Air Asia A320 at Bandar Seri Begawan on Jul 7th 2014, runway excursion on landing

Last Update: May 16, 2020 / 21:22:53 GMT/Zulu time

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Incident Facts

Date of incident
Jul 7, 2014

Classification
Incident

Cause
Runway excursion

Airline
AirAsia

Flight number
AK-278

Departure
Kuala Lumpur, Malaysia

Destination
Bandar Seri Begawan, Brunei

Aircraft Registration
9M-AQA

Aircraft Type
Airbus A320

ICAO Type Designator
A320

Airport
Brunei International Airport, Bandar Seri Begawan

Airport ICAO Code
WBSB

An Air Asia Airbus A320-200, registration 9M-AQA performing flight AK-278 from Kuala Lumpur (Malaysia) to Bandar Seri Begawan (Brunei) with 102 passengers and 7 crew, landed on Brunei International Airport's runway 03 at 15:30L (07:30Z) but veered right off the runway and came to a stop with all gear on soft ground. The aircraft was evacuated.

The airline confirmed the aircraft went off the runway while landing in Brunei, the causes of the runway excursion are under investigation. All passengers were safely evacuated.

On Jul 16th 2014 the French BEA reported in their weekly bulletin that the aircraft skidded and veered off runway 03 to the right. Brunei's AIB is investigating the occurrence rated a serious incident.

On May 16th 2020 the final report by AAIB Brunei, undated and released via Malaysia's Ministry of Transport, surfaced concluding the probable causes of the serious incident were:

The flight crew flying into Brunei International Airport was aware of the likelihood of encountering weather on their approach. The crew was proactive in requesting for weather information and the air traffic controllers provided frequent updates on the aerodrome’s weather condition.

During the approach, to the point where the flight crew descended to DA, they did not encounter any weather condition that required a go-around to be performed. The PIC monitored the FO and assessed that the FO was able to land the aircraft in the reported weather conditions, which were within the limitations imposed by the operator.

51 seconds before reaching DA, the PIC briefed the FO to perform a go-around if the visual reference with the runway cannot be established, which the FO acknowledged.

Two seconds after passing DA, the flight crew encountered intense rain to the extent that the PIC had to switch the wiper on to the “Fast Setting”.

Five seconds later, at 157 Feet AGL, the FO lost visual reference with the runway and decided to hand over control of the aircraft to the PIC instead of performing a go-around.

When the PIC took over controls of the aircraft, he saw only a row of white runway edge lights, which he believed to be the runway centreline lights. He provided inputs through the control stick and piloted the aircraft towards that row of lights which was the right runway edge lights.

The aircraft touched down on the runway pavement, close to the right edge of the runway. Shortly after, the aircraft veered onto the grass patch to the right of the runway edge.

Unable to bring the aircraft back to the runway, the PIC brought the aircraft to a stop on the grass patch and ordered an emergency evacuation.

The first officer (23, CPL, 970 hours total, 640 hours on type) was pilot flying, the captain (29, ATPL, 6100 hours total, 2554 hours on type) was pilot monitoring.

Upon first contact with Brunei Radar the crew queried the weatehr conditions and received information about winds from 210 degrees at 10 knots, no showers, visibility 5000 meters. About 13 minutes later the crew established contact with tower, tower cleared the flight to land on runway 03 advising winds were from 270 degrees at 7 knots. About 90 seconds later tower updated the weather information stating winds were from 210 degrees between 7 and 10 knots and it started to rain in the vicinity of the aerodrome. The captain queried whether there was rain over the aerodrome, tower reported rain only over the threshold of runway 03.

Descending through 1000 feet AGL the aircraft was fully stabilized with landing gear in landing position and flaps fully configured for landing. The FO called out he could see the runway approach lights, the captain called he was seeing the PAPIs, at 316 feet AGL the FO called to continue the approach, which the captain achknowledged, the autopilot was disconnected.

Shortly after, when the aircraft was about 1nm before touchdown, the rain intensified, the captain switched his windscreen wipers to fast.

Descending through 157 feet AGL the first officer lost visual reference of the runway and handed controls to the captain.

The report continues: "the PIC acknowledged verbally, “Okay I have control”. Almost immediately after the handover, the FO said, “I can’t see anything” which the PIC verbally acknowledged by saying, “Check”. This series of exchange ended at this point.

According to the PIC, he saw a row of white runway lights and continued with the approach steering the aircraft towards the lights. Data from the flight data recorder shows that the aircraft heading was 031 Degree when the FO handed over controls to the PIC. After taking over control of the aircraft, the PIC provided right roll input through the control stick and the aircraft heading increased to 034 Degree.

At 15:32:36, both main gears of the aircraft touched downon the runway pavement, close to the right edge of the runway. (About three seconds later, ambient noises corresponding to the aircraft veering off the runway was recorded on the Cockpit Voice Recorder (CVR))

The PIC applied left rudder input (as recorded in FDR, rudder position 7° increased reaching 22.5° in less than one second), however, he was unable to bring the aircraft back to the runway.

After the nose gear touched down on the grass patch at 15:32:47, the aircraft travelled across taxiway E4 onto another grass patch before coming to a stop (See Figure 1). Subsequently, the PIC requested for all the cabin crew members to be at their assigned stations.

According to the aerodrome controller, he activated the crash alarm to declare an air crash shortly after seeing the aircraft veer off the runway6. Once the aircraft came to a stop, the aerodrome controller established contact with the flight crew to ask how the situation was and requested for the number of persons on board.

