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Events from Jun 19th 1999 to Sep 29th 2020 www.avherald.com Incidents and News in Aviation List by: Filter: Incident: Singapore B773 at Munich on Nov 3rd 2011, runway excursion

By Simon Hradecky, created Monday, Jan 30th 2012 14:22Z, last updated Monday, Jan 30th 2012 14:22Z The German Bureau for Aviation Accident Investigation (BFU) released their investigation status report in their monthly bulletin in German reporting on approach the crew decided to perform a fully automatic landing into Munich's runway 08R when it became clear the weather conditions were below the limits that permitted the the first officer, pilot flying for the leg, to fly the landing.



The captain (45, ATPL, 12,416 hours total, 4,712 hours on type) became pilot flying, the first officer (35, ATPL, 3,681 hours total, 3,681 hours on type) became pilot monitoring. The airport was operating according to CAT I standards (no low visibility procedures in use). The aircraft was cleared for an ILS approach to runway 08R.



When the Boeing 777-300 was about 2.1nm before touch down a BAe Avro began its takeoff run on runway 08R. The Boeing 777 was subsequently cleared to land on runway 08R, winds from 130 degrees at 7 knots. When the Boeing 777-300 crossed the runway threshold, the Jumbolino was climbing out still short of the runway end.



A number of aircraft were holding before the CAT II/III hold short lines (outside the runway protected area).



6 seconds after the Boeing crossed the threshold the Jumbolino crossed the runway end, at the time of touchdown of the Boeing the Jumbolino was climbing out just past the runway end, 26 seconds after the Boeing crossed the threshold the Jumbolino overflew the localizer antenna in a height of 740 feet.



When the Boeing 777-300 descended through 30 feet AGL, the aircraft began to roll left, the left main gear touched down first about 490 meters/1610 feet past the threshold, the autopilot changed into roll out mode. The aircraft rolled towards the left edge of the runway and crossed the runway edge at about taxiway B4 1100 meters/3610 feet down the runway. At this point rudder inputs by the crew prompted the autopilot to disengage. The aircraft rolled in a slight right turn over grass for about 400 meters/1310 feet, reaching the farthest point of excursion to the left 1300 meters/4260 feet past the runway threshold, before it crossed the runway edge again onto the runway and crossed the runway at a track of 121 degrees magnetic crossing the right runway edge 1620 meters/5310 feet down the runway. The aircraft came to a stop south of the runway on grass about 60 meters off the runway and 1780 meters/5840 feet past the runway threshold.



Emergency services arrived about 2 minutes after landing, the passengers disembarked via two mobile stairs provided by fire brigades. No injuries occurred, the aircraft received no damage, there was only some dirt on the landing gear. The tracks in the grass had a maximum depth of 15cm (6 inches).



The BFU reported the captain said in an interview that he attempted a go-around when the aircraft began to roll left, according to his testimony he pressed the TO/GA button, the aircraft however did not respond. The captain also said that he retracted the ground spoilers that automatically extended upon touchdown.



The BFU reported that the flight data recorder showed all three ILS receivers recorded localizer signal deviations in both directions about 14 seconds before the autopilot changed into roll out mode, about 6 seconds prior to the roll out mode the localizer deviation increasingly showed a deviation of the aircraft to the right of the extended center line. The aircraft began to roll left in response to autopilot inputs to minimize the localizer deviation and reached 3.5 degrees bank angle to the left when the autopilot changed to roll out.



There were no indications of the TO/GA button being pressed on the flight data recorder, the flight data recorder showed that the ground spoilers extended about 2 seconds prior to the autopilot changing to roll out and retracted 10 seconds later. The cockpit voice recorder captured the captain commanding "flaps 20" and several sounds that were consistent with the TO/GA button being pressed two times and the speed brake handle being moved.



Aerial overview (Photo: BFU/Police):





Ground track of aircraft (Graphics: BFU):



By Simon Hradecky, created Monday, Dec 17th 2018 16:15Z, last updated Monday, Dec 17th 2018 16:15Z



Immediate Causes:



- The crew decided to conduct an automatic landing even though the conditions on the ground for a safe conduct were not given.



- Shortly before touch-down the airplane was deviated to the left of its flight direction by the disturbed LOC signal. A BAE 146-RJ85 taking off a short distance ahead of the B 777 caused the interference.



- The two pilots could not keep the airplane on the runway after touch-down because the autopilot was still engaged.



- The crew was confused by the behaviour of the airplane. They had not noticed that the go-around mode had already been deactivated by the initial touchdown of the left main landing gear.



Systemic Causes:



- The recommendation concerning the conduct of autoland landings under CAT I conditions published in the FCOM of the operator allowed the decision for an autoland landing without having to consider the required conditions on the ground.



