ROYAL AIR MAROC OVERVIEW OF THE INVESTIGATION PROCESS RUNWAY 35L - - PowerPoint PPT Presentation

Département Système de Gestion de la Sécurité

MENASASI SEMINAR 21 SEPT 2016

DIRECTION QUALITE SURETE SECURITE

ROYAL AIR MAROC

OVERVIEW OF THE INVESTIGATION PROCESS RUNWAY 35L SIDE EXCURSION EVENT B 737-800 LOCATION :CASABLANCA MOHAMED V - 17 JUNE 2015

Summary

• 1. Internal and External Notification Process
• 2. Data Collection
• 3. Analysis
• 4. Conclusion & Safety Recommendations

OVERVIEW OF THE INVESTIGATION PROCESS MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Internal and External Notification Process / Airline Alert Process

The Commander must notify The Manager On Duty of the OPERATIONS CONTROL CENTER (OCC) by any available means

• f any accident or serious incident occurring while he was responsible for the flight.

The Operations Control Center OCC Duty Manager is responsible for initiating appropriate response to incidents, accidents, and other significant events that involve RAM aircraft, facilities, passengers, employees, and any RAM code share carrier operations in accordance with the EMERGENCY OPERATIONS MANUAL.

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Internal and External Notification Process / BEAM Notification

EMERGENCY OPERATIONS MANUAL : Scenario ref 1091 ; Response level 1 ( Notification Required only according to the notification tree in appendix D) The SMS Department of Royal Air Maroc must then notify the “ Bureau d’enquête et d’analyse d’Accidents et Incidents (

• r BEAM)” and DAC Maroc and / or the relevant State by the quickest means available of any accident or serious incident

and, in the case of accidents only, at least before the aircraft is moved unless exceptional circumstances prevent this. Royal Air Maroc must submit a report to BEAM within 72 hours of the time when the accident or serious incident

• ccurred.

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Data Collection / Airport Layout

OVERVIEW OF THE INVESTIGATION PROCESS

Taxiway Mike at 2800m from threshold RWY 35L where the side excursion took place

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Data Collection / Flight Data 1st To be Received

Smart PCMCIA Card (called SPC): WEFA (Wireless Extension For ACMS) card, SPC, is the wireless extension for aircraft condition monitoring system (“ACMS”) card to be inserted into the DFDAMU (Digital flight data acquisition & management unit) WR (WEFA READY) front slot and in which a SIM card with a quad-band chipset is inserted to allow wireless communication with the ground using 3G technology. All B 737 NG equipped with a DFDAU SAGEM ED49 WEFA READY (“WR”) (261303876-1000) Media : Smart PCMCIA Card (called SPC) with 2 GB capacity

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Data Collection / Flight Data 1st To be Received

FDA Factual Information

• 1. The approach was stable with a normal landing and the

AUTOBRAKE selected at 2.

• 2. During the deceleration phase, the AUTOBRAKE has been

deselected at 58 Kts Ground Speed, the Speed Brakes were stowed and reversers set to FWD IDLE at the same time while decelerating through 48 Kts GS.

• 3. The right turn to vacate via taxiway Mike at 2800 meters from

the threshold was initiated at 35 Kts GS.

• 4. During the turn when passing through HDG 018°, Lateral

acceleration has peaked to 0.211G (Level 2 event per FDA program) while decelerating through 23.5 Kts GS.

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Data Collection / Flight Data 1st To be Received

FDA Factual Information

• 5. At the same time, the longitudinal acceleration dropped to zero in correlation with the

recorded brake pedal pressure: no more braking.

• 6. Right Rudder pedal was then locked hard to the right with light braking.
• 7. Runway side excursion occurred as the aircraft hit a small side walk where the normal

acceleration recorded a low of 0.756G followed by a peak of 1.3G.

• 8. Heading was 040° and GS was 22 Kts at the time of the excursion.
• 9. Crew managed to steer the aircraft back onto the paved surface of the Taxiway and

brought it to a standstill at a Heading of 100°.