The PIC requested for fire services and informed the aerodrome controller that there were 109 persons on board.

Upon completing the emergency evacuation checklist, the PIC ordered for an emergency evacuation to be carried out. The emergency slides of the four main cabin doors (two doors on each side of the forward and aft of the passenger cabin) were successfully deployed when the cabin crew opened the doors. All occupants in the aircraft evacuated through these four emergency slides.

The AAIB Brunei analysed:

According to the PIC, he had to switch on the wipers for both the left and right windshield to the “Fast” setting only after DA because they encountered the heavy rain which affected their visibility.

To the extent that the PIC had to switch on the wipers to the “Fast” setting when it was previously switched off suggests that the crew encountered a sudden intense rain, which severely reduced visibility of the runway, only after passing DA.

Seven seconds after the wipers were switched on; the FO handed over control of the aircraft to the PIC when he lost visual reference with the runway due to the intense rain, instead of performing a go-around as briefed by the PIC earlier.

According to the FO, he did not consider performing a go-around at that point in time. This was despite the PIC’s instruction that was given one minute earlier, to perform a go-around if the runway was non-visual. During the interview after the occurrence, the FO mentioned that the thought of performing a go-around at that point did not cross his mind. Instead, he believed that the PIC, being more experienced, would be able to land the aircraft.

In handing over the controls of the aircraft, the FO appears to be not confident in executing a go-around after losing visual reference with the runway and that he had greater confidence in the PIC landing the aircraft.

A handover of controls after DA poses these likely safety risks:

- The pilot receiving control of the aircraft may have insufficient time to react appropriately and establish positive control: and

- Should the pilot receiving control of the aircraft decide to perform a go-around, valuable time and altitude lost during the handover would have increased the challenge to execute a safe go-around.

The aircraft was 157 Feet AGL and 13 seconds away from touchdown when the handover of control occurred.

Studies on human (reaction document) indicate (that) the average human reaction time is about five to six seconds from perceiving to reacting. In the context of this occurrence, this process of perception to reaction would include:

- The PIC heard that the FO had handed over control to him

- The PIC understood that he had control of the aircraft

- Established situational awareness

- To provide input to the flight controls to control the aircraft

With 13 seconds to touch down, the PIC would have had enough time to maintain control of the aircraft. From the CVR recordings, the PIC acknowledged the handover without hesitation. However, he was unable to establish proper situational awareness to ensure that the row of lights he saw was the runway centreline lights.

From the FDR data, prior to the FO handing over controls of the aircraft, he had maintained the aircraft heading at 031 Degree with direct tailwind of 210 Degree and it was tracking along the extended runway centreline.

After taking over control of the aircraft, the PIC provided right roll input through the control stick, approximately one second after the handover, and the aircraft heading increased to 034 Degree. With no change of wind direction the aircraft started tracking to the right of the runway centreline until touchdown. From the CVR recordings, it is noted that the aircraft went onto the grass patch area about three seconds after touching down.

The PIC mentioned during the interview that when he took over the controls of the aircraft, he saw only one row of landing lights, instead three row of landing lights, and piloted the aircraft towards that row of lights. On hindsight, the PIC indicated that he was not sure if that row of lights was the centreline or edge lights of the runway. It is evident that the row of lights which he saw was the runway right edge lights and piloted the aircraft towards it.

Human factor analysis of the PIC’s actions in the final phase of approach suggests that the coning of attention9occurred. The handover of controls occurred so close to touchdown that it would have placed the PIC under increased stress level to land the aircraft safely. This resulted in the PIC not considering that the row of lights could be the runway edge lights and made the decision to steer the aircraft towards what he believed was the runway centreline lights, to land the aircraft.

This serious incident highlights the need for a go-around to be performed when the approach is destabilised below minima. The decision may be difficult to take but remains the proper one in such circumstances.

Metars:
WBSB 070930Z 21007KT 4000 -TSRA FEW005 FEW016CB BKN150 25/24 Q1008 TEMPO 5000 -TSRA
WBSB 070900Z 23009KT 3000 -TSRA FEW005 SCT014 FEW016CB BKN150 26/24 Q1008 TEMPO 24015G25KT 2000 TSRA
WBSB 070830Z 23009KT 3000 -TSRA FEW005 SCT014 FEW016CB BKN150 26/24 Q1008 TEMPO 24015G25KT 2000 TSRA
WBSB 070800Z 20008KT 3000SW -TSRA SCT014 FEW016CB BKN140 28/26 Q1007 TEMPO 24015G25KT 2000 TSRA
WBSB 070730Z 21009KT 3000SW -SHRA SCT015 FEW016CB BKN140 30/24 Q1007 TEMPO 24015G25KT 4000 SHRA
WBSB 070700Z 28011KT 8000 VCSH SCT016 FEW017CB BKN300 32/245 Q1006 NOSIG
WBSB 070630Z 24006KT 9999 SCT016 FEW017CB BKN300 32/25 Q1006 NOSIG
WBSB 070600Z 24004KT 9999 SCT016 FEW017CB BKN300 32/25 Q1007 NOSIG
WBSB 070530Z 29007KT 8000 VCSH SCT016 FEW017CB BKN300 32/25 Q1007 NOSIG
WBSB 070500Z 29007KT 9999 SCT017 BKN300 32/25 Q1007 NOSIG
WBSB 070430Z 22003KT 9999 SCT016 FEW017CB BKN300 32/24 Q1008 NOSIG
WBSB 070400Z 15003KT 9999 SCT016 SCT140 BKN300 32/25 Q1008 NOSIG