The BFU analysed:



After analysing and assessing the facts, the BFU came to the conclusion that the airplane veered off the runway because the localizer signals had been distorted by a departing aircraft. All three receiver antennas of the airplane received identical signals from the localizer on the ground so that on board no malfunction was indicated. Because there was only a short interference of the localizer signal neither the near field nor the far field monitor - which monitor the proper function of the ILS - registered a malfunction of the ILS. This means, the airplane followed the localizer signal.



The crew only realised about 30 ft above the runway that something was not correct as the airplane slightly banked to the left and then drifted left. The left main landing gear touched down directly afterwards which resulted in the disengagement of the go-around mode. This prevented the crew from being able to initiate an automatic goaround.



Crew Behaviour



The preparation and conduct of the approach and the intended automatic landing were in accordance with the valid flight operations procedures of the operator. The fact that both pilots had arrived from Singapore two days prior to this flight suggests that, at the time of the occurrence, they did not experience an increase in psychological stress due to jet lag. The flight occurred at a favourable time for the crew - in Singapore it would have been afternoon - and therefore fatigue is not really feasible.



The crew did not inform the approach controller of their intention to conduct an automatic landing.



The crew knew that under the prevailing CAT I flight operations the safety measures of all-weather operations CAT II/III were not present.



Therefore, the crew had to take into consideration that ILS interferences due to other airplanes on the ground or in the air were possible.



Based on the crew statements the BFU is of the opinion that the crew was prepared to initiate a go-around procedure in case of an incident. The PIC stated that as the airplane dipped the left wing shortly before touch-down he wanted to initiate a goaround and pushed the TO/GA button. Even though the PICs command Okay, flaps twenty. did not completely meet the requirements of the standard phraseology for a go-around Go-Around Flaps 20 it was his command to go-around. The analysis of the FDR showed that the co-pilot did not set the flaps to 20°. The crew stated that in their estimate a go-around procedure initiated manually with an airplane already on the ground would have been much more dangerous than remaining on the ground.



The FDR analysis in combination with the sonogram indicates that the TO/GA button was pushed simultaneously with the initial ground contact of the left main landing gear. The crew anticipated that the Go-Around Mode would initiate a go-around, but nothing happened. The Go-Around Mode had deactivated as designed by Boeing (system logic) by the initial ground contact of the main landing gear.



The PIC realised that the ground spoilers had already been deployed automatically and retracted them manually. This would not have been necessary. Had he pushed the thrust levers forward the ground spoilers would have been retracted automatically and the autobrake function deactivated.



The BFU is of the opinion that both pilots, the PIC due to him being an instructor pilot and the co-pilot having enough flying experience on type, were sufficiently familiar with the go-around procedure. These procedures were sufficiently described in the FCTM and had been trained sufficiently in the simulator in accordance with effective regulations.



Relocation of the Instrument Landing System



At Munich Airport the localizer antennas were moved from 350 m to 1,000 m beyond the runway threshold. The air traffic service provider stated that it had become necessary because of the Airbus A380 operation to prevent localizer interferences through reflections off airplanes.



The BFU is of the opinion that the position change of the LOC antenna effected the separation of approaching and departing aircraft. In order to prevent interferences with the LOC antenna separation inevitably would have to be increased. Furthermore, the broadcast antenna diagram has to be pooled better by about 3.6° to ensure the required accuracy for CAT II and CAT III approaches which results in an increase in energy supply by approximately 0.1 W.



Behaviour of the Air Traffic Controllers



The controller stated that he had been under a high workload, because of all-weather operations in the morning (CAT II/III), delays had occurred which, at the time of the occurrence, resulted in an increased departure rate in combination with approaches on runway 08R. This forced the controller to work on the edge of the separation minimum so that aircraft waiting to depart could do so quickly and traffic situation would become normal. Since the controller did not have any information that the crew intended to conduct an automatic landing he did not separate the aircraft in accordance with the required separation minima for CAT II/III but for CAT I conditions; i.e. separation between departing and approaching aircraft was one runway length. The air navigation service provider stated that if the controller had been informed he would not have allowed the BAE 146-RJ85, waiting on taxiway B4, to take off ahead of the B 777.



At the time of the occurrence the provision phase for CAT II/III was still active even though the weather situation would have allowed for the cancellation of all-weather operations CAT II/III in accordance with the Manual of Operations Air Traffic Services (MO-ATS). Air traffic had already begun to separate the aircraft in accordance with CAT I. Provided the crew had informed the controller about the planned autoland the option would have existed to return to CAT III operations. This would have been possible with relatively little effort because the protection zones were still free since the change from CAT II/III to CAT I conditions and the waiting departing aircraft still stopped at the CAT II/III holding point.



...



The investigation determined that autoland landings under CAT I conditions are conducted without informing air traffic control. If an international regulation for such cases existed that air traffic control had to be informed about an intended autoland the controllers would have been better prepared and might have made appropriate preparations.



