Airbus A320 takes off the WRONG way! Air Arabia flight 111

an aero arabia airbus a320 is getting ready for takeoff runway 3-0 in sharia the pilots are planning for an intersection takeoff but as they're entering the runway they turn the wrong way and start accelerating for takeoff how can something like this happen and what happened afterwards stay tuned [Music] a big thank you to magic spoon for sponsoring this video in this series i have featured a lot of both incidents and accidents and the reason i'm doing so is both to explain to you what actually happened and also to highlight how the aviation industry works with these kind of events in order to improve safety and make it safe for both you and me to travel by air it is never about pointing fingers or assigning blame it's always about why did this happen not who made this happen and this is something that i really want you to remember when i tell you this story on the 18th of september 2018 aero arabia airbus a320 was scheduled to fly from sharia international airport in united arab emirates over towards salala international airport in uman on board the aircraft there were 42 passengers four cabin crew members and two pilots the flight group consisted of a 51 year old captain who was very senior had a lot of experience on the aircraft and he was working as a line training captain just like i do and together with him on the day was a 34 year old first officer now she was doing her last stage of the mpl program multi-pilot license program and as part of that she had to operate for at least 100 sectors together with a commercial operator in this case aeroarabia now her training had been progressing really well and in the beginning of her training she had been operating with what we call a safety pilot that's a third pilot that sits together with the pilots in the cockpit up until the first officer has proven that in case of a pilot incapacitation if the captain would get sick for whatever reason she could operate the aircraft safely so she had proven that the safety pilot had been released and now she was flying by herself together with the captain the two of them had been operating for three days previously this was the fourth day of their roster together and they had been operating out of sharia as their home base which means that they had flown a lot in and out of there during the previous three days runway one two had been in use in sharia but on this fourth day the wind had slightly turned towards a north-westerly direction so runway 3-0 was going to be in use for the departure on that day now the weather in sharia was absolutely beautiful with some clear skies a temperature of 38 degrees so it was decided on an early stage that the first officer was going to be pilot flying for the first leg so the crew started to prepare in the cockpit for the departure first officer prepared for runway 3-0 departure check that the standard instrument departure was loaded into the fmc they did the performance calculations and when they did the performance calculation they did that from an intersection takeoff position bravo 1 four now this is something that we often do we try to take the performance from the closest available intersection that's so that if the cabin crew is ready and we are finished with our checklist or something we can minimize the taxi time and take off and if it turns out that we can't use that intersection we can always continue to taxi to full length and the performance will still be valid so runway 3-0 with the bravo 1-4 intersection would give an available takeoff distance of meters which was more than enough especially since the aircraft was quite light with only 42 passengers the takeoff speeds that they calculated was a v1 decision speed of 122 knots a rotation speed vr of 127 and a safe climbout speed v2 of 129 which are fairly low speeds because of the relatively low takeoff weight on top of this the crew also decided to use flex temperature this is a way to reduce the take of trust down to the minimum needed for that available takeoff distance and this is something that we do because we want to save on noise environmental impact and fuel and also the wear on the engine so in boeing we call this the assumed temperature in airbus is called a flex temperature it's basically the same thing at time 1220 utc air arabia flight triple 1 got clearance to push back from stand the captain was in charge of starting the engines and he started ending number one during the pushback but then he decided that he was going to start engine number two during taxi out so this is a procedure that some companies utilize once again to save on fuel and it means that one of the engines is going to be started during the taxi out or maybe even at the holding point doing so saves a bit of fuel but it also adds potentially a little bit of workload and something that you have to remember when you're doing this type of procedure which we don't do in my company by the way is that you always need to give the engine at least two minutes to warm up prior to setting take off thrust so this is mostly used where you have a very long taxi distance out to your takeoff position in sharia it's not the case we're only talking about a taxi distance of maybe three to four minutes in the air arabia airbus a320 fleet both the captain and the first officer have the ability to taxi the aircraft on the ground and the way that the standard operating procedures work is that the one who's going to be pilot flying for the subsequent flight is also the pilot who's going to be taxiing so in this case this was the first officer who was taxing the aircraft out and she was doing so while the captain was starting up engine number two during the taxi out possibly adding a little bit to the workload for both of them at this stage i've mentioned already that the first officer was on the training and when you're on the line training there's a list of items that you need to both practice and show that you're competent in in