Malaysia A333 at Melbourne on Mar 14th 2015, &quot;severe hard&quot; landing

Last Update: April 5, 2017 / 13:54:02 GMT/Zulu time

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Photo of Malaysia Airlines 9M-MTA, Airbus A330-300 — Malaysia Airlines 9M-MTA, Airbus A330-300 (Photo credit: Alec@B92 / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Mar 14, 2015

Classification
Accident

Airline
Malaysia Airlines

Flight number
MH-147

Departure
Kuala Lumpur, Malaysia

Destination
Melbourne, Australia

Aircraft Registration
9M-MTA

Aircraft Type
Airbus A330-300

ICAO Type Designator
A333

A Malaysia Airlines Airbus A330-300, registration 9M-MTA performing flight MH-147 (dep Mar 13th) from Kuala Lumpur (Malaysia) to Melbourne,VI (Australia), landed on Melbourne's runway 34 at 07:53L (20:53Z Mar 13th) and taxied to the apron.

9M-MTA is still on the ground in Melbourne 10 days after landing.

Australia's TSB reported the board is investigating "a severe hard-landing occurrence involving a Malaysian Airlines, Airbus A330 aircraft, registered 9M-MTA that occurred at Melbourne Airport, Victoria on 14 March 2015." The TSB rated the occurrence an accident and opened an investigation.

A passenger reported that during the flight the captain announced that all passengers should check their mobile phones to be switched off and repeated that announcement about 5 minutes later. Flight attendants walked through the aisles asking every passenger whether their mobile phones were turned off. The flight crew made another announcement, presumably in Malay to the same theme. No further announcements occurred, the passenger admitted being nerveous after the announcements but did not observe anything out of the ordinary and learned to know about the hard landing only through the coverage on The Aviation Herald, the passenger re-confirmed being on board of the flight MH-147 departing Kuala Lumpur on Mar 13th and arriving in Melbourne on Mar 14th.

On Apr 5th 2017 Australia's ATSB released their final report concluding the probable causes of the accident were:

Contributing factors

- The final approach became unstable at around 300 feet above the ground due to the control inputs from the captain.

- Inadequate monitoring and communication by the crew led to a lack of recognition of the undesirable flight state and the continuation of an unstable approach.

- Continuation of the unstable approach led to a high rate of descent at touchdown and resulted in a hard landing in excess of the aircraft design loads and short of the normal touchdown area.

Other safety factors

- the captain used an unapproved manual thrust procedure in an attempt to recover the approach.

The ATSB reported the captain (no details provided) was pilot flying, the first officer pilot monitoring. At 700 feet AGL the captain disconnected the autopilot, the ATSB wrote: "from that point until touchdown there was an increase in the frequency and magnitude of sidestick pitch control inputs by the PF. In response to these inputs the aircraft’s autothrottle system varied the engine thrust to maintain a target speed, as per system design, and the aircraft pitch angles fluctuated between approximately - 0.5° nose down and +5.0° nose up. The net result of the varying thrust settings and pitch angles was a fluctuating rate of descent between approximately 380 and 960 feet per minute."

SOPs require that upon an approach becoming unstable below 500 feet AGL the pilot flying should initiate a go around and/or the pilot monitoring should call out the unstable approach and encourage a go around.

The interviews with the flight crew however did not provide any clue that the pilot monitoring called the unstable approach, considered taking over control from the pilot flying or encouraged a go around.

At 60 feet AGL the captain momentarily moved the thrust levers into the TOGA detent, the flight mode annonciators changed accordingly, the first officer assumed a go around was being initiated. However, the captain reduced the thrust levers. The first officer noticed the thrust levers were being retarded, spotted the aircraft did not flare and applied nose up inputs simultaneously with the captain.

The ATSB stated that the movement of the thrust levers caused:

- disengagement of autothrottle inhiniting several auto flight system protections
- caused a pitch up tendency
- break down of the mental model shared between the pilots

Shortly thereafter the aircraft touched down at 700fpm and +2.61G about 170 meters/560 feet past the runway threshold and short of the touch down zone.

There were no injuries, the aircraft received substantial damage however.

The ATSB analysed:

Large and erratic pitch inputs by the PF, as well as large fluctuations in the rate of descent and visual reference of the PAPI lights provided opportunities for the crew to recognise an unstable approach. Despite this, there was no evidence of actions or support language to suggest that the unstable approach was identified. The operator’s procedures whereby an unstable approach should result in a go-around, were not followed.

The manual thrust technique used by the captain to arrest the sink and recover the approach was used on other aircraft types previously flown by the captain. There was no current approved procedure on the A330 for this technique. However, analysis of the flight data determined that this action alone did not contribute to or increase the severity of the hard landing.

The captain and first officer advised at interview that, in retrospect, they should have conducted a go-around in accordance with the operator’s training procedures. The Flight Safety Foundation publication noted earlier indicated that runway contact from a late go-around is preferable to attempting to recover an unstable approach.

Elements of an unstable approach are not unusual during flight operations. However the actions taken by flight crew in response are key to maintaining flight safety. The training records of the crew were reviewed to establish the possibility that a training or performance issue led to the PF’s actions. Apart from the PF’s misunderstanding of the use of the thrust levers to reduce the rate of descent, there was no indication of a systemic issue with either crew member.