CIVIL AVIATION AUTHORITY OF THE PHILIPPINES Aircraft Accident Investigation and Inquiry Board Aircraft Accident Report | 菲律宾民航管理局 飞机事故调查委员会 飞机事故报告 |
BASIC INFORMATION | 基本信息 |
Aircraft Registration No. : B-5498 Make and Model : Boeing 737-800 Owner/Operator : Xiamen Airlines Address of Operator : Xiamen, China Date/Time of Accident : August 16, 2018 / 2355H (1555UTC) Type of Operation : Scheduled Commercial Passenger Phase of Operation : Landing Type of Occurrence : Runway Lateral Excursion Place of Accident : Ninoy Aquino International Airport (RPLL) Manila, Philippines | 飞机注册号：B-5498 制造商和型号：波音737-800 所有者/经营商：厦门航空 运营商地址：中国厦门 事故发生日期/时间：2018年8月16日/2355H（1555UTC） 运营类型：定期商业客运 运行阶段：着陆 发生类型：跑道横向偏离 事故地点：尼诺·阿基诺国际机场（RPLL） 马尼拉，菲律宾 |
EXECUTIVE SUMMARY | 执行概要 |
On August 16, 2018, about 1555UTC/2355H local time, a Boeing 737-800 type of aircraft with Registry No. B-5498 operating as flight CXA 8667 sustained substantial damage following a runway excursion after second approach while landing on Runway 24 of Ninoy Aquino International Airport (NAIA), Manila, Philippines. The flight was a scheduled commercial passenger from Xiamen, China and operated by Xiamen Airlines. The one hundred fifty-seven (157) passengers and two (2) pilots together with the five (5) cabin crew and one air security officer did not sustain any injuries while the aircraft was substantially damaged. An instrument flight rules flight plan was filed. Instrument Meteorological Conditions (IMC) prevailed at the time of the accident. | 2018年8月16日，当地时间1555UTC/2355H左右，一架注册号为B-5498的波音737-800型客机执行CXA 8667航班，在菲律宾马尼拉的尼诺·阿基诺国际机场（NAIA）24号跑道着陆时，在第二次进近后偏离跑道，造成严重损坏。该航班是中国厦门的定期商业客运航班，由厦门航空公司运营。157名乘客、2名飞行员、5名乘务组成员和1名航空安全员没有受伤，而飞机严重受损。（该航班）提交的飞行计划基于仪表飞行规则，事故发生时处于仪表气象条件（IMC）。 |
During the first approach, the Captain who was the pilot flying aborted the landing at 30 feet Radio Altitude (RA) due to insufficient visual reference. A second approach was considered and carried out after briefing the First Officer (FO) of the possibility of another aborted landing should the flight encounter similar conditions. The briefing included a diversion to their planned alternate airfield. | 在第一次进近期间，作为操纵飞行员的机长在30英尺无线电高度（RA）由于没有足够的目视参考而放弃了接地。在向副驾驶（FO）通报了如果该航班遇到类似情况有可能再次中止着陆后，考虑和执行了第二次进近。通报包括转到他们的计划备降场。 |
The flight was “stabilized” on the second approach with flaps set at 30 degrees landing position, all landing gears extended and speed brake lever appropriately set in the ARM position. On passing 1,002 feet Radio Altitude (RA), the autopilot was disengaged; followed by the disengagement of the auto-throttle, three (3) seconds later. | 在第二次进近时飞机“稳定”下来，（构型是）襟翼设置在30度着陆位置，所有起落架放出，速度刹车手柄正确设置在ARM（预位）位置。在通过1002英尺无线电高度（RA）时，自动驾驶仪脱开；三（3）秒后，自动油门脱开。 |
The ILS localizer lateral path and Glide slope vertical path were accurately tracked and no deviations were recorded. The “reference” landing speed for flaps 30 for the expected aircraft gross weight at the time of landing was 145 knots and a target speed of 150 knots was set on the Mode Control Panel (MCP). The vertical descent rate recorded during the approach was commensurate with the recommended descent rate for the profile angle and ground speed; and was maintained throughout the approach passing through the Decision Altitude (DA) of 375 feet down to 50 feet radio altitude (RA). | 仪表着陆系统（ILS）的航向道水平轨迹和下滑道垂直轨迹被准确捕获，未记录到偏离。在着陆时的预期飞机全重下襟翼30的“参考”着陆速度为145节，而模式控制面板（MCP）上设置的目标速度为150节。在进近过程中所记录的垂直下降速率，与剖面角度和地速的推荐下降速率相符；在通过决策高度（DA）375英尺下至无线电高度（RA）50英尺之间的整个进近过程中，该速率得到保持。 |
