Runway excursion Serious incident Airbus A320-211 C-FDRP,
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ASN Wikibase Occurrence # 193815
 
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Date:Saturday 25 February 2017
Time:00:03
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different    
Airbus A320-211
Owner/operator:Air Canada
Registration: C-FDRP
MSN: 122
Year of manufacture:1990
Engine model:CFMI CFM56-5A1
Fatalities:Fatalities: 0 / Occupants: 125
Aircraft damage: Minor
Category:Serious incident
Location:Toronto–Lester B. Pearson International Airport, Ontario (YYZ) -   Canada
Phase: Landing
Nature:Passenger - Scheduled
Departure airport:Halifax International Airport, NS (YHZ/CYHZ)
Destination airport:Toronto-Pearson International Airport, ON (YYZ/CYYZ)
Investigating agency: TSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
An Air Canada Airbus A320-211 airplane, operating as flight AC623, was on a scheduled flight from Halifax/Stanfield International Airport (CYHZ), Nova Scotia, Canada to Toronto/Lester B. Pearson International Airport (CYYZ), Ontario, Canada with 2 flight crew members, 4 cabin crew members, and 119 passengers on board.
The flight departed Halifax at 22:44, approximately 2 hours later than scheduled. The captain was the pilot flying (PF), and the first officer was the pilot monitoring (PM).

While en route to CYYZ, the flight crew received automatic terminal information service (ATIS) information, which stated that runway 15R was being used for arrivals. The flight crew then conducted the category I (CAT I) instrument landing system (ILS) approach briefing for that runway.
During the flight, the flight crew consulted the low-visibility-approach requirements section of the quick reference handbook (QRH) and determined that, given the lighting that was available, they would require a runway visual range (RVR) of at least 1800 feet to use runway 15R at Toronto. At the time, the RVR for runway 15R was reported to be variable but decreasing, between 3000 and 5500 feet. The flight crew discussed the lack of centreline lighting on runway 15R and the possibility of using the autoland system if conditions worsened.
At 23:55, while the aircraft was descending through 4600 feet above sea level (ASL), air traffic control (ATC) cleared it for the ILS approach to runway 15R, which was flown using autopilot.
At 23:59, ATC cleared the flight to land. The controller informed the crew that they should expect to see the lights once reaching minimums (200 feet above ground level [AGL]), and that the previous landing aircraft had reported that the weather conditions were as forecast.
At 00:00, while descending through 1550 feet ASL (approximately 980 feet AGL), both flight crew members turned on their windshield wipers because the aircraft was flying through light to moderate rain.
At 00:01, while descending through 1235 feet ASL (665 feet AGL) and in the final approach phase of the descent, the aircraft passed through a layer of wind shear, which the flight crew had anticipated. From that point until the aircraft touched down, the wind speed remained less than 5 knots.
As the aircraft passed through 1070 feet ASL (500 feet AGL), it was still in instrument meteorological conditions (IMC) and its approach was stable, with an airspeed of 138 knots and a heading of 147° magnetic (M).
In accordance with Air Canada's standard operating procedures, upon reaching 200 feet AGL, the PM called "Minimums" and the PF, who had the approach lights in sight, responded "Landing".
At 100 feet AGL, the PF disengaged the autopilot. At 90 feet AGL, the PF began to input small, but increasing, alternating roll commands on the sidestick.
At 00:01:57, the aircraft crossed the displaced threshold at a height of 39 feet AGL; it was centred laterally on the localizer and horizontally on the glideslope. Until this point on the approach, the angle between the aircraft's longitudinal axis and the track over the ground was nearly zero.
Two seconds later, when the aircraft was descending through 26 feet AGL, the PF made a brief large right roll input (approximately 75% of maximum deflection) on the sidestick, and the aircraft responded by entering a 4° right bank. The aircraft heading began to increase slightly and the aircraft began to drift to the right of the runway centreline.
Approximately 1 second later, the PF reduced the thrust to idle.
At 00:02:05, at approximately 8 feet AGL, the aircraft was 32 feet to the right of the centreline, and the PM told the PF that the aircraft was drifting to the right. The PF acknowledged and input a left roll command and applied left rudder. The wings returned to level, although the drift to the right continued due to the aircraft's momentum.
At 00:02:07, the left main wheels touched down on the runway surface, followed quickly by a very brief right-main-wheel touchdown, or skip. At this point, the aircraft was on the paved runway surface, 2227 feet from the displaced threshold and 64 feet to the right of the runway centreline. The outboard wheel of the right main gear was approximately 20 feet from the right runway edge. The aircraft continued drifting to the right following the skip, and when the right main wheels touched down again, they were approximately 8 feet to the right of the paved runway surface, in wet grass.
As the aircraft continued to move laterally to the right, the nose wheel touched down on the grass, approximately 280 feet beyond the final right-main-wheel touchdown point, and struck 1 runway edge light. The outboard left main wheel and left engine cowling then each struck 2 runway edge lights, and the outboard left tire was punctured and deflated.
The PF engaged reverse thrust, and the aircraft engines began to ingest debris. Once the speed had been reduced, the PF steered the aircraft back onto the paved runway surface, then came to a stop 5422 feet from the displaced threshold. The aircraft had travelled 2390 feet through the grass.
At 00:02:33, the PM informed ATC that the aircraft was stopped on the runway, and the PF instructed the cabin crew and passengers to remain seated. A minute later, the PM informed ATC that the aircraft had undergone a runway excursion and requested assistance from aircraft rescue and firefighting (ARFF) personnel to inspect the aircraft for damage.
ARFF personnel arrived at 00:09, and the aircraft was inspected and secured. At 00:45, buses arrived, and the passengers were deplaned and transported to the terminal.

