Paul JOUAS
Flight Safety Director -Accident/incident Investigator
LATERAL RUNWAY EXCURSION AT LANDING
| Event date : 30 sept 2021 | Time : around 15:30Z |
| Place : Airport DAAG (elevation 82ft) | Aircraft : ATR 72-600 |
1. WEATHER INFORMATION
METAR : DAAG 301530Z 05017KT 9999 FEW026 26/18 Q1020=
- Wind from 050° at 17kt
- Visibility more than 10km
FDR wind indicates wind from 045 at 17kt in the last 100ft.
- Estimated headwind 13kt
- Estimated left crosswind 11kt
2. SERIOUS INCIDENT DESCRIPTION
After an ILS approach with 11 kt of crosswind, the aircraft experienced a runway excursion at ~84kt ground speed.
Runway excursion was on the left side of the runway
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- A first touchdown occurred at 15:30:45 roll angle was recorded at +0.5° (it was reverting from -1° left (at 5ft RA) continued to increase towards the right.
- MLG were recorded compressed
- VRTG reached +1.4G then MLG were recorded not compressed
- Ailerons started to be deflected in a right turn (and will be maintained in this order during the whole event)
- Ground speed was 99kt, heading increased from 084° to 087° in around 3 seconds then rudder started to be deflected to the left.
- From that time and until the complete stop of the aircraft on the left of the runway, rudder was always deflected to the left (it was consistent with efforts to the left and pedals to the left). The deflection reached the full deflection.
At 65kt Ground speed.
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- Power levers were moved from Flight Idle to REV in one second and during one second.
- Then power levers were moved forward to ground idle
Reaching 38kt Ground Speed
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- Power levers were moved to REV and maintained in this position until the complete stop
- Aircraft stopped at the edge of the taxiway with a heading at 010° (runway QFU was 091°)
3. SAFETY ACTION FROM THE REPORT
No safety actions have been identified by the Investigation board.
4. ATR RECOMMENDATIONS
“Should the aircraft drift from the centre line, rapid application of the brakes can be used to stop and secure the aircraft before further actions.”
- Threat and Error management (TEM) briefing principle have been put in place to enhance pilot reaction to unpredicted event. As such, ATR recommend the operator to put a particular focus on TEM briefing, especially during crosswind conditions.
- Part of the flight crew performance is ensured by the sterile cockpit philosophy. Sterile cockpit philosophy should be described in the Operating Manual and followed during operations.
- The report states that the captain (PF) asked the copilot (PM) to brake the aircraft which suggest he was not able to use the brakes. It is ATR recommendation to place the feet on top of the pedals to be able to use brakes when needed.
- The PM declares he did not notice the PF’s left rudder application. Good practices require the PM to place its feet on the pedal and follow PF actions on pedals to be able to detect and announce the deviation to finally recover if the error is not corrected.
- ATR suggests the operator to remind to it’s flight crew the feet policy on the pedals in relation to this event
5. FULL REPORT
