Final
Report № AIFN/0010/2018, issued on 10 January 2022
34
SR42/2021
The Aircraft systems and engines performed as designed. The Investigation noted that
there were industry known aircraft systems and software aids available to improve flight
crew situation awareness during the taxi and take-off phases of flight which were not
installed on the Incident Aircraft. Examples of these awareness augmentation systems
are runway awareness and advisory system (RAAS) and take-off surveillance (TOS2)
system which provide cockpit aural and/or visual alerts in detecting and eliminating
taxiway and runway confusion.
The Operator is recommended to establish a safety case to determine the possibility of
enhancing A320 alert systems with the installation of taxiway and runway detection
systems that will aid pilots’ situation awareness.
SR43/2021
The Operator clearly identifies “Critical phase of flight” to include taxiing and takeoff. Thus,
the flight crew briefing, if done in accordance to the SOP, both crewmembers would have
briefed about the expected taxi route, taxi time, runway in use and runway alignment
directions to be followed and rejected takeoff. As an intersection rolling takeoff was
planned from Bravo 14, the briefing was an opportunity for the flight crew to discuss
runway markings especially as there would not have been visual cues of a threshold and
‘30’ white markings. This would have enhanced the flight crew situation awareness and
most likely formed a barrier to reduce the likelihood of the Incident.
Even though the Operator had specific barriers in place including general taxi guidance,
line-up and positive runway identification, takeoff and landing runway verification and
crosscheck, and the
before takeoff checklist
, for both pilots to confirm the correct runway
prior to entering as well as prior to takeoff; the critical elements were probably missed
which resulted in both pilots having degraded situation awareness of the Aircraft position.
The breach in these barriers allowed the Copilot to continue to steer the Aircraft following
the taxi line leading to runway 12 centerline for the rolling takeoff.
The Commander perceived that the runway available was insufficient to reject the takeoff
and reacted to hi
s conclusion “I saw the end of runway coming.” The Aircraft manufacturer
guidance and the Operator’s policy for a rejected takeoff recognized the risks involved
with such a decision, thus the reason behind dividing the rejected takeoff into low and high
speed regimes.
The Operator is recommended to use this Incident to reinforce to the pilots the significance
of flight preparation briefing; positive runway identification; significance of knowing runway
signage, markings and distances; effective crew resource management during taxi and
takeoff; and safeguarding the aircraft and occupants when making the decision to reject
a takeoff based on low and high speed regimes.
SR44/2021
The Operator did not have a procedure for providing the flight crew with information about
the distance required to decelerate aircraft after a rejected takeoff considering the relevant
flight parameter, weather, and runway condition. Instead, the take-off speeds are given
readily in a matrix format which are included in the operational flight plan. If flight
crewmembers are involved, this would likely increase the situational awareness of the
flight crew and alert them about the distance required to stop on the runway before V
1
.
Which will most likely result in better decision-making. The Operator is recommended to
