning was present from time of touchdown and lasted for around 05 seconds. Probably due to dynamic aquaplaning crew felt poor deceleration rate immediately after touchdown.
The prevalent weather affected the duration of flare and developed a condition wherein dynamic aquaplaning was encountered. Hence, weather was considered as a contributory factor to the incident.
The DGCA reported both crew have undergone corrective training, hence no safety recommendation was issued as result of the investigation.
Related NOTAM:
A1449/18 NOTAMN
Q) VABF/QMRXX/IV/NBO/A/000/999/
A) VABB B) 1807100830 C) 1807100930
E) RWY 09/27 NOT AVBL FOR OPS DUE MAINT, SUBJECT TO VIS. HOWEVER RWY 14/32 AVBL FOR OPS
Metars:
VABB 101100Z 32012G22KT 0800 R27/1000 SHRA SCT010 BKN015 FEW025TCU OVC080 26/25 Q1002 NOSIG=
VABB 101030Z 25010KT 2100 SHRA SCT010 SCT015 FEW025TCU OVC080 27/26 Q1002 NOSIG=
VABB 101025Z 25010KT 0800 R27/1000 SHRA SCT010 SCT015 FEW025TCU OVC080 27/26 Q1002 NOSIG=
VABB 101000Z 27006KT 2100 -RA SCT012 SCT018 FEW025TCU OVC080 26/26 Q1002 TEMPO 1500 RA=
VABB 100930Z 27010KT 1500 -RA SCT012 SCT018 FEW030CB OVC080 26/25 Q1003 TEMPO 1500 RA=
VABB 100900Z 26010KT 2200 -RA SCT012 SCT018 FEW030CB OVC080 27/25 Q1003 TEMPO 1500 SHRA=
VABB 100830Z 25010KT 2200 -RA SCT012 SCT018 FEW030CB OVC080 26/25 Q1003 TEMPO 1500 SHRA=
VABB 100800Z 25010KT 2200 -RA SCT010 SCT015 FEW030CB OVC080 27/25 Q1003 TEMPO 1500 SHRA=
VABB 100730Z 29007KT 1700 RA SCT010 SCT015 FEW030CB OVC080 26/25 Q1004 TEMPO 0800 +SHRA=
VABB 100700Z 30008KT 1700 RA SCT010 SCT015 FEW030CB OVC080 26/25 Q1004 TEMPO 0800 +SHRA=
VABB 100630Z 29010KT 1700 RA SCT010 SCT015 FEW030CB OVC080 26/25 Q1004 TEMPO 0800 +SHRA=
VABB 100600Z 22006KT 2200 -RA SCT010 SCT015 FEW030CB OVC080 26/25 Q1003 TEMPO 1500 SHRA=
Incident Facts
Date of incident
Jul 10, 2018
Classification
Incident
Airline
Air India
Flight number
IX-213
Departure
Vijayawada, India
Destination
Mumbai, India
Aircraft Registration
VT-AXT
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Airport ICAO Code
VABB
This article is published under license from Avherald.com. © of text by Avherald.com.
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