Narrative: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: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.
- 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
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» Accident report summary
METAR Weather report:
10:00 UTC / 18:00 local time: METAR RPMD 021000Z 14002 9999 TS BKN015 CB SCT090 BKN290 29/26 Q1008 CB SW-SE AND OVHD DIST PCPN NW LITS N
Winds: 140 degrees at 2 knots; Visibility: 6 or more miles (10+ km); Ceiling: 1500 feet AGL; Clouds: broken clouds at 1500 feet AGL, scattered clouds at 9000 feet AGL, broken clouds at 29000 feet AGL; Thunderstorm; Temperature: 29°C; Dewpoint: 26°C; Pressure: 1008.0 mb. Cumulonimbus clouds were to the southeast and southwest.
Follow-up / safety actions
The Civil Aviation Authority of the Philippines (CAAP) on June 25, 2013 found that both crew members were liable for non-compliance with a number of Philippine Civil Aviation Regulations (PCAR) relating to operation below Decision Height, failure to execute a go around and declaring an emergency evacuation fifteen minutes after the accident.
The captain has been suspended for six months and will act as co-pilot for one year after his airline transport pilot license has been reinstated by the CAAP.
The copilot was suspended for three months, subject to his compliance with the requirements for the reinstatement of his Commercial Pilot License.
AAIIB issued 6 Safety Recommendations
Show all AD's and Safety Recommendations
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This map shows the airport of departure and the intended destination of the flight. The line between the airports does not
display the exact flight path.
Distance from Manila-Ninoy Aquino International Airport to Davao City-Francisco Bangoy International Airport as the crow flies is 958 km (599 miles).