West Atlantic ATP at Birmingham on May 22nd 2020, temporary runway excursion on second approach

Last Update: March 4, 2021 / 11:25:01 GMT/Zulu time

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Incident Facts

Date of incident
May 22, 2020

Classification
Incident

Flight number
PT-425

Aircraft Registration
SE-MAO

ICAO Type Designator
ATP

Airport ICAO Code
EGBB

A West Atlantic British Aerospace ATP, registration SE-MAO performing flight PT-425 from Guernsey,CI to Birmingham,EN (UK) with 2 crew, was on approach to Birmingham's runway 33 in stormy conditions at 13:43L (12:43Z), when the aircraft touched down far down into the runway, began to veer left and lifted off again for a go around. The aircraft positioned for another approach to runway 33 about 15 minutes after the balked landing, touched down again, again began to veer left, departed the runway surface with all gear, rolled parallel to the runway and returned onto the runway surface after slowing down.

The aircraft departed Birmingham about 47.5 hours after landing.

On Mar 4th 2021 the AAIB released their final bulletin releasing following conclusion into the serious incident:

Despite the challenging conditions, the crew did not discuss the conditions in any detail. They did not brief who would be holding the control column during either landing roll, or what actions they would take if they were required to abandon the approach or landing. The first approach resulted in confusion between the crew over going around which could have itself resulted in an incident or accident. The confusion was eventually overcome by the commander calling for a go-around.

The second approach resulted in a significant runway excursion due to the use of incorrect crosswind technique and the application of full right aileron. It is likely that the crew’s inexperience of landing in strong crosswinds contributed to the misalignment at touchdown. It is likely this application of right aileron was as a result of an inappropriate motor programme to steer the aircraft right.

Neither attempt at landing used the crosswind technique as laid down in the manufacturer’s and operator’s manuals. It was fortunate that the ground was hard due to a lack of recent rain. Except for the taxiway sign there were no other obstacles in the way of SE-MAO such as other aircraft or vehicles.

As a result, despite a 450 m excursion off the runway, there was no damage to the aircraft or the airport facilities, and no injuries to the crew who were the only people on board.

The AAIB summarized the sequence of events:

The crew of SE-MAO departed Guernsey Airport to fly to Birmingham International Airport at 1142 hrs. The weather in Birmingham for their arrival was forecast to be a strong wind from the southwest with good visibility and a high cloud base. The co-pilot was Pilot Flying (PF) for the sector. After being radar vectored for a Localiser (LLZ) DME approach to Runway 33 at Birmingham, the crew conducted a stable approach. At 1245 hrs during the flare to land the aircraft drifted to the right of the centreline with the nose about 20° left of the runway direction. A go-around was commenced, and the aircraft climbed away before being radar vectored for a further approach. At the request of the co-pilot, the commander became PF for the second approach which was again a stable LLZ DME for Runway 33. With 2 nm to go before touchdown, ATC announced the wind as from 230° at 14 kt gusting 27 kt. The aircraft touched down at 1258 hrs and, shortly afterwards, departed off the paved runway to the left. The distance from the aircraft first leaving the paved surface to when the last wheel returned to the paved surface was 450 m.

After stopping for an inspection by ground operations personnel, the crew taxied the aircraft to a stand. Subsequent engineering inspections revealed no damage to the aircraft although one main wheel tyre was replaced. There were no injuries to the crew who were the only occupants.

The AAIB analysed:

Conditions at Birmingham

The weather conditions at Birmingham were a strong wind from the south-west with good visibility and little cloud. The strong wind gave a significant crosswind on the runway. The wind was also generating some turbulence on the approach. The ATP has a certified crosswind limit of 34 kt (not including gusts), and both the forecast and actual wind conditions were less than this maximum certified limit. The operator of SE-MAO had no limitations on the co-pilot flying the aircraft when there was a strong crosswind, and there was no additional limitation on the co-pilot below the certified limit of the aircraft type.

Whilst the Met Office study showed that it is possible the wind could have been stronger than that given on the METAR, the wind given to the pilots would have been from the threshold anemometer. This anemometer has been calibrated in accordance with the relevant CAA procedures. The AIP warns that in strong winds the crews may encounter building induced turbulence and windshear.