As the aircraft passed over the threshold, the localizer deviation was established around zero dot but indicated the airplane began to drift to the left of the centerline followed by the First Officer (FO) making a call out of “Go-Around” but was answered by the Captain “No”. The throttle levers for both engines were started to be reduced to idle position at 30 feet RA and became fully idle while passing five (5) feet RA. At this point, the aircraft was in de-crab position prior to flare. At 13 feet RA, the aircraft was rolling left and continuously drifting left of the runway center line. | 当飞机越过跑道入口时，航向道偏离在零点附近建立，但指示出飞机开始向中心线左侧漂移，随后副驾驶（FO）发出“复飞”的喊话，但机长回答“不”。在30英尺RA，两个发动机的推力杆开始减少到慢车位置，通过五（5）英尺RA时到达了完全慢车。在这一位置上，飞机先于拉平消除了偏流角。在13英尺RA，飞机向左倾斜，并在跑道中心线的左侧继续漂移。 |
At 10 feet RA another call for go-around was made by the FO but was again answered by the Captain with “No” and “It’s Okay”. At this point, computed airspeed was approximately 6 knots above MCP selected speed and RA was approaching zero feet. Just prior to touchdown, computed airspeed decreased by 4 knots and the airplane touched down at 151 knots (VREF+6). The wind was recorded at 274.7 degrees at 8.5 knots. | 在10英尺处，副驾驶发出另一次复飞喊话，但机长再次回答“不”和“没问题”。此时，计算空速大约比MCP选定速度高出6节，RA接近零英尺。就在接地之前，计算空速下降了4节，飞机以151节（VREF+6）接地。风速记录为8.5节，274.7度。 |
Note: | 提示： |
1. VREF is the reference landing approach speed based on aircraft landing weight and flaps configuration for landing. 2. De-crab is a maneuver to straighten the aircraft in the air just before touchdown by means of the aircraft rudder. 3. Flare is a maneuver to reduce the rate of descent just before touchdown by means of the aircraft elevator. | 1. VREF是基于飞机着陆重量和襟翼着陆构型的参考着陆进场速度。 2. De-crab（消除偏流角）是在接地之前利用飞机方向舵在空中使飞机摆直的操作。 3. 拉平是一种利用飞机升降舵在接地之前减小下降速率的飞行操作。 |
Data from the aircraft’s flight data recorder showed that the aircraft touched down almost on both main gears, to the left of the runway centerline, about 741 meters from the threshold of runway 24. Deployment of the speed brakes was recorded and auto brakes engagement was also recorded. The auto brakes subsequently disengaged but the cause was undetermined. | 飞机飞行数据记录仪的数据显示，在跑道中心线左侧，距离24号跑道入口约741米，飞机几乎是以两个主起落架接地。记录到速度刹车的放出，也记录到自动刹车的衔接。随后自动刹车脱开，但原因尚未确定。 |
Upon touchdown, the aircraft continued on its left-wards trajectory while the aircraft heading was held almost constant at 241 degrees. After the aircraft departed the left edge of the runway, all landing gears collided with several concrete electric junction boxes that were erected parallel outside the confines of the runway pavement. | 接地后，飞机继续其向左的轨迹，而飞机航向几乎保持在241度不变。飞机离开跑道左侧边缘后，所有起落架与几个平行竖立在跑道道面范围之外的混凝土配电箱相撞。 |
The aircraft was travelling at about 147 knots as it exited the paved surface of the runway and came to rest at approximately 1,500 meters from the threshold of Runway 24, with a geographical position of 14°30’23.7” N; 121°0’59.1” E and a heading of 120 degrees (Figure 1). | 飞机以约147节的速度离开跑道的道面，在距离24号跑道入口约1500米处停稳，地理位置为北纬14°30 ' 23.7 "；东经121°0 ' 59.1 "，航向120°（图1）。 |
Throughout the above sequence of events from touchdown until the aircraft came to a full stop, the CVR recorded 2 more calls of “GO-AROUND” made by the FO. | 在上述从接地到飞机完全停止的事件过程中，CVR记录到副驾驶又发出了两次“复飞”的喊话。
