Narrative:Air Canada flight AC15, a Boeing 777-300ER, suffered a tailstrike while landing on runway 07R at Hong Kong-Chek Lap Kok International Airport.
The captain was the Pilot Monitoring (PM) and the Initial Operating Experience Training Captain for the first officer.
The crew anticipated an arrival and landing on runway 07L, however, there was a runway change to 07R. The weather was as expected with a wind velocity from 350 degrees at 12 knots.
The aircraft intercepted the ILS and was stabilised on the approach to runway 07R, on the correct descent profile with the autopilot engaged through 1000 ft. The FO disengaged the autopilot after descending through 500 ft. Following the reversion to manual flight, the approach profile became approximately half a dot above the glideslope.
At approximately 200 ft the aircraft entered into series of minor lateral roll deviations followed by a pronounced roll, first to the left and then to the right in response to the pilots control inputs.
In response to the increasing unstable oscillations neither pilot called for or initiated a go around, nor did the other two crew members in the cockpit. At the runway contact point, the aircraft was rolling left and then right with a high rate of descent and a nose high pitch attitude. This resulted in a hard landing with the right main landing gear contacting the runway followed by the left main gear while the aft lower fuselage contacted the runway surface.
The aircraft bounced with the right-hand main landing gear contacting the runway first. The aircraft bounced again, landing on the nose gear followed by both main gears.
After the runway contact and initial bounce there was no call for a go around and after touch down from the subsequent bounce the PM removed the PF's hand from the thrust levers and selected reverse thrust. There was no formal transfer of control and there was a further distraction when a beverage container was dislodged from the PF's holder and dropped on to the floor and the PF bent forward to retrieve it.
The aircraft then completed the landing roll and continued to the parking stand.
The flight crew had recorded the descent and landing using a GoPro or similar action cam mounted on the left hand cockpit side window (without authorization from the airline). The crew voluntarily provided the footage for the investigation.
Probable Cause:
Causes:
An unstable approach developed due to pilot induced lateral rolling oscillations which coupled with a high rate of descent resulted in an abnormal runway contact.
Contributing Factors:
1) Stabilised Approach Criteria
The late recognition by the PM that the stabilised approach criteria after the second (500 ft) arrival gate was outside the required tolerances.
2) Pilot Flying PIO Onset Recognition
The over controlling (high gain) by the PF resulted in PIO. There is no requirement for PIO onset recognition or recovery actions in the operators training procedures.
3) Go Around Decision
- The late recognition by the PM that the aircraft was in an unstable flight condition that should have resulted in an "unstabilised" or a "go around" call from the PM and required an immediate go around.
- The PF did not initiate a go around when the aircraft was in a PIO condition.
4) Pilot Flying Loss of Situational Awareness
Task saturation with the lateral oscillation and high gain corrections resulted in the high descent rate up to the runway contact point.
5) Pilot Monitoring Loss of Situational Awareness
Any decision to go around during the bounce was impeded due to the "startle effect", which delayed any response or action.
Accident investigation:
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Investigating agency: | AAIA Hong Kong  |
Status: | Investigation completed |
Duration: | 3 years | Accident number: | 05-2021 | Download report: | Final report
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Classification:
Tailstrike
Runway mishap
Sources:
» TSB A18F0282
METAR Weather report:
06:00 UTC / 14:30 local time:
VHHH 110630Z 33012KT 9999 FEW040 18/10 Q1020 NOSIG07:00 UTC / 15:00 local time:
VHHH 110700Z 33016KT 9999 FEW040 18/10 Q1020 NOSIG
Follow-up / safety actions
AAIA issued 7 Safety Recommendations
Issued: -- | To: Air Canada | 12-2021 |
It is recommended that Air Canada consider recognition and awareness training for Pilot Induced Oscillation (PIO) during the training process, in particular as a component for pilots converting across type. (Accepted - closed) |
Issued: -- | To: Air Canada | 13-2021 |
It is recommended that Air Canada consider awareness training for crew qualifying as IOETC to emphasise the requirement to monitor and recognise situations where the control of the aircraft may be compromised. This should also include guidance when the trainee is new to the type. (Accepted - closed) |
Issued: -- | To: Air Canada | 14-2021 |
It is recommended that Air Canada consider reviewing and where necessary revise the unstabilised approach criteria and the requirements for a go around to be carried out, setting out the requirements in a clear and unambiguous format to avoid any confusion that flight crew may have in interpreting them and the crew actions required. (Accepted - closed) |
Issued: -- | To: Air Canada | 15-2021 |
It is recommended that Air Canada consider reviewing and where necessary revise the formal handover of control criteria contained in the FOM incorporating the method when a pilot takes over control I have control/you have control setting out the requirements in a clear and unambiguous format to avoid any confusion that flight crew may have in interpreting them. (Accepted - closed) |
Issued: -- | To: Air Canada | 16-2021 |
It is recommended that Air Canada consider reviewing and where necessary revise the Sterile Flight Deck criteria contained in the FOM incorporating setting out the requirements in a clear and unambiguous format to avoid any confusion that flight crew may have in interpreting them. (Accepted - closed) |
Issued: -- | To: Air Canada | 17-2021 |
It is recommended that Air Canada consider reviewing and where necessary revise the removal of loose objects from the flight deck policy, including eating utensils and beverage containers, before the top of descent setting out the requirements in a clear and unambiguous format to avoid any confusion that cabin and flight crew may have in interpreting them. (Accepted - closed) |
Issued: -- | To: Air Canada | 18-2021 |
It is recommended that Air Canada consider incorporating policy and guidelines in the company manual suite regarding the reporting of potentially hazardous occurrences, for example a tail strike, to the relevant Air Traffic Services in the most expeditious manner setting out the requirements in a clear and unambiguous format to avoid any confusion that flight crew may have in interpreting them. (Accepted - closed) |
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Map
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 Toronto-Pearson International Airport, ON to Hong Kong-Chek Lap Kok International Airport as the crow flies is 12461 km (7788 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.