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09 Aug 2019 - Final report published into Xiamen 737-800 B-5498 Runway excursion after landing at Manila on 16 Aug 2018

On 16 Aug 2018 Xiamen Airlines 737-800, B-5498 (37574/3160 delivered Jan 2010), departed to the right side of runway 24 at Manila (RPLL) whilst landing in a thunderstorm at 1555z (23:55L). The aircraft was on its second approach after having previously gone around due to the weather. The left main landing gear collapsed and the #1 engine separated from the wing but there were no injuries.

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On 8 Aug 2019 the Philippine CAA published their final report into the incident.

It identified the primary causal factors as:

  1. The decision of the Captain to continue the landing on un-stabilized approach and insufficient visual reference.
    •  The Captain failed to maintain a stabilized landing approach moments before touchdown, the aircraft was rolling left and continuously drifting left of the runway centerline.
    •  The Captain failed to identify correctly the aircraft position and status due to insufficient visual reference caused by precipitation.
  2. The Captain failed to apply sound CRM practices.
    •  The Captain did not heed to the First Officer call for a Go-Around
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B-5498 in its final resting position

B-5498 in its final resting position Photo: Anjo Perez/Manila Airport Authority

EXECUTIVE SUMMARY

On August 16, 2018, about 1555UTC/2355H local time, a Boeing 737-800 type of aircraft with Registry No. B-5498 operating as flight CXA 8667 sustained substantial damage following a runway excursion after second approach while landing on Runway 24 of Ninoy Aquino International Airport (NAIA), Manila, Philippines. The flight was a scheduled commercial passenger from Xiamen, China and operated by Xiamen Airlines. The one hundred fifty-seven (157) passengers and two (2) pilots together with the five (5) cabin crew and one air security officer did not sustain any injuries while the aircraft was substantially damaged. An instrument flight rules flight plan was filed. Instrument Meteorological Conditions (IMC) prevailed at the time of the accident.

During the first approach, the Captain who was the pilot flying aborted the landing at 30 feet Radio Altitude (RA) due to insufficient visual reference. A second approach was considered and carried out after briefing the First Officer (FO) of the possibility of another aborted landing should the flight encounter similar conditions. The briefing included a diversion to their planned alternate airfield.

The flight was “stabilized” on the second approach with flaps set at 30 degrees landing position, all landing gears extended and speed brake lever appropriately set in the ARM position. On passing 1,002 feet Radio Altitude (RA), the autopilot was disengaged; followed by the disengagement of the auto-throttle, three (3) seconds later.

The ILS localizer lateral path and Glide slope vertical path were accurately tracked and no deviations were recorded. The “reference” landing speed for flaps 30 for the expected aircraft gross weight at the time of landing was 145 knots and a target speed of 150 knots was set on the Mode Control Panel (MCP). The vertical descent rate recorded during the approach was commensurate with the recommended descent rate for the profile angle and ground speed; and was maintained throughout the approach passing through the Decision Altitude (DA) of 375 feet down to 50 feet radio altitude (RA).

As the aircraft passed over the threshold, the localizer deviation was established around zero dot but indicated the airplane began to drift to the left of the centerline followed by the First Officer (FO) making a call out of “Go-Around” but was answered by the Captain “No”. The throttle levers for both engines were started to be reduced to idle position at 30 feet RA and became fully idle while passing five (5) feet RA. At this point, the aircraft was in de-crab position prior to flare. At 13 feet RA, the aircraft was rolling left and continuously drifting left of the runway center line.

At 10 feet RA another call for go-around was made by the FO but was again answered by the Captain with “No” and “It’s Okay”. At this point, computed airspeed was approximately 6 knots above MCP selected speed and RA was approaching zero feet. Just prior to touchdown, computed airspeed decreased by 4 knots and the airplane touched down at 151 knots (VREF+6). The wind was recorded at 274.7 degrees at 8.5 knots.

Data from the aircraft’s flight data recorder showed that the aircraft touched down almost on both main gears, to the left of the runway centerline, about 741 meters from the threshold of runway 24. Deployment of the speed brakes was recorded and auto brakes engagement was also recorded. The auto brakes subsequently disengaged but the cause was undetermined.

Upon touchdown, the aircraft continued on its left-wards trajectory while the aircraft heading was held almost constant at 241 degrees. After the aircraft departed the left edge of the runway, all landing gears collided with several concrete electric junction boxes that were erected parallel outside the confines of the runway pavement.

The aircraft was travelling at about 147 knots as it exited the paved surface of the runway and came to rest at approximately 1,500 meters from the threshold of Runway 24, with a geographical position of 14°30’23.7” N; 121°0’59.1” E and a heading of 120 degrees.