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Throughout the landing sequence, the thrust reversers for both engines were not deployed. Throttle Lever Position (TLP) were recorded and there was no evidence of reverse thrust being selected or deployment of reversers. | 在整个着陆过程中，两台发动机的反推都没有展开。推力杆位置（TLP）被记录到了，没有证据表明反推被选定或展开了。 |
After the aircraft came to a complete stop, the pilots carried out all memory items and the refence items in the evacuation non-normal checklist, which includes extending the flaps to a 40 degrees position. The aircraft suffered total loss of communication and a failure in passenger address system possibly due to the damage caused by the nose gear collapsing rearwards and damaging the equipment in the E/E compartment or the E-buss wires connecting the Very High Frequency (VHF) 1 radio directly to the battery was broken. The Captain then directed the FO to go out of the cockpit to announce the emergency evacuation. The cabin crew started the evacuation of the passengers utilizing the emergency slides of the left and right forward doors. There were no reported injuries sustained by the passengers, cabin crew, flight crew or the security officer. | 飞机完全停止后，飞行员执行了疏散非正常检查单中的所有记忆项目和参考项目，包括将襟翼放出到40度的位置。可能是由于前起落架向后方撞击而损害了电子设备舱中的设备，以及由于直接连接甚高频（VHF） 1号到电瓶的E-buss线路损坏，飞机完全失去了通讯功能，乘客广播系统也故障了。机长随后指令副驾驶走出驾驶舱宣布紧急疏散。乘务组成员利用左右前舱门的紧急滑梯开始疏散乘客。后续没有乘客、机组成员、乘务组成员或安全员受伤的报告。 |
Safety Corrective Actions by Xiamen Airlines | •厦门航空公司的安全纠正措施 |
Following the occurrence, Xiamen Airlines initiated the following safety corrective actions: a. Relevant manuals were reviewed and revised. b. The GO-AROUND POLICY was reviewed and strengthen. c. Training in rain and on wet contaminated runway during night operation were added to the initial and recurrent simulator training of Boeing 737 pilots. This is to cultivate the decisive ability in the critical phase of flight and improve operating capability in adverse weather conditions and special circumstances. d. Deeply analyzed the effect of unstable approach and adverse weather conditions to operational safety. e. It was specified in Standard Operations Procedures that take-off and landings are prohibited in heavy rains, and landing in moderate rain is prohibited during night flight where there is no runway center line light or center line light is unavailable. f. Strengthen the policy and training regulations on safety culture for Non-Chinese pilots. g. Ensure that all safety regulations and standards, and cultural concept of both CAAC and Xiamen Airline are effectively published, accepted and implemented by Non-Chinese pilots. h. Analyzed the CRM habits and characteristics of Non-Chinese pilots; increased the daily communication and proficiency cooperation between Chinese and Non-Chinese pilot. i. Optimized the safety meetings to improve the cooperation ability among multi-national pilots. j. Defined the function of operational risk control, identified the operational risk points of operation system, and provide timely updates involving weather information to flight crew on arrival airports. | 事件发生后，厦航采取了以下安全整改措施： a.审查和修订了有关手册。 b.“复飞政策”得到审查和加强。 c.在波音737飞行员的模拟机初训和复训中，增加了夜间运行期间在雨中和湿污跑道上的训练。这是为了培养在飞行关键阶段的决断能力，提高在恶劣天气条件和特殊环境下的运行能力。 d.深入分析不稳定进近及恶劣天气条件对运行安全的影响。 e.在标准作业程序中规定，在暴雨天气下禁止起飞和降落，在没有跑道中心线灯或中心线灯不可用的夜间飞行时禁止在中雨天气下降落。 f.加强非中国籍飞行员安全文化政策和培训规定。 g.确保CAAC和厦门航空的所有安全法规、标准和文化理念对非中国籍飞行员有效发布、被接受和执行。 h.分析非中国籍飞行员的CRM习惯及特点；加强中外飞行员的日常沟通与熟练合作。 i.优化安全会议，以提高多国飞行员之间的合作能力。 j.定义运行风险控制的功能，识别运行系统的运行风险点，向目的机场的飞行机组提供相关天气信息的实时更新。 |