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Data Collection / Damage assessment
• Both nose wheels were severely damaged as a result of the collision with the small

sidewalk.

• Also wheels 1, 2 & 3 had cuts that were out of tolerance.
• 1 Blue taxiway edge light destroyed

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Data Collection / Crew Interview & Reports

Flight crew’s were requested to submit a written report for the following day and were at the same time interviewed: Highlights from the Captain’s report and interview 1) They perceived to have initiated the right turn to vacate the runway onto Mike at a Ground Speed of 25 Kts 2) They felt pressured to vacate the runway as quickly as possible due to a company traffic behind to avoid him a Go-Around . 3) They believed something was wrong with the steering system of the aircraft. Highlights from the First officer’s report and interview The first officer basically said that that once on the ground, the aircraft was under the Commander’s Control and that while initiating the turn to vacate the Runway, the Commander spoke up about the loss of control on the aircraft’s tiller.

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Data Collection / FSTD simulation of the same event

Following their interview on the same day, the same event was reproduced three times on a FSTD exacltly the same way as what had been revealed by the Flight Data. The crew was unable to control the aircraft with the Tiller and each time veered off the runway.

• 1. Data Collection / Documentation

17/06/2015 11:00-> METAR GMMN 171100Z 33005KT 250V030 CAVOK 27/15 Q1016 NOSIG= Technical Log Book, Loadsheet, Operational Flight Plan, Hold Item List, AAB similar investigations

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 1. Data Collection / Maintenance inspections

No defect found on the nose wheel steering system as well as on the aircraft’s Tiller Last C Check (C06) on the 02 mai 2015, the latest maintenance inspections were performed relative to the landing gear :

• Perform a detail visual inspection of the nose wheel steering mechanical control path and rudder pedal steering

interconnect control path including rotary actuator.

• Perform a detail visual inspection of the nose wheel steering actuator rod ends and associated hardware

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 2. Analysis / Risk Controls

The BOEING operations manual stated that a ground speed of approximately 10 kt should be used for making a turn from runway on to dry a non high-speed taxiway, such as Taxiway Mike at Casablanca. The aircraft commenced the turn from the runway at around 36 Kts Ground Speed. The Commander stated that he did not want to cause the following aircraft to go- around by occupying the runway for too long. However, the commander would not have known how far behind the following aircraft was or how much time remained to vacate the runway without affecting its approach.

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 2. Analysis / Threat and Error Management & Organizational influences

Airport threat: Casablanca Mohammed V a Major Hub with heavy traffic during peak hours 07:00 ; 11:00 & 19:00 but no suitable High Speed Turnoff taxiway. Taxiway Papa and Mike on runway 35L are respectively at 1500 m (too close) & 2800m ( too far) down the runway. Occasional Operational pressure on Pilots to expedite vacating the runway and avoiding low taxi speed until the Runway is vacated. Aircraft Handling Errors: Fast Taxi Speed Extract from LOSA 2014 report “Most Frequent: Fast Taxis (Intentional and Unintentional) were logged on 11% of flights and two-thirds of them were coded as undesired aircraft states due to excessive speeds. During landing on 35L, Taxiway P is not designated as a high speed turnoff. Normal taxi speed must be resumed before exiting at P. The Captain made the exit at 45 knots. “

OVERVIEW OF THE INVESTIGATION PROCESS

MENASASI SEMINAR 21 SEPT 2016

RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015

• 3. Conclusion

The aircraft departed the paved surface of the taxiway because it turned to vacate the runway at a speed too high for the conditions.

• 4. Safety Recommendations

OVERVIEW OF THE INVESTIGATION PROCESS

Safety Communication : Risk awareness through an adequate safety bulletin sharing this event Training and Checking : Strict enfoncement of OEM BOEING taxi speed recommandations as follows Taxi Errors notation

• Tolerance 10 to 12 Kts ;
• 13 to 15 Erreur code 2 acceptable with debrief;
• 16 Kts UAS Error Code 1 Fail

External: Lobby for the construction of a HST at CASABLANCA MOHAMMED V