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ATP, Birmingham UK, 2020

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Summary
On 22 May 2020, a BAe ATP made a go around after the First Officer mishandled the landing flare at Birmingham and when the Captain took over for a second approach, his own mishandling of the touchdown led to a lateral runway excursion. The Investigation found that although the prevailing surface wind was well within the limiting crosswind component, that component was still beyond both their handling skill levels. It also found that they were both generally inexperienced on type, had not previously encountered more than modest crosswind landings and that their type training in this respect had been inadequate.
Event Details
When May 2020
Actual or Potential
Event Type
Human Factors, Runway Excursion
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BRITISH AEROSPACE ATP
Operator West Atlantic
Domicile Sweden
Type of Flight Public Transport (Cargo)
Origin Guernsey Airport
Intended Destination Birmingham International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Landing
LDG
Location - Airport
Airport Birmingham International Airport
General
Tag(s) Landing Flare Difficulty,
Approach Unstabilised after Gate-GA,
Deficient Crew Knowledge-handling,
PIC less than 500 hours in Command on Type,
Copilot less than 500 hours on Type
HF
Tag(s) Inappropriate crew response - skills deficiency,
Procedural non compliance
RE
Tag(s) Significant Crosswind Component,
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 May 2020, a BAe ATP (SE-MAO) being operated by West Atlantic on a scheduled cargo flight from Guernsey to Birmingham in day VMC with just the two pilots on board rejected its initial landing attempt at destination from the runway and during its second attempt left the side of the runway after touchdown and only regained it after approximately 450 metres. The aircraft was undamaged due to the hard firm ground over which the excursion occurred and there was no damage to any ground installations or injury to the pilots.

Investigation

A Field Investigation was carried by the UK AAIB. The 2 hour SSCVR and FDR were removed from the aircraft and their data successfully downloaded and a copy of the QAR data, which more reliably replicated the same data as that provided by the magnetic tape FDR, although because of requirements at the time C of A was issued, less than 30 parameters were recorded. Airport CCTV data and video footage of both landing attempts taken by a witness located outside the airfield boundary were also available.

It was noted that the 57 year-old Captain had a total of 4,984 hours flying experience which included 211 hours on type. The First Officer had a total of 730 hours flying experience which included approximately 250 hours on type and was in his first job as a professional pilot.

It was noted that the landing weight of the aircraft was around 30% less than the allowable maximum and confirmed that the loaded centre of gravity was within limits. The surface wind for both approaches was generally from the southwest at 16-28 knots and had remained as forecast during the period with no precipitation and a consequently dry runway surface. Shortly before the second landing and excursion, the two minute mean wind velocity was passed as 230° at 14 knots gusting to 27 knots read from an anemometer located next to the runway 33 TDZ.

The Investigation found that clear wheel tracks remained from the runway excursion and used GPS markers and a suitably instrumented UAS to compile an aerial survey of the area where the excursion had occurred which could be compared to recorded flight data.

What Happened

The runway 33 ILS GS was out of service because of work in its vicinity and so the flight was cleared for a LOC DME approach. The prevailing wind velocity represented a significant but variable crosswind component although it was well within AFM limits with lesser limits applicable to either of the pilots. With the First Officer acting as PF, a stable approach was flown despite some turbulence using a wings-level approach ‘crabbed’ to the left by 20° in order to track the runway extended centreline. However, he then failed to properly align the aircraft with the runway in the flare and just as it was about to touch down on the left main gear with its longitudinal axis still off the runway centreline by 8° and increasing, he called a go around. It appears that the Captain did not hear this call since he then responded with “land it, land it”. The First Officer therefore moved the power levers back towards flight idle and the aircraft touched down for a second time with its longitudinal axis now about 15° to the left of the runway centreline as a result of a continued failure to achieve directional control using full right rudder. The Captain called for a go around and after 8 seconds on the ground, the First Officer got the aircraft into the air in a heading now 24° left of the runway centreline and thereafter flew a go around in accordance with SOPs.

