Middle East A332 at Abidjan on Aug 21st 2011, runway excursion resolved in go-around

Last Update: December 4, 2012 / 19:02:02 GMT/Zulu time

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Photo of MEA Middle East Airlines OD-MEA, Airbus A330-200 — MEA Middle East Airlines OD-MEA, Airbus A330-200 (Photo credit: markyharky / Flickr / License: CC by)

Incident Facts

Date of incident
Aug 21, 2011

Classification
Report

Cause
Runway excursion

Airline
MEA Middle East Airlines

Flight number
ME-575

Departure
Beirut, Lebanon

Destination
Abidjan, Côte d'Ivoire

Aircraft Registration
OD-MEA

Aircraft Type
Airbus A330-200

ICAO Type Designator
A332

A MEA Middle East Airlines Airbus A330-200, registration OD-MEA performing flight ME-575 from Beirut (Lebanon) to Abidjan (Cote Ivoire) with 233 passengers and 12 crew, was on an ILS approach to Abidjan's runway 21 in visibility reported at 1600 meters/5250 feet and calm winds. Descending through 300 feet AGL the captain, pilot flying, disconnected the autopilot and continued manually, the flight data recorder soon after recorded a deviation of the aircraft to the right of the extended center line. Descending through 100 feet radio altitude the aircraft tracks a trajectory parallel to and right of the extended center line. The aircraft crossed the runway threshold at 46 feet AGL and 7 meters/23 feet to the right of the runway center line at about 03:15L (03:15Z). The first officer, pilot monitoring, recognized they were aligned with the right hand edge lights of the runway and asked the captain to turn left. About 5 seconds after crossing the runway threshold, engine thrust at idle, 20 feet radio altitude, thrust levers moved into idle position, about 400 meters down the runway at 137 KIAS 4 knots below computed Vref at 209 degrees magnetic heading, the captain applied left aileron, left rudder and nose up control inputs, the aircraft a maximum deviation to the right of 10 meters/33 feet at 4 feet AGL before a left bank angle of about 5 degrees established, the aircraft began to turn left and climb again. 12 seconds after crossing the threshold, 800 meters down the runway at 131 KIAS, the aircraft was on the runway center line again at a heading of 202 degrees and 15 feet AGL, pitch attitude +7 degrees and left bank of 5 degrees. 2 seconds later the left bank angle reduce to 4 degrees, the captain applied right rudder inputs, another 2 seconds a rate of descent of 500 feet per minute has been reached. 17 seconds after crossing the runway threshold, 1150 meters/3780 feet past the runway threshold and 19 meters/62 feet left of the runway center line, the left main gear touched down on the left shoulder beyond the left edge of the runway at 600 feet per minute rate of descent, 5 degrees of left bank, 5 degrees of nose up, heading 207 degrees, the right main gear touched down onto paved surface shortly afterwards. Right rudder is still applied, 3 seconds after main gear touch down the thrust levers are pushed into TOGA, heading at that time 220 degrees at 121 KIAS (20 knots below Vref), two seconds later both main gear leave the ground again, the aircraft established on a 6 degrees right bank and 5 degrees nose up, a maximum of 37 meters/121 feet left of the center line is reached, and the aircraft climbs out to safety. During the climb the crew reported a go-around and requested tower to inspect the runway lights indicating the possibility they may have hit the left hand edge lights. The aircraft entered a holding pattern at 2700 feet, while the runway inspection was being carried out. The crew requested visibility data again, tower stated visibility was 1600 meters, the crew complained visbility was zero, a subsequent request with the weather station revealed a RVR of 350 meters (crew limit 600 meters) with visibility of 400 meters. The runway inspection did not find any damaged runway lights. In view of the visibility the crew decided to divert to Accra (Ghana) where the aircraft landed without further incident about 75 minutes later.

The French BEA published the final report in French released by Cote Ivoire's Autorite Nationale de l'Aviation Civile (ANAC), who concluded the cause of the serious incident was:

the commander's decision to continue the approach despite having lost visual reference to the left side.

Following factors contributed to the incident:
- failure to transmit updated visibility values when the values transmitted at the beginning of the approach were no longer valid
- failure to transmit runway visual range (RVR) data during the approach
- lack of information available to the crew that transmissometers (editorial note: sensors to measure RVR) were available at the aerodrome
- lack of visbility of runway markings indicating the runway edges at large parts of the runway
- lack of visibility of the runway center line markings
- lack of runway center line lighting
- the crew resource managed creating a plan to re-align with the runway center line instead of going around in conditions where visual reference was lost
- a possible momentary confusion of the commander on the nature of line marker lights taking edge marker lights as center line lights although the runway was not equipped with center line lights
- the investigation commission however holds the opinion that the effectiveness of the aborted landing performed by the captain broke the chain of events and prevented the serious incident developing into a serious accident.

ANAC reported the captain (62, ATPL, 18,894 hours total, 2,808 hours on type) was pilot flying, the first officer (25, CPL, 3,034 hours total, 840 hours on type) was pilot monitoring. The crew had briefed the ILS approach to runway 21, Vref was computed at 141 knots, the autobrakes were set to medium.

