Air Arabia A320 departed in wrong direction, GCAA releases final report

On September 18, 2018, an Air Arabia flight ABY111 departed the gate at Sharjah International Airport, United Arab Emirates (UAE) to Salalah International Airport, Sultanate of Oman with 48 persons onboard.

According to the details, an Air Arabia Airbus A320-200, registration A6-ANV took off from Runway 12 instead of Runway 30 after obtaining air traffic control (ATC) clearance for takeoff. The 48 persons onboard included 42 passengers, two flight crewmembers and four cabin crewmembers.

The copilot, under training, was the pilot flying (PF) and occupied the right cockpit seat. The Commander on the flight was a training captain and occupied the left seat. As per the newly release report by the UAE General Civil Aviation Authority (GCAA), the copilot in training inadvertently steered an Airbus A320 onto the wrong runway during a rolling takeoff at Sharjah Airport. However, the captain took over control and the aircraft lifted off 20-40 meters beyond the end of runway.

On Sep 19th 2018 Air Arabia instructed their pilots that all intersection departures were banned with immediate effect after one of their flights took off from an intersection in the wrong direction. Both pilots were suspended pending the investigation.

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On October 5, 2018, the GCAA reported: “Air Arabia flight ABY111 was cleared for takeoff at OMSJ runway 30, B14 intersection. However, crew mistakenly lined up for runway 12. After entering the runway, and realizing that the remaining distance for takeoff was short (about 1,100 meters), the commander took over controls and continued the takeoff while selecting flaps at 2nd used TOGA power. The aircraft took off at the end of runway. After takeoff, a call from ATC was received informing the crew about the wrong runway used.”

However, on January 10, 2022, the GCAA has released their final report. According to the report, the probable causes of the serious incident were:

• The Air Accident Investigation Sector (AAIS) of UAE determines that the cause of the runway confusion was the Copilot steering the Aircraft right onto the wrong runway during a rolling takeoff.
• Entry to the wrong runway was due to degraded situation awareness of the Aircraft direction by both flight crewmembers due to lack of external peripheral visual watch and runway confirmation.

Contributing Factors to the Serious Incident

A contributing factor to the Incident was that the air traffic controller did not monitor the Aircraft movement after take-off clearance was given.

The GCAA reported the first officer under training (34, MPL, 159 hours total, 159 hours on type) occupying the right hand seat was pilot flying, the training captain (51, ATPL, 22,184 hours total, 15,536 hours on type) in the left hand seat was pilot monitoring. A rolling takeoff was to be conducted.

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Findings relevant to the Aircraft

1. The Aircraft was certified, equipped, and maintained in accordance with the existing requirements of the Civil Aviation Regulations of the United Arab Emirates.
2. The Aircraft records indicated that it was airworthy when dispatched for the flight.
3. The No. 3 main wheel tire sustained cuts because of impact with an approach light during the Aircraft liftoff from runway 12.

Findings relevant to the flight crew

1. The flight crewmembers were licensed and qualified for the flight in accordance with the existing requirements of the Civil Aviation Regulations of the UAE.
2. Both crewmembers were fit for duty.
3. The Commander was a certified flight instructor.
4. The Copilot was a second officer undergoing a multi-pilot license (MPL) training program.
5. Both flight crewmembers conducted together 4-day pairing.
6. In day 1 and day 2 of the pairing, the Copilot performed an intersection takeoff from Bravo 6 for runway 12 on each day.
7. The takeoff from the incorrect runway occurred on day 4 of the pairing.

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Findings relevant to the flight operations

1. The Commander briefed the Copilot about conducting a single-engine taxi and a rolling takeoff.
2. The Copilot was the pilot flying and was responsible for taxiing the Aircraft.
3. The taxi conducted from the parking stand to holding Bravo 14 was a short taxi of about 3 minutes.
4. The Commander did not notify the air traffic control about his intention to conduct a rolling takeoff.
5. Before takeoff checklist was completed in the vicinity of runway 12/30 holding point Bravo 14.
6. The Commander read back the Tower take-off clearance correctly with the confirmation of runway 30.
7. The Copilot entered the runway following a taxi line for runway 12.
8. Neither the Commander nor the Copilot confirmed runway 30 direction after take-off clearance was given by Tower.
9. When the thrust levers were advanced to FLX/MCT, the Copilot called out that the flight mode annunciator (FMA) was not indicating RWY.
10. The Commander realized that the Aircraft was on the wrong runway when the Aircraft CAS was at about 57 knots.
11. The Commander took control of the Aircraft and decided to continue the takeoff.
12. The Commander increased the engine thrust to takeoff/go-around (TOGA), and nine seconds later, he changed the flap configuration to Flaps 2.
13. The Copilot was applying a nose down attitude on the sidestick up until the Aircraft rotated.
14. The Commander did not attempt to use the sidestick priority.
15. The Commander acted as the pilot flying and the pilot monitoring during take-off roll and climb.
16. The Commander stated that the Copilot was “frozen and startled.”
17. The Aircraft liftoff occurred at about 30 meters beyond the end of runway 12 from the runway safety area.
18. The Commander did not notify the Operator about the Incident.
19. The Commander continued the flight to the destination and returned the pilot flying duties to the Copilot.
20. During the Aircraft liftoff from the runway safety area, one approach light for runway 30 was damaged.
21. The cockpit voice recorder (CVR) recordings for the Incident were overwritten.

Findings relevant to air traffic control

1. The air traffic controller was licensed and was medically fit.
2. The controller did not detect that the Aircraft had turned right and had commenced the takeoff from runway 12.
3. The controller became aware of the Aircraft taking off from the wrong runway about eight seconds before the Aircraft was airborne.
4. The controller was responsible for both Tower and the Ground frequencies when the Incident occurred.
5. The controller was relieved from duty after the Incident.
6. The air traffic control operations were conducted from a standby tower located above the airport fire services.
7. The view from the standby tower had surveillance deficiencies identified during the safety case assessment.
8. As part of risk- mitigation for the identified hazards, a remote surface management system (RSMS) was installed, which included closed-circuit television (CCTV).

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Findings relevant to Sharjah International Airport

1. There was no study prepared by the airport for determining the operational need for intersection take-off sign indicating the take-off run available (TORA).
2. The airport operator complied with the requirements of the Civil Aviation Regulations for the taxiways and runway 12/30 and installed the necessary markings, lighting, stop bars and signage.
3. The lead-on lights were functional and centerline marking was visible from runway holding point Bravo 14 to runway 30 and if followed, would avoid runway confusion.
4. The airport was not equipped with ground movement radar (GMR) system.

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