At the request of the First Officer, the Captain then took over as PF and after radar vector to finals, flew another stabilised approach with a similar crab angle to that used on the first approach. This time, touchdown again occurred without full removal of the approach crab angle with the aircraft longitudinal axis aligned 10° to the left of the runway centreline and increasing. It peaked at a misalignment of 24° when full right rudder was belatedly applied. The Captain also applied full right aileron, which resulted in an 8° bank to the right which was enough to lift the left main gear clear of the runway. The aircraft then departed the left side of the 45 metre wide runway whilst simultaneously in a right turn resting on the nose and right main gear. After seven seconds clear of the runway, the aircraft began to track parallel to it for a further 7 seconds before regaining it. It was noted that normal landing procedures would have required the Captain to hand over the control column to the First Officer at 80 knots but by then the aircraft had already left the runway.

Stills from a video recording taken by a witness outside the aerodrome boundary showing the aircraft during its first (left) and second (right) attempts to land. [Reproduced from the Official Report]

The illustration above showing the aircraft leaving the runway during the second landing also shows a taxiway sign for taxiway ‘L’ just ahead of that taxiway. The aerial survey showed that the left wing passed over this with clearance calculated as just over 1 metre. Whist this sign was outside the 4.2 metre diameter of the six bladed propeller, it was higher than the lowest point of the rotational arc and whilst all airside signage is designed to be frangible, it was considered that had the propeller hit the sign, some damage to the aircraft would have been inevitable.

Crew Crosswind Landing Skills

The Investigation found that neither pilot had received much training on crosswind landing procedures nor did they or the aircraft operator appear to have recognised the degree of relative risk to which the crew would be exposed to during a relatively normal crosswind landing.

Their type rating had not required recording of crosswind landings as a discrete item in the training programme despite being a required element of the type rating. Although both recalled completing one crosswind landing during their FFS sessions, neither recalled receiving any specific training in the relevant handling techniques, and stated that the wind used for this landing had been nowhere near the 34 knot AFM limit. Whilst the syllabus for their subsequent line training had included crosswind landings, this could be and was signed off as a discussion item. Following successful line checks, both pilots were then released to unsupervised flying duties. They then both subsequently completed their first routine recurrent FFS training on type during the winter of 2019/20 and these particular sessions were found to have included a crosswind landing as part of the items taken from the list of items which must be covered every three years. Both pilots reported having flown some crosswind landings on the line before the investigated event but neither could remember any landing where the crosswind component had “exceeded 20 - 25 knots”. However they were both current and had been flying throughout the previous three-month period. It was considered of note that West Atlantic had “no restrictions on the crosswind limit for either newly qualified flight crew members or inexperienced co-pilots”.

CVR data showed that despite this relative unfamiliarity with crosswind landings at the higher end of the permitted range (up to 34 knots), at no time had the crew discussed the control column inputs that might need to be made given the strength of the crosswind for either of the approaches made.

The formally documented Conclusion of the Investigation was as follows:

Despite the challenging conditions, the crew did not discuss the conditions in any detail. They did not brief who would be holding the control column during either landing roll, or what actions they would take if they were required to abandon the approach or landing. The first approach resulted in confusion between the crew over going around which could have itself resulted in an incident or accident. The confusion was eventually overcome by the Captain calling for a go-around.
The second approach resulted in a significant runway excursion due to the use of incorrect crosswind technique and the application of full right aileron. It is likely that the crew’s lack of experience of landing in strong crosswinds contributed to the misalignment at touchdown.
Neither attempt at landing used the crosswind technique as laid down in the manufacturer’s or operator’s manuals.
It was fortunate that the ground was hard due to a lack of recent rain. Except for the taxiway sign there were no other obstacles in the way of the aircraft such as other aircraft or vehicles. As a result, despite a 450 metre excursion off the runway, there was no damage to the aircraft or the airport facilities, and no injuries to the crew who were the only people on board.

Safety Action taken by the aircraft operator as a result of this event was noted as having included the introduction of crosswind landing training to recurrent simulator sessions. It was also noted that it was intended to introduce crosswind limits for new First Officers.

The Final Report was published on 4 March 2021. No Safety Recommendations were made.

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