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Air Accident Investigation Sector
Runway Confusion
Takeoff from Wrong Runway
Operator:
Make and Model:
Nationality and Registration:
Place of Occurrence:
State of Occurrence:
Date of Occurrence:
Serious Incident
̶ Final Report ̶
o
AAIS Case N
: AIFN/0010/2018
Air Arabia
Airbus A320-214
The United Arab Emirates, A6-ANV
Sharjah International Airport
The United Arab Emirates
18 September 2018
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Summary of Contents for Runway Airbus A320-214
- Page 1 Air Accident Investigation Sector Serious Incident ̶ Final Report ̶ AAIS Case N : AIFN/0010/2018 Runway Confusion Takeoff from Wrong Runway Operator: Air Arabia Make and Model: Airbus A320-214 Nationality and Registration: The United Arab Emirates, A6-ANV Place of Occurrence:...
- Page 2 This Investigation was conducted by the Air Accident Investigation Sector of the United Arab Emirates pursuant to Civil Aviation Law No. 20 of 1991, in compliance with Air Accident and Incident Investigation Regulation, and in conformance with the requirements of Annex 13 to the Convention on International Civil Aviation.
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Page 3: Investigation Process
Occurrence Brief Occurrence File Number AIFN/0010/2018 Occurrence Category Serious Incident Name of the Operator Air Arabia Manufacturer Airbus Industries Aircraft Model Airbus A320-214 Engines Two, CFM56-5B4 Nationality The United Arab Emirates Registration A6-ANV Manufacturer Serial Number 5984 Type of Flight... - Page 4 (Aircraft) – the aircraft involved in this serious incident (Commander) – the commander of the flight (Copilot) – the copilot of the flight (Incident) – this investigated serious incident (Investigation) – the investigation into the circumstances of this serious incident ...
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Page 5: Abbreviations
Abbreviations A/THR Auto thrust AAIS The Air Accident Investigation Sector of the United Arab Emirates ACARS Aircraft Communications Addressing and Reporting System AIFN Accident/Incident File Number Air safety report Air traffic control ATIS Air traffic information system ATPL Air transport pilot license Calibrated airspeed Civil Aviation Regulations CAVOK... - Page 6 Radio telephony Runway mode in FMA OMSJ Sharjah International Airport OOSL Salalah International Airport Second officer Standard operating procedure Type rating examiner Type rating instructor TOGA Takeoff/go-around The United Arab Emirates Universal time coordinated Final Report № AIFN/0010/2018, issued on 10 January 2022...
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Page 7: Synopsis
Aircraft flap setting from 1+F to flap 2 position. The Aircraft lifted off 20 to 40 meters beyond the end of runway 12. No. 3 main wheel tire received cuts when it struck one approach light during the liftoff. -
Page 8: Table Of Contents
Meteorological Information .................. 9 Aids to Navigation ....................9 Communications ....................9 1.10 Aerodrome Information ..................10 1.10.1 Runway 12/30 and taxiway signage ...........10 1.10.2 Air traffic control standby tower ............12 1.11 Flight Recorders ....................13 1.12 Wreckage and Impact Information ..............13 1.13... - Page 9 Organizational and Management Information .............14 1.17.1 The Operator..................14 1.17.2 Air navigation services ...............19 1.18 Additional Information ..................20 1.18.1 Runway awareness and advisory system (RAAS) ......20 1.18.2 Take-off surveillance and performance analysis .........20 1.19 Useful or Effective Investigation Techniques ............21 2. Analysis General ......................22...
- Page 10 List of figures Figure 1. Damaged No. 3 main wheel tire Figure 2. Damaged runway 30 light Figure 3. Location of the damaged runway 30 approach light on the runway end safety area (RESA) Figure 4. Airbus A320 dimensions Figure 5. Airbus A320 PFD indications (RWY green indicates correct runway) Figure 6.
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Page 11: Factual Information
Aircraft in case of rejected takeoff. The OFP stated in the matrix of data that for a takeoff on runway 30 at Bravo 14 intersection, the take-off distance available would be 3,050 meters, which was about 1,000 meters shorter that the runway length. - Page 12 As per the Commander’s statement, he was busy completing the before takeoff checklist and did not realize that the Aircraft had turned right onto runway 12 instead of runway 30. He shortly realized that the Aircraft was on the wrong runway but decided to continue the takeoff believing that the remaining take-off runway available was insufficient to reject the takeoff.
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Page 13: Injuries To Persons
The Aircraft was intact. The No. 3 main wheel tire on the right main landing gear struck a runway approach light located at the runway-end safety area, which resulted in cuts to the inboard sidewall and tread (figure 1). The tire remained inflated during the flight. As per the Commander's statement, he could not notice any cuts on the tire as the cut was on the lower invisible part of the tire. -
Page 14: Other Damage
The No. 3 main wheel tire struck the runway 30 approach light. The support post of the approach light was made of steel and was bolted to the runway surface with a height of 70 centimeters. The base of the light support structure was completely detached, and the light assembly was broken (figure 2). - Page 15 16 and 17 September. The Copilot was the pilot flying for the two departures from OMSJ, and both were intersection takeoff at Bravo 6 for runway 12. The Investigation did not find negative observations or comments about the Copilot’s performance by previous instructors.