Crew training and experience

Both crew members were reasonably inexperienced on the aircraft type. Although crosswind landings were an element of their type rating courses, neither could remember having flown in conditions at or near the aircraft limit. Neither pilot used the full crosswind technique as outlined in the manufacturer’s or operator’s manuals.

First approach and go-around

The co-pilot flared the aircraft and it briefly touched down although insufficient rudder had been applied to line the aircraft up with the runway. As a result of not pointing down the runway, the co-pilot decided to perform a go-around and called “go-around”. The commander either did not hear him or did not hear him correctly and instead called for the co-pilot to land the aircraft. As a result, the co-pilot closed the thrust levers that he had begun to open, and the aircraft again touched down about 20° nose left of the runway direction. The co-pilot did not have full right rudder applied and as a result the aircraft diverged from the centre of the runway in the strong crosswind. The commander called for a go-around which the co-pilot acknowledged. Go-around power was selected, and the go-around performed as per the SOPs.

Reversing a decision having started a go-around places an aircraft at significant risk. Applying power during the landing roll invalidates any landing performance calculation, and a breakdown of crew co-ordination can create significant confusion on the flight deck.

Whatever the reason for a go-around decision, once that decision is taken and the actions begun, it should be carried out with both crew members performing the tasks required. Should the other crew member have not heard the call or have misheard the call then it is necessary to restate the intentions immediately so that the crew have a joint and shared understanding of the actions underway.

Second approach

The second approach was flown by the commander at the request of the co-pilot. The aircraft was flared without being lined up with the runway and, after two short bounces, the aircraft touched down about 20° nose left of the runway heading. As the aircraft settled onto its landing gear and friction at the tyres increased, the aircraft began to head in the direction the wheels were pointing, which was to the left edge of the runway. This swing to the left was probably made worse by the weathercock effect of the crosswind, with insufficient right rudder applied at touchdown. The commander did not apply into‑wind aileron although, as the aircraft swung left, he did apply full right rudder to steer the aircraft to the right. As the aircraft headed for the edge of the runway, the left main wheels lifted off the tarmac due to the application of full right aileron causing the aircraft to roll about the axis between nose and main tyres, and the commander could not stop the aircraft leaving the paved surface.

The application of full right aileron was almost certainly the result of an inappropriate automatic process (motor programme). Moving the steering wheel right when wanting to steer a car right and moving the control wheel to place the right aileron to full deflection are the same movements. It is likely therefore that as the commander reached his maximum ability to consciously process the inputs coming in from his senses, he subconsciously reverted to a more familiar automatic process and attempted to ‘steer the car’.

The SOPs required the handover of the control column to the co-pilot at 80 kt but the aircraft had already left the paved surface by that stage.
Metars:
EGBB 221520Z 24015G26KT 190V280 CAVOK 17/04 Q1014=
EGBB 221450Z 23016KT 200V270 CAVOK 18/04 Q1014=
EGBB 221420Z 23015G25KT 190V260 9999 FEW040 18/04 Q1014=
EGBB 221350Z 23016G27KT 200V270 9999 FEW040 18/04 Q1013=
EGBB 221320Z 23018G31KT 190V280 CAVOK 18/04 Q1013=
EGBB 221250Z 24015G26KT 190V280 9999 SCT048 18/05 Q1013=
EGBB 221220Z 25015G25KT 210V280 9999 SCT048 17/05 Q1013=
EGBB 221150Z 23015G25KT 190V270 9999 SCT047 17/05 Q1013=
EGBB 221120Z 23016KT 200V270 9999 SCT046 18/05 Q1013=
EGBB 221050Z 23015G25KT 190V260 9999 SCT039 17/05 Q1012=
EGBB 221020Z 23014KT 200V260 9999 BKN042 17/05 Q1012=
EGBB 220950Z 24012KT 190V280 9999 SCT041 16/06 Q1012=
EGBB 220920Z 23014KT 190V270 9999 SCT039 16/06 Q1012=
Incident Facts

Date of incident
May 22, 2020

Classification
Incident

Flight number
PT-425

Aircraft Registration
SE-MAO

ICAO Type Designator
ATP

Airport ICAO Code
EGBB

This article is published under license from Avherald.com. © of text by Avherald.com.
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