Xiamen B738 at Manila on Aug 16th 2018, runway excursion on landing
Last Update: August 8, 2019 / 19:10:35 GMT/Zulu time
Incident Facts
Date of incident
Aug 16, 2018
Classification
Accident
Cause
Runway excursion
Airline
Xiamen Airlines
Flight number
MF-8667
Departure
Xiamen, China
Destination
Manila, Philippines
Aircraft Registration
B-5498
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Airport ICAO Code
RPLL
Manila Airport reported flight MF-8667 went off the runway at about 23:55L during a heavy downpour. All occupants of the aircraft are safe. Investigators from the CAA Philipinnes are already on site.
On Aug 17th 2018 China's CAAC reported MF8667 (B738/B5498) went left off the runway in Manila. 157 passengers and 8 crew remained uninjured. At the time of landing there was a strong thunderstorm, visibility 2000 meters, winds from 280 degrees at 11 knots, cloud ceiling 540 meters. The CAAC have dispatched a team of investigators to Manila to assist the Philippine Accident Investigation. The CAA as well as the China East Aviation Authority formed a joint working group to review Xiamen Airlines. The industry has been reminded to take resolute measures to observe safety margins.
On Aug 8th 2019 the Civil Aviation Authority of the Philippines (CAAP) released their summary of the final report concluding the probable causes of the accident were:
Primary Cause Factors
a. The decision of the Captain to continue the landing on un-stabilized approach and insufficient visual reference.
- The Captain failed to maintain a stabilized landing approach moments before touchdown, the aircraft was rolling left and continuously drifting left of the runway centerline.
- The Captain failed to identify correctly the aircraft position and status due to insufficient visual reference caused by precipitation.
b. The Captain failed to apply sound CRM practices.
- The Captain did not heed to the First Officer call for a Go-Around.
Contributory Factors
a. Failure to apply appropriate TEM strategies
Failure of the Flight Crew to discuss and apply appropriate Threat and Error Management (TEM) strategies for the following:
- Inclement weather.
- Cross wind conditions during approach to land.
- Possibility of low-level wind shear.
- NOTAM information on unserviceable runway lights.
b. Inadequate Company Policy on Go-Around
- Company’s Standard Operation Procedures were less than adequate in terms of providing guidance to the flight crew for call out of “Go-Around” during landing phase of the flight.
c. Runway strip inconsistent with CAAP MOS for Aerodrome and ICAO Annex 14
- The uneven surface and concrete obstacles contributed to the damage sustained by the aircraft.
The CAAP described the sequence of events:
During the first approach, the Captain who was the pilot flying aborted the landing at 30 feet Radio Altitude (RA) due to insufficient visual reference. A second approach was considered and carried out after briefing the First Officer (FO) of the possibility of another aborted landing should the flight encounter similar conditions. The briefing included a diversion to their planned alternate airfield.
The flight was “stabilized” on the second approach with flaps set at 30 degrees landing position, all landing gears extended and speed brake lever appropriately set in the ARM position. On passing 1,002 feet Radio Altitude (RA), the autopilot was disengaged; followed by the disengagement of the auto-throttle, three (3) seconds later.
The ILS localizer lateral path and Glide slope vertical path were accurately tracked and no deviations were recorded. The “reference” landing speed for flaps 30 for the expected aircraft gross weight at the time of landing was 145 knots and a target speed of 150 knots was set on the Mode Control Panel (MCP). The vertical descent rate recorded during the approach was commensurate with the recommended descent rate for the profile angle and ground speed; and was maintained throughout the approach passing through the Decision Altitude (DA) of 375 feet down to 50 feet radio altitude (RA).
As the aircraft passed over the threshold, the localizer deviation was established around zero dot but indicated the airplane began to drift to the left of the centerline followed by the First Officer (FO) making a call out of “Go-Around” but was answered by the Captain “No”. The throttle levers for both engines were started to be reduced to idle position at 30 feet RA and became fully idle while passing five (5) feet RA. At this point, the aircraft was in de-crab position prior to flare. At 13 feet RA, the aircraft was rolling left and continuously drifting left of the runway center line.
At 10 feet RA another call for go-around was made by the FO but was again answered by the Captain with “No” and “It’s Okay”. At this point, computed airspeed was approximately 6 knots above MCP selected speed and RA was approaching zero feet. Just prior to touchdown, computed airspeed decreased by 4 knots and the airplane touched down at 151 knots (VREF+6). The wind was recorded at 274.7 degrees at 8.5 knots.