order to get them signed off and for your line training to be finished now one of those items is something called a rolling take-off this is where the aircraft assets lining up on the runway initiates the takeoff roll immediately without stopping on the runway it's very beneficial to do this especially during strong crosswinds because it can stop engine surges from happening for example but it's also just a good thing to do when there's high traffic density and you want to minimize your time on the runway so the crew had briefed before departure that the first officer was going to do this so it's likely that as she's now taxiing out she's thinking through how to properly do this what the standard operating procedures are how to and when to start moving the truss lever and so on another contributing factor to what is about to happen was that the air traffic control tower on sharia on this day was on the maintenance and instead they were using a standby tower now this tower was lower than the original tower and there was actually some light posts that were obscuring the view of the take-off positions specifically for bravo 14 where this aircraft is about to depart now this had been recognized the fact that it was lower so there had been cctv cameras installed on both runway ends pointing towards the runway but those cameras weren't showing all of the area around the intersections now before we go into the exact details of what happened when the crew started lining up i just want to share this short message from my sponsor who's making it possible for me to produce this type of material it's the beginning of the year and i'm trying to get back into shape again and when you're trying to lose a few kilos you realize very quickly that you can't eat almost anything everything is off limits and that's especially true when it comes to breakfast and breakfast cereal but then i remember that i was contacted by these guys magic spoon a few weeks ago and they claimed that they had these cereals that they'd made specifically for grown-ups which were no added sugar low carbs gluten free and and i thought yeah i'll give it a shot so they sent over a box and and it's true they are really really good me and my wife are actually fighting over them because we only have a few of these boxes left now if you want to check them out and really feel like a kid again when you're eating breakfast so then use this link here below which is madison.com left that'll give you five dollars of your first purchase and and i really recommend that you go and check them out at time 12 24 and 21 seconds aeroarabia flight triple 1 has reached the hall in position at bravo 1-4 the captain switches from the ground atc controller to the tower agency controller and he calls up telling the tower that they are ready for departure the tower controller responds to this message saying that air arabia flight 111 is now clear for takeoff from with three zero surface wind is three three third degrees at 11 knots the crew reads back this clearance and starts moving the aircraft the tower controller then goes on to speak to some of the other aircraft which is at a holding point further down the runway the first officer now releases the parking brake adds a little bit of thrust the aircraft starts moving past the holding position at bravo 1-4 to watch the runway and as she's doing this she is also calling for the captain to execute to before take off checklist below the line this is the part of the checklist that we do as we're entering the runway and it includes items like putting the strobe lights on for example and selecting the outer brake selector to max in the case of the airbus 320. only a few seconds after the aircraft starts moving the flight data recorder indicates that the auto brake selector is moved to max showing that the checklist is well on the way of being completed as the aircraft is now moving out towards the runway there are clear signs on the sides of the taxiway which indicates which runway is going in which directions there are also lead-on markings and lead on light but the lights are turned off at this stage because it's daylight as they're coming out onto the runway now the first officer instead of turning left to line up with runway 3-0 now turned right and that means that she's now lining up in the direction of runway 1-2 but since they're taking off from a intersection they only have about 1 000 meter until the end of the runway this is not noticed by the captain the first officer who is now turning in the same direction that she has been doing on the previous three days this time the wrong direction is likely focused on synchronizing the turn with her trust level movements to make sure that the aircraft doesn't stop and that she performs a rolling takeoff just like you had been discussing before now there are numerous ways to see that they're on the wrong take-off position here including markings on the runway for example but since they're taking off from an intersection she wasn't expecting to see for example the runway three zero markings that would be further down the runway but there are other indicators like for example the touchdown zone marking for runway three zero in any case the turn is continued towards the right and for some reason the captain seemed to be preoccupied by something inside of the cockpit because he's not looking out at this point here you'd be right to ask isn't there any system available that can warn the pilots that are about to make a mistake like this and yes there is there is a system called wrath which stands for runway awareness and advisory system that system works together with the gps and the internal nav database to tell the pilots where they are in reference to runways for examples and taxiways so in this case if ras was installed the aircraft would have told them that they are on runway 1-2 and that is 1030 meters available and that would obviously be a big warning sign to them that something is obviously wrong there