Incident Overview

Date: Sunday 2 June 2013
Aircraft Type: Airbus A320-214
Owner/operator: Cebu Pacific Air
Registration Number: RP-C3266
Location: Davao City-Francisco Bangoy International Airport (DVO) – ÿ Philippines
Phase of Flight: Landing
Status: Substantial, repaired
Casualties: Fatalities: 0 / Occupants: 171
Component Affected: Aircraft Landing Gear (Left Main Gear, Nosegear, and Right Main Gear)Aircraft Landing Gear (Left Main Gear, Nosegear, and Right Main Gear)
Category: Accident
An Airbus A320 passenger plane sustained damage during a runway excursion accident at Davao City-Francisco Bangoy International Airport (DVO). The flight, a domestic service from Manila (MNL) to Davao City, experienced a near-miss landing due to a misjudgment of the runway and a series of errors by the pilots. The aircraft touched down on the right-hand portion of the runway, resulting in significant damage to the landing gear. The aircraft subsequently rolled, causing further damage to the nosegear and left main gear. The pilots’ actions, including a failure to maintain a stable landing approach and a misinterpretation of the runway centerline, contributed to the accident. The incident highlights the potential for human error, pilot skill degradation, and inadequate procedures, particularly in challenging weather conditions.An Airbus A320 passenger plane sustained damage during a runway excursion accident at Davao City-Francisco Bangoy International Airport (DVO). The flight, a domestic service from Manila (MNL) to Davao City, experienced a near-miss landing due to a misjudgment of the runway and a series of errors by the pilots. The aircraft touched down on the right-hand portion of the runway, resulting in significant damage to the landing gear. The aircraft subsequently rolled, causing further damage to the nosegear and left main gear. The pilots’ actions, including a failure to maintain a stable landing approach and a misinterpretation of the runway centerline, contributed to the accident. The incident highlights the potential for human error, pilot skill degradation, and inadequate procedures, particularly in challenging weather conditions.

Description

An Airbus A320 passenger plane sustained damage in a runway excursion accident at Davao City-Francisco Bangoy International Airport (DVO), Philippines. Cebu Pacific Air flight 5J-971 was a domestic service from Manila (MNL) to Davao City. The aircraft touched down on runway 23 at a point about 30 m before the marked touchdown point (TP) about 190 m from the threshold. The airplane came down on the right-half portion very near the right edge lights. The aircraft continued to the right edge of the runway until the right hand main landing gear fell-off the cemented runway at about 129 m from the touchdown point, followed by the nosegear and the left hand main gear about 511 m from TP. With all landing gears on the soft ground the aircraft rolled for about 330 m more with an indication of trying to return to runway and it momentarily crossed over the concrete entrance taxiway of the parking ramp before it made a full-stop on a grassy area ahead and near the runway, about 845 m from TP. The passengers deplaned via the forward left-hand evacuation slide, which was deployed about fifteen minutes after landing. PROBABLE CAUSE The Aircraft Accident Investigation and Inquiry Board determined that the probable causes of this accident are the following: – Pilots’ lack of event proficiency in low-visibility non-precision approach and landing at night. Human Factor. Pilot Error. Psychological (Psychomotor skill, recent experience). The PIC as pilot flying Pilot Flying (PF) failed to maintain a stabilized landing approach (under precipitation) until below the MDA so that moments before the touchdown (precipitation becoming heavy), the aircraft was still at left of runway centerline with the FO calling (to align) RIGHT which was done by PF but having lost grasp of the centerline, the correction exceeded the centerline with FO calling ( to correct toward the unlighted center ) LEFT but the aircraft already touched down aligned to the right edge lights that was misconstrued by the PF as the center lights ( based on the repeated expressions of the PF during the landing roll until the aircraft has fully stopped ). – The emergency procedure for go-around was necessary but not utilized. Human Factor. Pilot Error. Psychological (Learning, Emotion/ Mental Narrowed Attention) The pilot probably was experiencing Narrowed Attention due to apprehension by being acutely conscious of the difficulty ahead ( bad weather ). Added to this was his proficiency status ( one flight to Davao in last 3 months ) and at confusion to notice things in the periphery of his attention i.e., to execute a go-around and make another approach well-prepared on the techniques with lower precipitation level. Contributory Factors: – Adverse weather condition. Environmental factor. Natural Environment The weather condition severely affected the judgment and decision-making of the PIC even prior to the approach to land. Heavy rainfall obscured the horizontal visibility of the pilots preventing a clear view of the runway. – Absence of runway center lights. Environmental factor. Man-made Environment (Aerodrome) The PIC misconstrued the edge lights as the runway center lights. Low-visibility approaches require that these lights be present to help guide the pilots toward the runway center. – Inadequate CRM procedures. Human factor. Psychological. (Training) Standard and non-standard call-outs and responses are the hallmarks of an effective cockpit/CRM environment. There were lapses, omissions and contradictory words employed during the landing approach. – Inadequate pilot re-currency training methods. Human Factor. Psychological. (Training) Missed approach procedures during low-visibility non-precision approaches were seldom practiced during the re-currency training of the pilots. The over-use of baseline airports with runway center lights deprived the pilots the opportunity to hone their instrument flying skills in basic airports where they usually operate that has no center lights. – Lack of policy on the advisory role of air traffic controllers ( ATC ). Human Factor. Psychological. (Training) During adverse weather conditions the ATC has no participation in the safety decisions which would require runway closure during critical aerodrome conditions especially in environmental conditions below runway visual minima

Source of Information

http://www.caap.gov.ph/images/aaiib/2013acc/RP-C3266.pdfhttp://www.caap.gov.ph/images/aaiib/2013acc/RP-C3266.pdf

Primary Cause

Pilot Error ? Specifically, a failure to maintain a stable landing approach under adverse weather conditions, leading to a misjudgment of the runway centerline and a loss of control.Pilot Error ? Specifically, a failure to maintain a stable landing approach under adverse weather conditions, leading to a misjudgment of the runway centerline and a loss of control.

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