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Page 16: Air Traffic Controller
30 at Bravo 20 holding point; visually scanning runway 30 approach path and the departure end of runway 30; and checking the strip markings on the flight progress strips. The controller was relieved from duty after the Incident, in accordance with Sharjah Air Navigation Services policy contained in the operations manual of air traffic services. -
Page 17: Engines Data
MCDU. As per the Aircraft’s manufacturer flight crew operating manual (FCOM), during line-up on the runway for takeoff, the lateral mode column indicates RWY in green color as illustrated in figure 5, provided the following conditions are fulfilled: ... -
Page 18: Thrust Lever Detent Positions
The flight crew can select the autobrake deceleration rate of low, medium or maximum by a pushbutton. As per the standard operating procedure (SOP), the selection of maximum braking is required for takeoff at all times. 1.6.5 Thrust lever detent positions The A320 thrust levers can be positioned in six detents along with the console panel. -
Page 19: Meteorological Information
Dew point 21, QNH 1005 hPa NO SIG=” The METAR of the OMSJ at the time of the Incident stated that runway 30 was in use for takeoff, and the wind was blowing from direction 330 degrees at 11 knots. There were no clouds;... -
Page 20: Aerodrome Information
Civil Aviation Regulations CAR Part IX - Aerodromes. In case a right turn is made, the aircraft will be on runway 12 with the runway available of 1006 meters, Final Report № AIFN/0010/2018, issued on 10 January 2022... - Page 21 30 touchdown zone white bar markings as well as the aiming point with start of runway 30 threshold white markings approximately 650 meters from Bravo 14 runway intersection. Figure 6. Taxiway Bravo 14 to runway 12/30 taxi lines Figure 7.
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Page 22: Air Traffic Control Standby Tower
Additionally, for ABY111 Incident , the following was confirmed by the Investigation: Lead-on lights for runway 30 that were installed after stop-bar at Bravo 14 were OFF The uni-directional runway 30 edge lighting was at 30 percent setting ... -
Page 23: Flight Recorders
According to the Aircraft’s manufacturer calculation that at the time of the take-off initiation, the runway remaining was 984 meters. For both scenarios, it was possible to safely stop the Aircraft if maximum engine reverse thrust was used, automatically applying maximum braking. The calculated runway distance remaining were: ... -
Page 24: Simulator Sessions At The Operator's Flight Simulator
The Investigation requested the Operator to perform simulator flight sessions using OMSJ airfield and runway visual cues, ABY111 flight plan data, and close to actual taxi speeds and taxi time to determine if it was possible to reject the takeoff. In addition, the simulator sessions were used to determine the time taken to perform the before takeoff checklist ‘below the line’... - Page 25 Before commencement of the take-off roll, the OM-A ─ Line-up and Positive Runway Identification stated: “…both pilots shall verify that the aircraft is lined up on the correct runway and closely as possible to the runway centerline by utilizing runway markings, ILS [instrument landing system] verification, etc.”...
- Page 26 Be careful that in low visibility, edge lights could be mixed up with the center line lights. ‐ The ILS signal, If the runway is ILS equipped, the flight crew can press the ILS pb (or LS pb): The LOC deviation should be centered after line up. ‐ The runway symbol on the ND, ‐...
- Page 27 The OM-A listed several reasons why a takeoff may be rejected which included “Incorrect runway line-up technique”. In addition, the OM-A ─ Control of Aircraft, stated: “… The decision to continue the take-off or to reject rests solely with the Captain.
- Page 28 … ● Above V Takeoff must be continued, because it may not be possible to stop the aircraft on the remaining runway. … Decision Callouts The decision to reject the takeoff and the stop action is the responsibility of the Captain and must be made prior to V speed.