Findings as to causes and contributing factors
1. For undetermined reasons, during the transition to flare, while the aircraft was on the runway centreline, the pilot flying made a right roll command input, which resulted in the aircraft entering a shallow right bank and beginning to drift to the right.
2. The flight crew had limited visual cues available to accurately judge the aircraft's lateral position given the weather conditions, reduced windshield wiper capability and lack of runway centreline lighting.
3. Once over the runway surface, the flight crew had to judge the aircraft's lateral position based solely on their assessment of the degree of asymmetry between the runway edge lights. As a result, the onset of drift was not initially noticed.
4. The severity of the drift was not recognized until the aircraft was less than 10 feet above ground level and rapidly approaching the runway edge, leaving limited time to correct the aircraft's trajectory before the aircraft contacted the surface.
5. Once the flight crew recognized that the aircraft would exit the paved runway surface, the pilot flying continued the landing roll as opposed to executing a go-around following contact with unknown terrain and objects.


Weather reported about the incident time (05:03 Z):

CYYZ 250515Z VRB07KT 3/4SM R15L/2600VP6000FT/U R24R/3000V6000FT/U R15R/3000VP6000FT/U -TSRA BR VV002 03/03 A2956 RMK FG8 OCNL LTGIC SLP016
>> CYYZ 250500Z VRB02KT 3/8SM R15L/2800FT/N R24R/3000FT/D R15R/3500FT/U -TSRA FG VV001 03/03 A2956 RMK FG8 OCNL LTGIC PRESFR SLP018
CYYZ 250450Z 22005KT 170V230 3/8SM R15L/3000FT/N R24R/3500V5000FT/U R15R/3500FT/U -TSRA VV001 03/03 A2959 RMK FG8 OCNL LTGIC PRESRR SLP028
CYYZ 250429Z VRB03KT 3/8SM R15L/3000FT/N R24R/3000FT/N R15R/3000FT/D FG VV001 03/03 A2956 RMK FG8 PRESFR SLP017


Accident investigation:
cover
  
Investigating agency: TSB
Report number: A17O0025
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report

Sources:

https://flightaware.com/live/flight/ACA623
https://www.flightradar24.com/data/flights/ac623#c90599e
TSB Report A17O0025

Media:

Revision history:

Date/timeContributorUpdates
25-Feb-2017 07:54 harro Added
12-Dec-2017 21:03 AF5541 Updated [Total occupants, Source, Embed code]
12-Dec-2017 21:04 harro Updated [Source]
25-Apr-2018 16:53 harro Updated [Total occupants, Narrative]
25-Apr-2018 16:54 harro Updated [Narrative]

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