Data from the aircraft’s flight data recorder showed that the aircraft touched down almost on both main gears, to the left of the runway centerline, about 741 meters from the threshold of runway 24. Deployment of the speed brakes was recorded and auto brakes engagement was also recorded. The auto brakes subsequently disengaged but the cause was undetermined.
Upon touchdown, the aircraft continued on its left-wards trajectory while the aircraft heading was held almost constant at 241 degrees. After the aircraft departed the left edge of the runway, all landing gears collided with several concrete electric junction boxes that were erected parallel outside the confines of the runway pavement.
The aircraft was travelling at about 147 knots as it exited the paved surface of the runway and came to rest at approximately 1,500 meters from the threshold of Runway 24, with a geographical position of 14°30’23.7” N; 121°0’59.1” E and a heading of 120 degrees.
Throughout the above sequence of events from touchdown until the aircraft came to a full stop, the CVR recorded 2 more calls of “GO-AROUND” made by the FO.
Throughout the landing sequence, the thrust reversers for both engines were not deployed. Throttle Lever Position (TLP) were recorded and there was no evidence of reverse thrust being selected or deployment of reversers.
After the aircraft came to a complete stop, the pilots carried out all memory items and the refence items in the evacuation non-normal checklist, which includes extending the flaps to a 40 degrees position. The aircraft suffered total loss of communication and a failure in passenger address system possibly due to the damage caused by the nose gear collapsing rearwards and damaging the equipment in the E/E compartment or the E-buss wires connecting the Very High Frequency (VHF) 1 radio directly to the battery was broken. The Captain then directed the FO to go out of the cockpit to announce the emergency evacuation. The cabin crew started the evacuation of the passengers utilizing the emergency slides of the left and right forward doors. There were no reported injuries sustained by the passengers, cabin crew, flight crew or the security officer.
Related NOTAM:
B3806/18 NOTAMN
Q) RPHI/QMRLC/IV/NBO/A /000/999/1431N12101E005
A) RPLL B) 1808161945 C) 1808170400
E) RWY06/24 CLSD DUE DISABLED ACFT.
Metars:
RPLL 161800Z 00000KT 5000 -RA BKN020 OVC080 24/24 Q1005 NOSIG RMK A2968=
RPLL 161739Z 15003KT 120V200 2500 RA BKN020 OVC080 24/24 Q1005 TEMPO 5000 RMK A2968=
RPLL 161700Z VRB01KT 4500 -RA FEW018CB BKN020 OVC080 24/24 Q1006 TEMPO 7000 -TSRA RMK A2971=
RPLL 161619Z 26007KT 6000 -RA BKN020 OVC080 24/24 Q1006 NOSIG RMK A2971=
RPLL 161600Z 28011KT 250V310 2000 +TSRA FEW018CB BKN020 OVC080 24/24 Q1007 TEMPO 5000 TSRA RMK A2974 CB OHD=
RPLL 161500Z 25017KT 2500 +TSRA FEW020CB BKN022 OVC080 24/24 Q1007 TEMPO 5000 TSRA 2974 CB OHD=
RPLL 161435Z 27021KT 3000 +RA SCT022 OVC090 25/25 Q1006 TEMPO FM1500 6000 RA RMK A2971=
RPLL 161400Z 22007KT 140V260 7000 -RA SCT022 OVC090 26/26 NOSIG RMK A2971=
RPLL 161325Z 24013KT 8000 -SHRA SCT022 OVC090 26/26 Q1006 TEMPO 7000 RA RMK A2971=
RPLL 161300Z 23007KT 9999 SCT023 BKN100 28/28 Q1006 NOSIG RMK A2971=
RPLL 161200Z 23008KT 9999 SCT023 BKN100 27/27 Q1005 NOSIG RMK A2968=
RPLL 161100Z 24012G23KT 9999 SCT022 SCT100 29/29 Q1005 TEMPO 9000 -SHRA RMK A2968=
RPLL 161000Z 24014KT 9999 FEW025 BKN300 29/28 Q1004 NOSIG RMK A2965=
RPLL 160930Z 23012G24KT 8000 -SHRA SCT018 OVC070 27/26 Q1005 RMK A2968 PLS DISREGARD THIS DATA TNX=
Incident Facts
Date of incident
Aug 16, 2018
Classification
Accident
Cause
Runway excursion
Airline
Xiamen Airlines
Flight number
MF-8667
Departure
Xiamen, China
Destination
Manila, Philippines
Aircraft Registration
B-5498
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Airport ICAO Code
RPLL
This article is published under license from Avherald.com. © of text by Avherald.com.
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