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D328, Norwich UK, 2012

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Summary
On 22 March 2012, a Scot Airways Dornier 328 left the side of the runway shortly after touchdown following an unstable visual sequel to a non precision approach at Norwich and then carried out a go around without further event. The aircraft was undamaged by the excursion but a runway edge light was broken. The subsequent Investigation noted the gross violation of Operator SOPs in respect of the way the initial approach had been conducted, the absence of necessary crew procedures following a serious incident and the absence of any OFDM programme.
Event Details
When March 2012
Actual or Potential
Event Type
Human Factors, Runway Excursion
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft FAIRCHILD DORNIER 328
Operator ScotAirways
Domicile United Kingdom
Type of Flight Public Transport (Passenger)
Origin Manchester International Airport
Actual Destination Norwich International
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Landing
LDG
Location - Airport
Airport Norwich International
General
Tag(s) Approach not stabilised
HF
Tag(s) Manual Handling,
Plan Continuation Bias,
Procedural non compliance
RE
Tag(s) Off side of Runway
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 22 March 2012, a Dornier 328 being operated by Scot Airways for Loganair under a Flybe franchise on a scheduled domestic passenger flight from Manchester to Norwich briefly departed the left side of the runway shortly after a daylight touchdown at destination in normal ground visibility following a non precision approach before carrying out a go around and a subsequently successful Instrument Landing System (ILS) approach and landing on the opposite runway direction. The aircraft was undamaged by the excursion but a runway edge light was broken.

Investigation

A Field Investigation was carried out by the UK AAIB. It was noted that there had been a delay in reporting the occurrence to the AAIB and that the Cockpit Voice Recorder (CVR) data had been overwritten. Flight Data Recorder (FDR) data was recovered and successfully replayed and the NVM from the Terrain Avoidance and Warning System (TAWS) equipment was also retrieved. In addition, ATC radar recordings were also available. The FDR data was used to review the NDB/DME approach flown to runway 09, for which it was noted that the aircraft commander had been designated as PF. It was noted that the Co Pilot had recently qualified as a Captain on the aircraft type. The track and vertical profile of this approach based on FDR data are shown in the illustration here.

Track and vertical path against the procedure flown (reproduced from the Official Report)

It was noted that by the time the inbound track was acquired at 2000 feet amsl, the aircraft had been configured for landing and the landing checks had been completed. The AP remained engaged and VS mode was used for the descent to the MDA of 580 feet amsl. In the absence of the required visual reference upon reaching MDA, the PF had selected ALT HOLD on the MCP and continued for 10 seconds before disconnecting the AP and commencing further descent after gaining sight of the landing runway through the prevailing haze at just over a mile from the threshold. Radar data showed that the inbound track flown prior to visual acquisition of the runway had, although aligned with the extended runway centreline, been offset to the right throughout by approximately 0.4nm.

The manoeuvring undertaken upon becoming visual in an attempt to align with the runway whilst also conducting a steep descent resulted in excessive bank angles, first to the left and then at low level to the right. The latter was found to have triggered a Bank Angle Alert from the Terrain Avoidance and Warning System (TAWS) between 84 ft and 53 ft as a maximum recorded right bank angle of 29.5º was reducing from 28 º to just over 25 º. The aircraft had crossed the runway threshold with right bank applied and tracking towards the right hand edge of the runway where a firm touchdown occurred. The crew reported that “as the aircraft touched down, or possibly just before, the co-pilot called ‘go around’; this was flown by the commander without event”.

In respect of the late ‘go around’ call, the co-pilot advised the Investigation that he had been “slightly concerned” during the visual manoeuvring but “had confidence in the commander’s ability and so did not interject”. He stated that he had not called ‘go-around’ before the aircraft was over the runway, despite it being unstable, as “he thought the commander was going to line up with the centreline and land safely”.

The Operations Manual was examined and found to mandate and define both a stabilised approach and the CDFA process for all non precision approaches but fail to adequately define crew actions following a Serious Incident.

The Conclusion of the Investigation was that:

“In this incident, the commander, who was the PF, was not visual with the runway at MDA and, in accordance with the company operating manual, should have initiated a go-around. Instead he levelled the aircraft in the hope of gaining visual references with the runway. When he did gain this visual reference the aircraft was not in a position to land without applying significant angles of bank at low level. This resulted in the aircraft touching down and tracking off the runway, with the right landing gear leaving the paved surface.”

The Final Report AAIB Bulletin: 12/2012 EW/G2012/03/04 was published on 13 December 2012. No Safety Recommendations were made.

Further Reading