Cebu Pacific A319 at Manila on Jun 13th 2013, runway excursion

Last Update: September 9, 2016 / 13:00:12 GMT/Zulu time

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Incident Facts

Date of incident
Jun 13, 2013

Classification
Incident

Cause
Runway excursion

Airline
Cebu Pacific Air

Flight number
5J-448

Departure
Iloilo, Philippines

Destination
Manila, Philippines

Aircraft Registration
RP-C3197

Aircraft Type
Airbus A319

ICAO Type Designator
A319

Airport
Ninoy Aquino International Airport, Manila

Airport ICAO Code
RPLL

A Cebu Pacific Airbus A319-100, registration RP-C3197 performing flight 5J-448 from Iloilo to Manila (Philippines) with 95 passengers and 6 crew, landed on Manila's runway 24 at about 16:12L (08:12Z) in heavy rain but temporarily veered off the runway destroying 5 runway lights before coming to a stop on the runway. The aircraft subsequently taxied to the apron, where the passengers disembarked normally.

The CAAP (Civil Aviation Authority Philippines) released their summary of final report concluding the probable causes of the occurrence, rated an accident, were:

The Aircraft Accident Investigation and Inquiry Board determined that the probable cause of this accident was:

Primary Factor:

- Inadequate Pilot skill/technique applied on unusual aircraft attitude during landing IFR with unpredicted abnormal wind shift effect. (Human Factor. Psychological. Learning. Motor conditioning) The Pilot was overconfident and dependent on the auto system of the aircraft for adjustment on shifts of wind direction and drift effect and failed to make adequate and effective corrective actions (motor skills/techniques) on the instant changes of wind direction and speed at time just before touchdown.

Contributory Factors

- Abrupt shifts of wind direction and speed at the critical moments just before touchdown. (Environmental. Natural Environment. Wind condition) The sudden change in wind direction from the left forward quadrant to the left rear quadrant induced aircraft positive drift with late pilot response that resulted in critical skidding of the aircraft to the right with gears momentarily departing the runway pavement. The pilot was overtaken by events in making timely recognition and corrective actions to prevent entering into such dangerous situation.

- Lack of aerodrome advisory on surges of wind. (Environmental. Man-made Environment. Real time wind information) The non-availability of aerodrome information on the developing and shifting wind direction and speed that exceeded aircraft/flight limits resulted in delayed recognition and action by the pilot.

Underlying Factors

- Inadequate Training of pilot in the probable critical scenarios at the different ladders of approach and landing. (Human Factor. Psychological. Learning. Motor conditioning) The pilot was overtaken by event during the instantly developed changes and shifts in wind condition during landing and failed to make necessary judgment or application of appropriate motor skill/technique for recovery from such unusual environmental condition.

- Inadequate aerodrome capability to provide real-time wind advisory to aircraft on landing approach. (Environmental. Man-made environment. Aerodrome Weather Radar) The aerodrome capability (radar) needs enhancement to be able to determine surges in aerodrome wind that affect landing flight path especially in the area below MDA and until touchdown and pre-warn/advise pilots on the landing approach. Adequacy of equipment such as LLWR to detect wind shear or microburst and infrastructure support can be looked into.

The CAAP reported the crew was performing an ILS approach to runway 24, weather reported prior to the approach were winds from 140 degrees at 9 knots, moderate rain and wet runway. The aircraft was descending through 1000 feet AGL fully stabilized. Prior to Descending through 90 feet AGL the winds were calm and picked up between 80 and 35 feet radar altitude at variable direction (160-060 degrees) increasing to 6 knots. When the aircraft descended through 35 feet until weight on wheel sensors activated the winds changed to 112 degrees at 12 knots.

Descending through 70 feet AGL the rudder position of the aircraft was deflected to -2 degrees in average with up to -5 degrees, the aircraft was at 121 knots over ground at a true heading of 240 degrees. Below 35 feet radar altitude the aircraft's true track changed from 240 to 230 degrees at 119 knot over ground, the drift angle increased to 5 degrees and reached 9 degrees just before the weight on wheel sensors activated.

Following touchdown the winds changed further to 117-128 degrees and 25-36 knots. The aircraft's track changed to 220 degrees, the drift angle increased to +12 degrees, the aircraft skidded towards the right edge of the runway, the right main gear hit 5 runway edge lights and temporarily went onto soft ground. When the nose wheel settled on the runway the wind had dissipated, the reversers were activated and the aircraft steered back to the runway center line and vacated the runway via taxiway E4.

Tower reminded the crew to check their landing gear prior to handing the aircraft off to ground frequency.

At the terminal maintenance personell found several cuts to both right hand main tyres.

Metars:
PLL 131000Z 00000KT 9000 -RA SCT023 OVC100 28/26 Q1004 NOSIG RMK A2965
RPLL 130900Z 04002KT 8000 -RA SCT023 OVC090 27/26 Q1004 TEMPO 9000 RMK A2965
RPLL 130800Z 33003KT 290V030 8000 +TSRA FEW022CB SCT023 OVC100 26/26 Q1004 TEMPO TSRA RMK A2965 CB, E
RPLL 130700Z 26011G22KT 190V290 8000 TSRA FEW022CB SCT023 OVC100 28/25 Q1004 TEMPO -TSRA RMK A2965 CB, W
RPLL 130600Z 25008KT 200V290 9999 FEW022CB SCT023 BKN100 30/26 Q1004 TEMPO 7000 -RA RMK A2965 CB, N AND SW MVNG OVHD
RPLL 130500Z 13009KT 9999 FEW022CB SCT023 SCT100 33/25 Q1004 NOSIG RMK A2965 CB, N AND SW
RPLL 130400Z 13009KT 080V170 9999 FEW022CB SCT023 SCT100 32/26 Q1005 NOSIG RMK A2968 CB, W