India A320 at Surat on Oct 4th 2017, overran end of runway
Last Update: November 27, 2020 / 15:00:17 GMT/Zulu time
On Nov 27th 2020 India's DGCA released their final report concluding the probable cause of the serious incident was:
The aircraft continued landing with unstablized approach and prolonged flare resulted into delayed touchdown and subsequent runway excursion.
The DGCA complained that the crew did not report the overrun, but wrote up faulty brakes in the techlog. Maintenence did not find any faults with the brakes and returned the aircraft to service. A later runway inspection found the damage to the threshold/end lights. Thus only on Oct 27th 2017 an investigation was opened. Editorial note: the report refers to the touchdown 1300 meters ahead of the displaced threshold, which created huge confusion also with this editor, as a leanding ahead of the (displaced) threshold made no sense with the rest of the report - only the map cleared up, that whenever they report "ahead of the threshold" they actually meant "past the threshold".
The DGCA summarized the sequence of events:
The actual length of runway 22 at Surat airport is 2905m. The threshold of runway 22 was displaced by 1000m and the available landing distance was 1905m. Due to this the ILS approach procedure for runway 22 was withdrawn and the amended Glide Path -INOP procedure was published. All these information were available vide NOTAM. As per the crew they were aware of the current NOTAM’s prior to operating the incident flight.
At approx. 0145 UTC Surat ATC tower cleared AI493 to land on runway 22. The aircraft carried out localizer only approach for RWY 22. During approach the aircraft was continuously having high rate of descend below 2000ft radio altitude (RA) and was high on approach. The aircraft touched down approximately 1300m ahead of the displaced threshold runway 22 leaving a very less margin of 605m to stop the aircraft.
Immediately on touchdown, the crew used MAX braking and MAX REV for stopping the aircraft. The aircraft overshoot the runway coming to rest within the runway strip, damaging 01 runway end light and 02 threshold lights of runway 22. Subsequently at 0147 UTC AI493 affirms ATC to have landed on with all operations normal. As per METAR report the visibility at the time of approach and landing was 5 km and no significant trend was reported by Surat ATC.
The crew made a snag entry in the pilot defect report book, stating low braking action. During troubleshooting by AME at Surat for this pilot defect reported, all operations were found normal. Thereafter, the aircraft departed to Delhi. Later on runway inspection by Surat ATC, it was found that the lights of runway 22 were damaged.
No damage to the aircraft or injuries to passengers/crew were reported.
The crew did not report the incident and after transit inspection by AME operated subsequent sector AI 494(STV – DEL), hence CVR for the subject incident was not downloaded.
The DGCA analysed:
No snag related to brakes was reported 15 days prior to or after the incident sectors. The aircraft was released for flight on the day of incident in an airworthy condition. From DFDR it is observed that maximum manual braking was applied immediately on touchdown. The brake is continuously applied for 14 seconds after which the aircraft ground speed is decelerated to 15 knots. The crew made a PDR entry of low braking action; however no damages or abnormalities to the aircraft were noticed during inspection after the incident or in subsequent sectors.
The actual length of runway 22 of Surat aerodrome is 2905m. Due to maintenance work of runway, the threshold of runway 22 was displaced by 1000m.The landing distance available was 1905 m. Due to displaced threshold, the ILS approach procedure was temporarily withdrawn and the amended GP-INOP procedure was available. All these information were intimated through Notice to Airmen. The visibility at Surat airport during the time of incident was 5000 m.
Both the operating crew had adequate rest as per Flight duty time limitations prior to operating the incident sector. Also, they had valid license and were medically fit to operate the flight.
The aircraft took off from Delhi to Surat at 00:23 UTC. The takeoff and enroute was uneventful. During approach to Surat aircraft was cleared to carry out a localizer only approach for runway 22. The aircraft was in correct landing configuration. During approach a variation in wind speed and wind direction is observed up till a height of 185ft resulting in varying tailwind components. The rate of descend is found to be above 1000ft/min up till a radio height of 185 ft as against the stabilization criteria required at 500 ft. The approach speed is observed to be higher than Vapp of 135 knots throughout the approach. The aircraft was at 1029ft at 2DME against 840ft as published in the NOTAM. The aircraft was not stabilized by 500ft RA. The flare was initiated by increasing pitch from 1.8 degree at 01:46:07 at 38 ft RA. After 05 seconds the pitch reached to 5.6 degree and the aircraft was at approx 7 ft RA at 01:46:12. Subsequently there are variations in pitch angle and the aircraft floats on the runway for approx 07 seconds. As per SOP, the auto throttle was disconnected at 20ft RA and the thrust lever angle reads zero degree subsequently. The aircraft touched down approximately 12sec after the initiation of flare. The aircraft touched down on runway at approx 1300m ahead of the displaced threshold. The aircraft was continuously high and fast during the final approach. The crew continued the approach although the approach was not stabilized by 500ft RA. The g value recorded at touchdown is 1.15 and the landing weight was 60t which are within limits. Immediately on touchdown, maximum manual braking and maximum reversers were used by the PIC to bring the aircraft to stop. The aircraft travelled near to the runway end lights and then initiated the turn to backtrack damaging the runway lights.
Crew resource management could not be checked due non availability of Cockpit voice recorder. As per crew they were aware of all the current NOTAM.
This article is published under license from Avherald.com. © of text by Avherald.com.
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