Throughout the above sequence of events from touchdown until the aircraft came to a full stop, the CVR recorded 2 more calls of “GO-AROUND” made by the FO.

Throughout the landing sequence, the thrust reversers for both engines were not deployed. Throttle Lever Position (TLP) were recorded and there was no evidence of reverse thrust being selected or deployment of reversers.

After the aircraft came to a complete stop, the pilots carried out all memory items and the refence items in the evacuation non-normal checklist, which includes extending the flaps to a 40 degrees position. The aircraft suffered total loss of communication and a failure in passenger address system possibly due to the damage caused by the nose gear collapsing rearwards and damaging the equipment in the E/E compartment or the E-buss wires connecting the Very High Frequency (VHF) 1 radio directly to the battery was broken. The Captain then directed the FO to go out of the cockpit to announce the emergency evacuation. The cabin crew started the evacuation of the passengers utilizing the emergency slides of the left and right forward doors. There were no reported injuries sustained by the passengers, cabin crew, flight crew or the security officer.

Flight Operations

a. The flight was conducted in accordance with the procedures in the Company Operations Manual.
b. The flight crew carried out normal radio communications with Manila Approach and Tower Controller.
c. The Captain was the pilot flying during the two approaches to ILS runway 24 of Ninoy Aquino International Airport.
d. At 46 feet and 10 feet respectively, the FO made a call out of go-around but the captain disregarded the call.
e. The aircraft touched down on runway 24 almost on both wheels at the left portion of the runway about 741 meters from the threshold and exited the runway.
f. As the aircraft continued to roll parallel the runway both main landing gears and the nose gear collided with several cemented electric junction boxes resulting in the LH Main Gear and Left Engine to be sheared off. The cemented electric junction boxes at the grassy soft ground were inconsistent with the CAAP Aerodrome MOS.
g. RH Main landing gear were folded inwards into the RH Wheel Well, the Nose Landing Gear was folded backwards damaging the E/E Bay.
h. The pilots were unable to respond to calls from the ATC and neither make any calls to ATC. The pilots were also unable to communicate with the cabin crew through the service interphone system and to make announcements using the passenger address system.
i. The failure of the aircraft communications systems were probably due to the damage to the E/E bay compartment and broken wires directly connecting the E-Buss of the VHF-1 to the battery.
j. The aircraft finally settled at a distance about 1500 meters from the threshold of Runway 24 with last heading of 120 degrees.

Weather

At the time of accident there were thunderstorms and intermittent heavy rains observed.

CAUSE FACTORS

Primary Cause Factors

  1. The decision of the Captain to continue the landing on un-stabilized approach and insufficient visual reference.
    •  The Captain failed to maintain a stabilized landing approach moments before touchdown, the aircraft was rolling left and continuously drifting left of the runway centerline.
    •  The Captain failed to identify correctly the aircraft position and status due to insufficient visual reference caused by precipitation.
  2. The Captain failed to apply sound CRM practices.
    •  The Captain did not heed to the First Officer call for a Go-Around

Contributory Factors

a. Failure to apply appropriate TEM strategies
Failure of the Flight Crew to discuss and apply appropriate Threat and Error Management (TEM) strategies for the following:

 Inclement weather.
 Cross wind conditions during approach to land.
 Possibility of low-level wind shear.
 NOTAM information on unserviceable runway lights.

b. Inadequate Company Policy on Go-Around

 Company’s Standard Operation Procedures were less than adequate in terms of providing guidance to the flight crew for call out of “Go-Around” during landing phase of the flight.

c. Runway strip inconsistent with CAAP MOS for Aerodrome and ICAO Annex 14

 The uneven surface and concrete obstacles contributed to the damage sustained by the aircraft

 

SAFETY RECOMMENDATIONS

As a result of this investigation, the Aircraft Accident Investigation and Inquiry Board made the following safety recommendations:

 For Xiamen Airlines to review and strengthen their policies of actions to be taken by the pilot flying once a call out of “Go-Around” is made by the pilot monitoring during landing.
 For Xiamen Airlines to establish policies on no fault “Go-Around” and to ensure that it is being implemented, understood by flight crew thru inclusion in their initial and recurrent training.
 For Xiamen Airlines to review recurrent ground training syllabus to improve/adapt CRM and TEM with consideration to company in-service scenarios like this accident and other findings as a result of flight crew interview in the conduct of their flight data monitoring (FDM) program.
 For MIAA to review Disabled Aircraft Removal Plan (DARP) and ensure the suitability of equipment to the current operation of NAIA.
 For CAAP to disseminate the above Safety Recommendations to Philippine Operators.

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