are other numerous really good applications of ras as well they can tell you that you're about to take off in a taxiway it can tell you when you're coming in for landing that you have an unstable approach or that you have a too long landing there's numerous applications it's a fantastic system but it's not installed on this aircraft there's also an internal airbus system called takeoff surveillance system that works together with the ecam messaging to tell the pilot that they're not on the correct runway if the system feels that takeoff trust is being set but not in the position that has been pre-programmed into the fmc but this system is not installed either on this aircraft instead the first officer as she sets tech of trust goes over and she starts reading out the flight mode announciations from her primary flight display this is standard operating procedure in aeroarabia and when she comes to the point where runway should be enunciated that box is blank so that is a clear indication that the aircraft thinks that they're not on the correct take-off runway so the first officer calls this out to the captain and here is where the captain realizes what is about to happen the aircraft is now accelerating through around 50 knots and as they pass 57 knots the captain takes a very curious decision because at this point he reaches over takes control of the aircraft and adds maximum trust now at this point there's actually about 730 meters left of the runway and he has at 57 knots so why would he take the decision to start accelerating rather than rejecting the takeoff well one thing that you have to be aware of of this runway is that the landing runway 3-0 has something called the displaced threshold this means that the landing distance available is shorter than the takeoff distance available so the threshold markings for runway 3 0 will come about 300 meters into the runway so from the captain's perspective what he's seeing now as he's looking up and he realizes and he gets the startle of oh we're about to take off on the wrong one runway is that he sees the threshold markings coming and that's likely much much more closer than the 730 meters he actually has available said and on the aircraft is now accelerating further down the runway and at 109 knots that's nine seconds after he took the decision to continue the takeoff he reaches over and he select flaps two instep of laps one this is likely because he realizes that runway is just too short and he wants to get a little bit more lift so that will enable him to rotate the aircraft a little bit earlier and get it airborne the aircraft finally takes off about 30 meters into the stopway so that's 30 meters after the end of the runway the speed when they take off is about 132 knots and when they do the right main gear slams into one of the approach lights for runway 3-0 damages the approach light obviously but also makes a couple of deep cuts into the number three main wheel but air traffic control doesn't realize this until well later and the flight crew doesn't feel that this is happening so what options did the captain have in this case then well later simulations of this incident show that if the captain would have selected to reject the takeoff just close the trust levels and select maximum reverse trust that would have given him maximum outer brake at that point and the aircraft would have come to a complete stop well before the end of the runway and these simulations they actually showed as well that if he would have taken the decision to reject the takeoff at 100 knots so that's about seven seconds after he made the decision to go the aircraft would still have had enough distance to stop within the available runway distance and the reason they checked it at 100 knots is because that's where on the airbus a320 the aircraft goes from the low speed regime during which you are really supposed to be able to reject for anything into the high-speed regime where you should be more gold-minded and bring the aircraft into the air so even when the captain reached over to select flaps 2 he was in a position where he could have successfully rejected the takeoff but that did not happen instead the aircraft now start to climb out air traffic control has been trying to reach the aircraft during the takeoff roll there was no response back then but then as the aircraft gets airborne they call once again and this time the captain answers the call so what about the first officer then what was she doing well during the takeoff role when she realized that they were taking off in the wrong direction and the captain subsequently took over controls she froze up due to the sheer stress onset and the startle effect and what you should know as well is that the standard operating procedure for takeoff in the airbus is that the pilot flying should apply nose down pressure on the control stick on his or her side they should keep that to about 60 knots up to about 80 knots where they should lightly let go of the forward pressure in this situation where this was all happening and the the whole situation was developing as fast as it did she was actually sitting with that same amount of forward pressure and because the captain had not formally taken controls he had neither said my controls he hadn't said go which is also the decision when you say either go or stop in a situation where that kind of decision making needs to happen there was some confusion about who had the control so the first officer was still remaining with forward pressure on her control stick all the way until rotation now the captain had the ability to press his priority button and if he would have kept that pressed for 40 seconds that would have given controls over to him but that didn't happen either so in those type of situations the flight control computer will try to average out the input from the right and the left side stick but the first officer did let go of her side stick as they started rotating if he would have clearly said my controls