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Page 29: Air Navigation Services
(RSMS) was installed. SANS stated: “ Installation of an ATC [air traffic control] grade video camera system to provide surveillance of the main apron, maintenance area/apron and the runway, runway thresholds and associated taxiway hold points.” In addition, SANS stated: “The provision of a CCTV [closed-circuit television] camera system installed on the... -
Page 30: Additional Information
The Investigation was not presented with risk assessment of intersection takeoffs for runway 12/30 as SANS did not identify intersection takeoffs from Bravo 14 for runway 30 and Bravo 6 for runway 12 as hazards. In addition, intersections Bravo 14 and Bravo 6 were not identified as hot spots. -
Page 31: Useful Or Effective Investigation Techniques
For ABY111 flight, the Aircraft manufacturer concluded that the TOS2, the system would have triggered: (a) The ECAM caution ‘NAV NOT ON FMS RUNWAY’ as the Aircraft lined up on the wrong runway 12; and (b) The ECAM red warning ‘T.O RUNWAY TOO SHORT’ as the take-off runway available was 1,000 m after the Aircraft lined up on runway 12. -
Page 32: Analysis
20 knots, the Copilot almost simultaneously applied a nose down sidestick input and advanced both thrust leavers to FLX/MCT detent. Because there was no need to stop the Aircraft on the runway, the Copilot continued to steer and align the Aircraft onto runway 12 centerline for the rolling takeoff. -
Page 33: Flight Crew Performance
30 meters with passing 132 knots CAS. The flight crew and air traffic controller were not aware that one of the approach lights of runway 30 was damaged by No. 3 main wheel tire during the Aircraft liftoff... -
Page 34: Flight Crew Briefing
However, the Incident training flight, which was on day 4 of the pairing, required the Copilot to steer the Aircraft to the left at the intersection Bravo 14 for alignment with runway 30. As per the Copilot’s training records, this was her first intersection takeoff from Bravo 14 without the presence of the cover pilot. -
Page 35: Take-Off Decision
However, it is probable that the Commander did not scrutinize the trainee Copilot performance due to his confidence that she will carry a routinely successful intersection takeoff on runway 12 from Bravo 6 intersection as he witnessed earlier on days 1 and 2 of their four-day pairing. -
Page 36: Crew Performance
The Commander perceived that the remaining runway available was insufficient to reject the takeoff as indicated by his statement to the Investigation “I saw the end of runway coming.” The Aircraft manufacturer's guidance and the Operator’s policy for a rejected takeoff recognizes the risks involved with such a decision. -
Page 37: Aerodrome - Taxiway And Runway
Regulations concerning taxiway and runway markings, lighting, stop bars, and signage. The Investigation confirmed that the lead-on lights were functional and the centerline marking was visible from runway holding point Bravo 14 to runway 30, and if followed, would correctly lead to the planned take-off runway. -
Page 38: Air Traffic Control
Bravo 20 holding point had already confirmed to Tower they had stopped and no other aircraft was on approach for runway 30. Due to the distance of Bravo 14 intersection as well as the known surveillance impediments at the standby tower, the scanning techniques employed by the controller has to be comprehensive so that they maintain situational awareness of aircraft on the taxiways and runway. - Page 39 The controller was unaware that the flight crew had planned a rolling takeoff. The controller had a level of confidence that the flight crew were aware that runway 30 would have required a left turn from Bravo 14 intersection and would not have considered any possibility that the flight crew might have runway confusion.
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Page 40: Conclusions
In day 1 and day 2 of the pairing, the Copilot performed an intersection takeoff from Bravo 6 for runway 12 on each day. The takeoff from the incorrect runway occurred on day 4 of the pairing. 3.2.3 Findings relevant to the flight operations The Commander briefed the Copilot about conducting a single-engine taxi and a rolling takeoff. -
Page 41: Findings Relevant To Air Traffic Control
The Commander stated that the Copilot was “frozen and startled.” The Aircraft liftoff occurred at about 30 meters beyond the end of runway 12 from the runway safety area. The Commander did not notify the Operator about the Incident. -
Page 42: Findings Relevant To Sharjah International Airport
Causes The Air Accident Investigation Sector of United Arab Emirates (AAIS) determines that the cause of the runway confusion was the Copilot steering the Aircraft right onto the wrong runway during a rolling takeoff. Entry to the wrong runway was due to degraded situation awareness of the Aircraft direction by both flight crewmembers due to lack of external peripheral visual watch and runway confirmation. -
Page 43: Safety Recommendations
For increased situation awareness, the following phraseology was introduced: PF: “Lining up Left/Right for Runway XX.” PM: “Affirm/Negative” after crosscheck.” In addition, the Aircraft Operator made changes to the trainee pilot’s intersection takeoffs with lessons learnt from the Incident. - Page 44 V Which will most likely result in better decision-making. The Operator is recommended to...
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Page 45: Safety Recommendations Addressed To Sharjah Air Navigation Service (Sans)
SR45/2021 The Investigation believes that based on the statement from the Commander, the traits demonstrated by the Copilot reflects that she was mentally affected to continue her responsibilities as a pilot. -
Page 46: Appendix A. Aby111 Takeoff Along Runway 12
Appendix A. ABY111 Takeoff Along Runway 12 Final Report № AIFN/0010/2018, issued on 10 January 2022... -
Page 47: Appendix B. Sharjah Airport Chart
Appendix B. Sharjah Airport Chart Final Report № AIFN/0010/2018, issued on 10 January 2022... -
Page 48: Appendix C. Airbus Normal Checklist
Appendix C. Airbus Normal Checklist Final Report № AIFN/0010/2018, issued on 10 January 2022...
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