Département Système de Gestion de la Sécurité 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 MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015 Summary 1. Internal and External Notification Process 2. Data Collection 3. Analysis 4. Conclusion & Safety Recommendations MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS 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 of 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. MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS 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 ( or 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 occurred. MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015 1. Data Collection / Airport Layout Taxiway Mike at 2800m from threshold RWY 35L where the side excursion took place MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015 1. Data Collection / Flight Data 1st To be Received 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 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. MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015 1. Data Collection / Flight Data 1 st 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. MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS RUNWAY 35L SIDE EXCURSION EVENT B 737-800 – CASABLANCA MOHAMMED V 17 JUNE 2015 1. Data Collection / Flight Data 1 st 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°. MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS 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 MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS 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. MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS 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 MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS 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 MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS 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. MENASASI SEMINAR 21 SEPT 2016
OVERVIEW OF THE INVESTIGATION PROCESS 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. “ MENASASI SEMINAR 21 SEPT 2016
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