Safety Corrective Actions taken by MIAA | •MIAA采取的安全纠正措施 |
As a result of the accident, MIAA performed rehabilitation of runway 06/24 strip and concrete electric junction box. The rehabilitation is in compliant with the required transition slope as well as with the standards stated in CAAP Manual of Standards for Aerodromes and ICAO that may compromise the safety of aircraft. | 作为事故的结果之一，MIAA对06/24号跑道升降带和混凝土配电箱进行修复。修复工作与所需过渡坡面匹配，也符合CAAP机场标准手册和国际民航组织规定的可能危及飞机安全的标准。 |
FINDINGS | 调查结论 |
Aircraft a. The aircraft was certified, equipped and maintained in accordance with Civil Aviation Authority of China (CAAC) regulations and approved procedures. b. The aircraft has a valid Certificate of Airworthiness, Registration and had been maintained in compliance with CAAC regulations. c. The Maintenance records indicated that the aircraft was equipped and maintained in accordance with Boeing existing regulations and approved procedures was provided by the Aircraft Maintenance and Engineering Department of Xiamen Airlines. | •飞机 a.飞机按照中国民用航空局（CAAC）的规定和批准的程序进行认证、装备和维护。 b.该飞机具有有效的适航认证、注册认证，并已按照中国民航总局的规定进行维护。 c.维修记录显示，该飞机是按照波音公司现有规定装备和维修的，经批准的程序由厦门航空的飞机维修工程部提供。 |
Flight Operations a. The flight was conducted in accordance with the procedures in the Company Operations Manual. b. The flight crew carried out normal radio communications with Manila Approach and Tower Controller. c. The Captain was the pilot flying during the two approaches to ILS runway 24 of Ninoy Aquino International Airport. d. At 46 feet and 10 feet respectively, the FO made a call out of go-around but the captain disregarded the call. e. The aircraft touched down on runway 24 almost on both wheels at the left portion of the runway about 741 meters from the threshold and exited the runway. f. As the aircraft continued to roll parallel the runway both main landing gears and the nose gear collided with several cemented electric junction boxes resulting in the LH Main Gear and Left Engine to be sheared off. The cemented electric junction boxes at the grassy soft ground were inconsistent with the CAAP Aerodrome MOS. g. RH Main landing gear were folded inwards into the RH Wheel Well, the Nose Landing Gear was folded backwards damaging the E/E Bay. h. The pilots were unable to respond to calls from the ATC and neither make any calls to ATC. The pilots were also unable to communicate with the cabin crew through the service interphone system and to make announcements using the passenger address system. i. The failure of the aircraft communications systems were probably due to the damage to the E/E bay compartment and broken wires directly connecting the E-Buss of the VHF-1 to the battery. j. The aircraft finally settled at a distance about 1500 meters from the threshold of Runway 24 with last heading of 120 degrees. | •飞行操作 a.飞行按照公司运行手册中的程序进行。 b.机组成员与马尼拉进场和塔台管制员进行正常的无线电通讯。 c.机长是菲律宾尼诺阿基诺国际机场24号盲降跑道两次进场时的操纵飞行员（PF）。 d.在46英尺和10英尺的高度，副驾驶分别发出了一次喊话，但机长没有接受喊话。 e. 在距离入口约741米的跑道左侧，飞机在24号跑道几乎以两个主轮同时接地并离开跑道。 f.当飞机继续平行于跑道滑行，主起落架和前起落架与几个混凝土配电箱相撞，导致左侧主起落架和左发动机剪切性脱离。在草地松软地面上的这些混凝土配电箱不符合CAAP的机场标准手册。 g.右侧主起落架向内折入右轮舱，前起落架向后折入并损坏了电子舱。 h.飞行员无法回应空管的呼叫，也无法呼叫空管。飞行员也无法通过服务内话系统与乘务组成员联系，也无法通过乘客广播系统发出通告。 i.飞机通讯系统的故障可能是由于电子舱的损坏和VHF-1的E-buss与电池之间直接连接的线路断开。 j.飞机最终在距离24号跑道入口约1500米的地方停止，最后航向为120度。 |
