A388, Singapore Changi Singapore, 2023
A388, Singapore Changi Singapore, 2023
Summary
On 2 March 2023, an Airbus A380-800 landing at Singapore in heavy rain drifted to the right of the runway centreline after the autopilot was disengaged before touching down close to the runway edge. The aircraft continued to drift right and the right main landing gear briefly left the runway and damaged several edge lights before regaining it. The handling pilot did not use the correct technique to regain the runway centreline before or after touchdown and go-around calls from the monitoring pilot shortly before and immediately after touchdown were respectively not understood/heard despite compliance with such calls being mandatory.
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Landing
Location - Airport
Airport
HF
Tag(s)
Inappropriate crew response - skills deficiency,
Manual Handling,
Plan Continuation Bias,
Procedural non compliance
RE
Tag(s)
Off side of Runway
Outcome
Damage or injury
Yes
Aircraft damage
Minor
Non-aircraft damage
Yes
Non-occupant Casualties
No
Off Airport Landing
No
Ditching
No
Causal Factor Group(s)
Group(s)
Aircraft Operation
Safety Recommendation(s)
Group(s)
Aircraft Operation
Investigation Type
Type
Independent
Description
On 2 March 2023, an Airbus A380-800 (A6-EVJ) being operated by Emirates on a scheduled international passenger flight from Dubai to Singapore Changi as EK354 touched down close to the right hand runway edge. When this drift was not corrected, the right main gear briefly exited the runway onto the adjacent grass before regaining it and completing the landing roll. One right main gear tyre deflated and another was damaged after coming into contact with three consecutive runway edge lights which were all destroyed.
Investigation
A Serious Incident Investigation was carried out by the Singapore Transport Safety Investigation Bureau (TSIB). The FDR and the CVR were removed from the aircraft and relevant data were successfully downloaded from both recorders.
The 51 year-old Captain who had been acting as PF for the sector, had a total of 13,098 hours flying experience of which 5,778 hours were on type. The 40 year-old First Officer, had a total of 9,571 hours flying experience of which 1,512 hours were on type.
What Happened
At about 15 nm from touchdown and already established on the runway 02L ILS approach, both pilots observed clouds over the north northwest area of the airport but, having checked the weather radar, concluded that the build-up was at that time was insignificant. However, it had already been raining at the airport for long enough to allow the ATIS to be updated.
The approach lights were nevertheless clearly visible from 3nm onwards until, according to the Captain, at about 200 feet agl, just before he disconnected the AP, the intensity of the rain suddenly increased which had surprised him and “somewhat affected his handling of the aircraft”. He stated that “although the wipers were set to high speed, the view out of the flight deck was alternating between clear and blurry depending on the sweep of the wiper”. It was found subsequently that the RVR being reported at the time was between 1500 and 2100 metres.
Shortly after the AP had been disconnected at 180 feet agl, both pilots reported having noticed that the aircraft was beginning to drift towards the right of the extended runway centreline. The First Officer called “centreline” and the Captain responded by making both pitch and roll sidestick inputs to try and arrest the drift. The Captain stated that although he had been aware that the aircraft was not aligned with the runway centreline, he judged that the offset was still compatible with a safe landing.
At about 30 feet agl, the First Officer called “go-around” but the Captain responded with “no it's OK” and continued with the landing. As the aircraft was touching down on the runway, the First Officer again called “go-around” but this time with no response from the Captain who continued with the landing roll.
FDR data indicated that when the aircraft was about 15 feet agl, the Captain had momentarily and simultaneously made a sharp left rudder input (from 2° to 9°) and a left roll input which together resulted in a bank angle to the left of less than half a degree. Whilst these inputs resulted in the aircraft turning back towards the runway centreline, it continued to drift towards the runway edge. The rudder was then returned to neutral and a right roll input was made which resulted in a bank angle to the right of up to 4° following which the aircraft touched down close to the edge of the runway before veering slightly further to the right (see ground track on the illustration below).
The Captain subsequently stated that having believed the aircraft had remained on the 60 metre-wide runway, he had simply steered it back towards the runway centreline and, whilst doing so, had selected the thrust levers to reverse.
The ground track of the landing at Changi. [Reproduced from the Official Report]
The pilots stated that as the speed had reduced through around 80 knots, they had seen an ECAM message indicating low tyre pressure before exiting the runway and continuing to the designated parking gate. Once stopped, ground staff advised that one of the right main gear tyres had deflated and after confirming this by a visual inspection, the crew reported this to ATC.
ATC sent a runway inspection vehicle to carry out a runway inspection and inspect the taxi route and the aircraft itself and on completion of this check were informed that “no foreign object debris had been found”. ATC were already aware of an edge lighting outage on the same runway but did not link this to the tyre deflation and so the crew were informed of the absence of any debris. Only during a scheduled runway inspection an hour later were three consecutive runway edge lights found to have been destroyed by impact - the same ones which had already been reported to be indicating as failed on the lighting panel. This inspection found light fitting debris scattered on the runway shoulder pavement area and in the adjacent grass and “some light fitting debris pieces were also found on taxiway W7, a RET for use in the 19R direction.
Inspection of the aircraft right main gear tyres during removal and replacement of the deflated tyre resulted in the discovery of another damaged but still inflated tyre which had a circular incision in it with a diameter similar to a runway edge light.
The location of the three damaged runway edge lights. [Reproduced from the Official Report]
The punctured tyre. [Reproduced from the Official Report]
The tyre with the circular incision. [Reproduced from the Official Report]
Why It Happened
The aircraft operator’s OM was found to state that “either the PF or the PM could initiate a go-around” and that “once the (go-around) decision has been announced, it is irrevocable, and the missed approach shall be completed”. The OM was also found to state that “if, during the approach, it becomes apparent that the approach and landing cannot be completed as briefed, a go-around must be initiated”. Both pilots stated that prior to the occurrence, they had both been aware of and understood the operator’s go-around policy.
The Captain told the investigation team that on hearing the First Officer’s first “go-around” call, he had not understood what the First Officer had said but instead of asking him to repeat or clarify this, his response of “no it’s OK” was just so that he could get on with focusing on landing the aircraft. The absence of any response to the First Officer’s second “go-around” call was, he claimed, because he did not hear it. The Investigation considered that this behaviour by the Captain was indicative of poor CRM.
The Captain’s failure to correct the drift right towards the edge of the runway was found, by reference to the aircraft manufacturer’s operational and safety documentation, to have been attributable to his failure to use the right technique to correct a deviation during approach which is to apply only roll input and in this instance more of it. It was stated clearly that “applying rudder input is not an appropriate method to correct lateral deviations”.
Safety Action taken by Emirates Airline as a result of the investigated event was noted to have included adding a reminder to pilots’ annual CRM and Technical Training detail that once a go-around is announced by the PM or the PF, it must be carried out with the PM ready to take control and fly a missed approach even if the aircraft touches the ground.
Two Safety Recommendations were made as a result of the Investigation findings as follows:
- that Emirates Airline reminds its pilots of the appropriate technique to correct lateral deviation during approach and landing. [2023-011]
- that Emirates Airline reminds its pilots on the importance of crew resource management and of asking the originator of a message to repeat the message if they do not understand the message. [RA-2023-012]
The Final Report was published on 13 October 2023.