that would have likely walked in the first operator up from her startle because she is then expected to say you have control and then you can go into some kind of normalcy even though this was a very extreme situation but the story doesn't end here during the takeover air traffic control had tried to contact the aircraft but they didn't get a response back after rotation when the aircraft was already airborne air traffic control called them up again and this time the captain did respond to the radio call air traffic control then informed them that runway 3-0 is in use just not much use at that point but there was no further discussion about why this had actually happened air driver control had not noticed that the aircraft has actually damaged the approach lighting system so that information was not given to the flight crew instead they were handed over to the departure control and departure control just gave them on route clearance to continue on the route towards oman it doesn't seem to have been any more discussion happening between neither the pilots and air traffic control or via the pilot to their company headquarters about this incident when it came to the status of the first officer the first officer was severely shaken by this and it is likely that she wouldn't be in a capacity or in a frame of mind to continue to work in her role as pilot monitoring even less as pilot flying but even though this flight continued to watch oman and the captain handed over the controls back to the first officer and she then operated as pilot flying for the remainder of the flight in the subsequent investigation there was some discussion about whether or not this aircraft should have just leveled off and got back in and landed again because of the you know state of the first officer but it was also noted that there was no real guidance to fly through on how to act in situations like this when one of the flight crew members had degraded performance but wasn't incapacitated and this was one of the findings by the investigation that airlines needed to give better guidance to their pilot on when it would be suitable to actually return because of the state of mind of one of the flight crew members when the aircraft landed in oman the crew was contacted by arabia operations control which had been made aware of the incident and they were offered to travel back as passive passengers on a different flight but the captain went out he did a walk around of the aircraft he did not find the damage of the number three main wheel because likely those cuts was actually on the downside of the wheel so he said well there's nothing wrong with the aircraft and we are fully capable to operate back so they operated back again a very unfortunate consequence both of the aircraft continuing to the destination and also by flying back home again was that the cockpit voice recorder was erased for the incident it only covers the last two hours of the flight and since this flight was more than two hours long it meant that there was no record of this so that couldn't be used for the subsequent investigation however the flight data recorded could be and of course you also had the witness statement of the air traffic controller and the both pilots that were involved so what did we learn from this serious incident then well first of all that systems like ras the runway awareness and alerting systems are very good systems to have installed in my airline we have them installed on all of our aircraft and they serve as a great tool and a last barrier to keep incidents like this from happening in the first place secondly we also need to as pilots be aware that pilots on the training will make mistakes that's part of your learning process this first officer had no intention of taking off in the wrong direction but she likely did so because she turned in the same direction that she had been doing the last couple of days when runway 1 2 was in use and she was likely concentrating on doing the rolling takeoff part of the takeoff as good as she probably possibly could and this is why it is so important that we stick to standard operating procedures that we brief before we go you know which runways you use how are you supposed to turn what kind of signage are you expecting what kind of runway markings are you expecting so the whole anticipation of the flight and the briefing part is really really important the investigation also highlighted that the use of single engine taxi out and one engine started during taxi could potentially add workload and in a training situation it might not be the best thing to do there was also mentioning about the performance software how it would be good if it would graphically show the pilots what the accelerated stop distance actually was to re-emphasize for in this case the captain how much distance he actually needed to stop the aircraft from different speeds but what i really want to highlight with this video is that everyone can make a mistake it is human to make mistakes but it's up to both the airline procedures the systems we have installed in the aircraft and of course the vigilance of the pilots to stop these things from happening now if you want to see another video where a pilot got really startled and it led to a very serious event then check out the video up here if you want to support me in the work that i do consider becoming a part of my patreon crew or get yourself some merch have an absolutely fantastic day and remember the acronym class [Music]

Channel: Mentour Pilot

Views: 2,342,991

Keywords: captain, mentour pilot, mentor pilot, crash investigation, full epsiodes, aviation, pilot, crash, air crash investigation, final report, boeing, airbus, piper, cessna, disaster, fatal crash, air incident, air disasters 2022, air arabia flight 111, air arabia, A320 takeoff, a320, united arab emirates, dubai, cockpit a320, air arabia a320, short takeoff, wrong turn

Id: tXGET4-N9FA

Length: 23min 31sec (1411 seconds)

Published: Sat Feb 05 2022