If the airport does not operate on LVP, it should become global standard to inform air traffic control on time about an intended autoland landing.

On Dec 17th 2018 Germany's BFU released their final report concluding the probable causes of the serious incident were:The BFU analysed: By Simon Hradecky, created Thursday, Nov 3rd 2011 13:53Z, last updated Thursday, Nov 3rd 2011 13:53Z



Munich's southern runway was closed until about 19:30L (originally estimated until 22:00L).



A number of passengers reported in common, that the aircraft touched down unusually hard, veered to the left exiting the runway to the left, then veered right and crossed the runway before coming to a stand still right off the runway. After about 15 minutes the passengers disembarked through the two forward left hand doors, there was no visible damage to the aircraft. The onward leg to Singapore was cancelled, the passengers are currently being rebooked onto other flights to Singapore.



Observer "Flyer" on the ground said the aircraft touched down past the 1000 feet marker but within the touch down zone, veered left beyond the left runway edge onto grass between taxiways B4 and B6, then veered right and went across the runway exiting the runway to the right before coming to a stand still.



The incident aircraft was able to leave Munich for Singapore as flight SQ-327F on Nov 5th.



Metars:

EDDM 031320Z 08010KT 9000 FEW007 BKN230 07/05 Q1009 NOSIG

EDDM 031250Z 08008KT 7000 SCT007 SCT230 07/06 Q1010 NOSIG

EDDM 031220Z 09008KT 7000 SCT005 SCT230 05/05 Q1010 NOSIG

EDDM 031150Z 08007KT 4000 BR OVC004 05/05 Q1010 BECMG 5000 SCT005

EDDM 031120Z 07010KT 2200 BR OVC003 05/05 Q1010 BECMG 3000 OVC005

EDDM 031050Z 10008KT 2000 BR FEW002 OVC003 04/04 Q1011 BECMG 3000 OVC005

EDDM 031020Z 09009KT 1900 BR SCT002 OVC003 04/04 Q1012 NOSIG

EDDM 030950Z 11007KT 1500 BR FEW001 OVC002 04/04 Q1012 NOSIG



Relevant NOTAM:

A4459/11 - RWY 08R/26L CLSD DUE TO DISABLED ACFT. 03 NOV 11:57 2011 UNTIL 03 NOV 21:00 2011 ESTIMATED. CREATED: 03 NOV 11:58 2011



Video of touchdown and rollout (Video: MucAviation):

https://www.youtube.com/watch?v=0rn-iI7wX-Y



9V-SWQ right of runway 08R (Photo: Moddin):





Map (Graphics: AVH/Google Earth):







A Singapore Airlines Boeing 777-300, registration 9V-SWQ performing flight SQ-327 from Manchester,EN (UK) to Munich (Germany) with 143 passengers and 15 crew, veered right off runway 08R while landing in Munich at about 12:10L (11:10Z) and came to a stop with all three gear off the paved surface. The passengers disembarked via mobile stairs, no injuries occurred.Munich's southern runway was closed until about 19:30L (originally estimated until 22:00L).A number of passengers reported in common, that the aircraft touched down unusually hard, veered to the left exiting the runway to the left, then veered right and crossed the runway before coming to a stand still right off the runway. After about 15 minutes the passengers disembarked through the two forward left hand doors, there was no visible damage to the aircraft. The onward leg to Singapore was cancelled, the passengers are currently being rebooked onto other flights to Singapore.Observer "Flyer" on the ground said the aircraft touched down past the 1000 feet marker but within the touch down zone, veered left beyond the left runway edge onto grass between taxiways B4 and B6, then veered right and went across the runway exiting the runway to the right before coming to a stand still.The incident aircraft was able to leave Munich for Singapore as flight SQ-327F on Nov 5th.Metars:EDDM 031320Z 08010KT 9000 FEW007 BKN230 07/05 Q1009 NOSIGEDDM 031250Z 08008KT 7000 SCT007 SCT230 07/06 Q1010 NOSIGEDDM 031220Z 09008KT 7000 SCT005 SCT230 05/05 Q1010 NOSIGEDDM 031150Z 08007KT 4000 BR OVC004 05/05 Q1010 BECMG 5000 SCT005EDDM 031020Z 09009KT 1900 BR SCT002 OVC003 04/04 Q1012 NOSIGEDDM 030950Z 11007KT 1500 BR FEW001 OVC002 04/04 Q1012 NOSIGRelevant NOTAM:A4459/11 - RWY 08R/26L CLSD DUE TO DISABLED ACFT. 03 NOV 11:57 2011 UNTIL 03 NOV 21:00 2011 ESTIMATED. CREATED: 03 NOV 11:58 2011Video of touchdown and rollout (Video: MucAviation):9V-SWQ right of runway 08R (Photo: Moddin):Map (Graphics: AVH/Google Earth):

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