Weather a. At the time of accident there were thunderstorms and intermittent heavy rains observed. | •天气 事故发生时，观测到雷暴和间歇性大雨。 |
Aircraft Recovery a. Telescopic wheeled type crane lifting capacity specified in Disabled Aircraft Removal Plan (DARP) manual for NAIA is only limited to 50 tons. | •飞机恢复 a.《失能飞机移出方案（DARP）手册》为NAIA规定的伸缩式轮式起重机的起重能力仅限50吨。 |
CAUSE FACTORS | 致因 |
Primary Cause Factors | 主要致因 |
a. The decision of the Captain to continue the landing on un-stabilized approach and insufficient visual reference. The Captain failed to maintain a stabilized landing approach moments before touchdown, the aircraft was rolling left and continuously drifting left of the runway centerline. The Captain failed to identify correctly the aircraft position and status due to insufficient visual reference caused by precipitation. b. The Captain failed to apply sound CRM practices. The Captain did not heed to the First Officer call for a Go-Around. | a.在进近条件不稳定和目视参考不足时，机长决定继续着陆。 •机长未能在接地前保持稳定的着陆进近力矩，飞机向左倾斜，并持续向跑道中心线的左侧漂移。 •由于降水导致目视参考不足，机长未能正确识别飞机位置和状态。 b.机长未能实施可靠的CRM管理。 机长没有理会副驾驶要求复飞的喊话。 |
Contributory Factors | 次要致因 |
a. Failure to apply appropriate TEM strategies Failure of the Flight Crew to discuss and apply appropriate Threat and Error Management (TEM) strategies for the following: Inclement weather. Cross wind conditions during approach to land. Possibility of low-level wind shear. NOTAM information on unserviceable runway lights. b. Inadequate Company Policy on Go-Around Company’s Standard Operation Procedures were less than adequate in terms of providing guidance to the flight crew for call out of “Go-Around” during landing phase of the flight. c. Runway strip inconsistent with CAAP MOS for Aerodrome and ICAO Annex 14 The uneven surface and concrete obstacles contributed to the damage sustained by the aircraft | a.未能实施适当的TEM策略 机组成员未能为以下情况讨论并实施适当的威胁和错误管理（TEM）策略： •恶劣天气。 •进近着陆时的侧风条件。 •低空风切变的可能性。 •无法使用跑道灯时的NOTAM信息。 b.公司复飞政策不完善 •公司的标准作业程序关于指导机组成员在飞行着陆阶段“复飞”喊话的项目是不够的。 c.机场跑道升降带不符合CAAP的机场标准手册及ICAO附件14的要求 •不平整的表面和混凝土障碍物对于飞机遭到损坏也是原因 |
SAFETY RECOMMENDATIONS | 安全建议 |
As a result of this investigation, the Aircraft Accident Investigation and Inquiry Board made the following safety recommendations: For Xiamen Airlines to review and strengthen their policies of actions to be taken by the pilot flying once a call out of “Go-Around” is made by the pilot monitoring during landing. For Xiamen Airlines to establish policies on no fault “Go-Around” and to ensure that it is being implemented, understood by flight crew thru inclusion in their initial and recurrent training. For Xiamen Airlines to review recurrent ground training syllabus to improve/adapt CRM and TEM with consideration to company in-service scenarios like this accident and other findings as a result of flight crew interview in the conduct of their flight data monitoring (FDM) program. For MIAA to review Disabled Aircraft Removal Plan (DARP) and ensure the suitability of equipment to the current operation of NAIA. For CAAP to disseminate the above Safety Recommendations to Philippine Operators. | 作为调查的结果，飞机事故调查委员会作出以下安全建议： •厦门航空公司审查和加强关于在着陆时一旦监控飞行员发出“复飞”喊话时操纵飞行员应采取的行动的政策。 •厦门航空制定无故障“复飞”政策，并确保该政策得到执行，通过将其纳入初训和复训来使飞行机组理解这一政策。 •厦门航空公司对地面复训大纲进行审查，以改进/适应CRM和TEM，应考虑到类似于本事故和在进行飞行数据监控（FDM）项目时对机组成员访谈得出的其他结论的运行场景。 •MIAA审查失能飞机移出方案（DARP），确保设备适合当前NAIA的运行。 •CAAP向菲律宾运营商宣贯上述安全建议。
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