ANAC reported that a runway inspection the following morning showed wheels tracks on the left hand shoulder of the runway, 14 runway left edge lights were off with 3 being damaged and portions of the left runway shoulder being damaged. The tracks of the left main gear started 1152 meters past the runway threshold 23.5 meters to the left of the runway center line reaching a maximum of 37.5 meters to the left of the runway center line. Tracks of the right hand main gear touched down 20.5 meters after the left main gear 15 meters left off the center line and ended 24.1 meters to the left of the center line, both tracks indicating the aircraft skidded.

Another crew was flown to Accra to pick the incident aircraft up, an inspection by this new crew together with ASECNA (Agency for Aerial Navigation Safety in Africa and Madagascar) investigators showed ocher dust inside the left forward wheel of the left main gear and a leak to the blue hydraulic system at the left main gear brakes. The #2 brake was disabled under minimum equipment list requirements, an assessment of the landing data was made finding no operational limits (e.g. vertical acceleration) had been exceeded, the aircraft positioned to Beirut afterwards. In Beirut scratches at the right aft wheel of the right main gear were discovered.

The weather at the time of the incident was characterised by visibilities between 2000 and 350 meters, four to seven octers of cloud with ceiling at 500 feet and calm winds. A special Metar released 43 minutes prior to the occurrence indicated 800 meters of visibility in fog indicating a minimum visibility of 200 meters. A Metar released 15 minutes prior to the aborted landing in Abidjan indicated visibilities of 1600 meters, a Metar 15 minutes after the aborted landing indicated 2000 meters visibility, both Metars indicating mist, a special Metar released 25 minutes after the occurrence stated 400 meters visibility in fog with the trend of further reduction of visibility to 200 meters.

In flight the crew received following Metars via ACARS:
210230Z 16002KT 3000 DIAP R21 / / / / / / N BR SCT005 22/22 Q1014 TEMPO 0800 FG BKN004
210300Z 00000KT 1600 BR DIAP BKN005 22/22 Q1014 TEMPO 3000 BKN004
The special Metar released 43 minutes prior to the occurrence was not transmitted to the crew.

ANAC reported the crew provided testimony that the runway had been clearly visible at about 1600 to 1200 feet MSL, the aircraft then went through a number of layers losing visual contact with the runway until visual contact was established again at 500 feet MSL. At the time of the flare, at a height of 10 feet, visibility reduced dramatically. The first officer noticed the aircraft was approaching diffuse lights at the right hand side and thus called out "turn left, turn left". The aerodrome controller provided testimony that he did not establish visual contact with the aircraft until after the aircraft had gone around and was climbing out.

Weather services reported that although RVR was not included in the Metars it was duty of the aerodrome meteorological observer to collect data like runway visual range data, the observer would count the runway lights visible from his position to determine the RVR due to the lack of automated RVR detection via the transmissometers.

ANAC reported that all navigation aids including the ILS category I at the aerodrome were working normally and to specifications. The transmissometers (RVR sensors) however were not working, they had been broken since Nov 2nd 2009 and were replaced only after the serious incident on Nov 19th 2011. Runway 21 is equipped with edge and threshold lights, but has no center line lighting. The runway 21 markings had been hand painted in February 2010 and were found much faded and weak by ANAC investigators arriving following the occurrence, especially the edge and center line markings were hardly noticeable.

The cockpit voice recorder recordings were not preserved as result of the diversion to Accra. The flight data recorder was downloaded after the aircraft returned to Beirut.

ANAC analysed that the aircraft slowly drifted to the right during final approach at about 0.2 degrees to the right of the runway heading, the minor drift left after the autopilot disconnection probably not being detected by the crew due to the difficulty to identify visual references. Decision height had been at 221 feet, until then the runway was clearly visible. Visibility deteriorated only after the aircraft descended through 120 feet AGL and reduced further during the flare. During the ascent from 4 to 15 feet AGL past the runway threshold external visual reference was significantly lost. The faded runway markings added to the difficulty to align the aircraft for the flare.

It was permissable for ILS category I to produce RVR values by an observer counting the runway lights visible. A transmissometers had been installed at the aerodrome, however was inoperative, crews however were not informed about the transmissometer being inoperative.

With the special weather report 43 minutes prior to the occurrence reporting a visibility of 800 meters the inclusion of the RVR value became mandatory, the report however did not provide a RVR value, no measurement had been performed. The regular Metar 15 minutes prior to the occurrence indicated 1600 meters of visibility still within the range requiring the inclusion of a RVR value, no measurement however was performed and no RVR value provided.

It was the first officer who first detected the aircraft had drifted off to the right and called to turn left prompting the attempt to realign the aircraft, the crew then noticed the aircraft came too close to the left hand side prompting the captain to attempt turning right and go around. The operator demands crews to go-around if visual references are being lost below decision height. In the occurrence visual references were gradually degraded but not entirely lost delaying the crew reaction to go-around.

ANAC finally analysed that the decision to go around was quickly enough before activation of auto-spoilers and before activation of auto-brakes permitting a climb out to safety.