Air France A319 at Casablanca on Aug 8th 2011, landed on wrong runway

Last Update: August 22, 2012 / 12:17:52 GMT/Zulu time

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Incident Facts

Date of incident
Aug 8, 2011

Classification
Incident

Airline
Air France

Aircraft Type
Airbus A319

ICAO Type Designator
A319

The French BEA released the final report in French, which was produced by Morocco's Bureau d Enquetes et d Analyses D Accidents d Aviation Civile (MBEA) and concluded the probable causes of the serious incident were:

- A visual approach had not been considered and briefed by the crew.

- the conduct of flight was inappropriate regarding cockpit resource management

- slight deviation of the aircraft from the required approach trajectory

- confusion of the runway by the crew during the visual approach.

Following factors contributed to the serious incident:

- the change of approach strategy was neither addressed during the approach nor subsequent briefings

- the configuration of the Casablanca Mohamed V Airport represents known risks of confusion of the two runways or confusion of a runway and a taxiway.

When the crew contacted Casablanca approach they were advised to expect runway 35L and cleared to descend to 3000 feet. The crew subsequently reported they had the runway in sight and were cleared for a visual approach to runway 35L and after turning final were handed off to tower. Tower cleared the aircraft to land on runway 35L. After landing another station radioed that the aircraft had landed on runway 35R, neither the AF crew nor tower had realised the aircraft had landed on the wrong runway.

The flight data recorder however identified the crew had tuned ILS runway 35L. When the aircraft descended through 500 feet AGL the course deflection indication showed 4.0 dots "fly left" indicating the aircraft was to the right of the extended center line of runway 35L. Upon touchdown the course deflection indicator continued to show 4.0 dots "fly Left".

The MBEA further reported that on downwind while descending towards 3000 feet MSL the crew got behind the aircraft. The aircraft was between 4000 and 3000 feet AGL descending at 500 feet per minute decelerating to 220 KIAS when approach instructed the aircraft to turn final and handed the aircraft off to tower, the aircraft was still doing 230 KIAS, in addition the aircraft encountered 30 knots tailwind at that time. The aircraft reached 3000 feet MSL at 175 KIAS with a tailwind of 15 knots on final approach course. While the crew was still catching up with the aircraft the tailwind reduced to 0 knots at about 1250 feet AGL and became a head wind of 5 knots at 1000 feet AGL. At that point the aircraft was descending at 1000 feet per minute at a speed more than 10 knots above selected Vapp (Vref+5), the localizer course deflection indicator indicated 4.6 dots "fly left". The crew visually aligned with the extended runway center line 35R however, the approach appeared stabilized at 500 feet AGL and the aircraft touched down on runway 35R.

The MBEA reported that the operator's manual stated a crew may accept a visual approach, but may also refuse a visual approach.

The MBEA reported the crew was well rested and felt/showed no signs of fatigue. It was the first time captain and first officer had been rostered together. During the approach briefing neither of the crew members considered the possibility of a visual approach. The first officer stated however he may have been over confident after being taken in surprise by the captain's decision for the visual approach and did not stress his point of view to return to the originally planned ILS approach strongly enough. Following the captain's decision he turned the aircraft around to align with the runway, but was still running behind the aircraft and was occupied to meet the stabilisation criteria that everything else went unnoticed.

The captain said in post flight interviews he was not focussed on the visual approach and made the decision between 5000 and 4000 feet based on the cloud base. The plane was a little high and a little fast. After turning final he was focussed on the glide path, which was good all the time, and did not check the localizer indication. The captain voiced his opinion that the event did not impede safety and thus did not meet the criteria of a serious incident in his opinion. Had another aircraft been seen, the problem would not have arisen.

The captain of a Royal Maroc flight AT-560 was at the holding point of runway 35R and had been cleared to line up runway 35R for departure after the Air France Airbus had been cleared to land runway 35L. He observed the A320 on final was high and not aligned with runway 35L, therefore he decided to not cross the hold short line of runway 35R despite the clearance to do so. After observing the A320 land on runway 35R he radioed his observation to tower.

The MBEA analysed the airport had been frequently involved in landings on the wrong runway as result of a recurring confusion of either the two runways or runway and taxiway. As result according warnings had been published in Morocco's AIP. Had the AF crew observed those warnings it would have been unlikely to confuse the runways.

The MBEA analysed further that the aircraft was virtually alone, it was the only aircraft on frequency of tower. He could therefore observed the aircraft, but laxity prevailed so that controller did not recognize the aircraft misaligned nor did he recognize they had touched down on the wrong runway.
Incident Facts

Date of incident
Aug 8, 2011

Classification
Incident

Airline
Air France

Aircraft Type
Airbus A319

ICAO Type Designator
A319

This article is published under license from Avherald.com. © of text by Avherald.com.
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