FINAL REPORT

BOMBARDIER BD-700, REGISTRATION M-YSAI

RUNWAY EXCURSION

16 JUNE 2013

AIB/AAI/CAS.094

Air Accident Investigation Bureau of Singapore

Ministry of Transport
Singapore

25 June 2014
The Air Accident Investigation Bureau of Singapore

The Air Accident Investigation Bureau (AAIB) is the air accidents and
incidents investigation authority in Singapore responsible to the Ministry of
Transport. Its mission is to promote aviation safety through the conduct of
independent and objective investigations into air accidents and incidents.

The AAIB conducts the investigations in accordance with the Singapore Air
Navigation (Investigation of Accidents and Incidents) Order 2003 and Annex 13 to
the Convention on International Civil Aviation, which governs how member States
of the International Civil Aviation Organization (ICAO) conduct aircraft accident
investigations internationally.

In carrying out the investigations, the AAIB will adhere to ICAO’s stated
objective, which is as follows:

“The sole objective of the investigation of an accident or incident shall be

the prevention of accidents and incidents. It is not the purpose of this
activity to apportion blame or liability.”

Accordingly, it is inappropriate that AAIB reports should be used to assign

fault or blame or determine liability, since neither the investigation nor the reporting
process has been undertaken for that purpose.

© 2014 Government of Singapore 1

 Contents
GLOSSARY OF ABBREVIATION .............................................................................. 3
SYNOPSIS...................................................................................................................... 4
AIRCRAFT DETAILS ................................................................................................... 4
1 FACTUAL INFORMATION .............................................................................. 5
1.1 History of the flight .......................................................................................... 5
1.2 Injuries to persons ............................................................................................ 7
1.3 Personnel information ...................................................................................... 7
1.4 Flight recorders ................................................................................................ 8
1.5 Additional Information..................................................................................... 8
1.5.1 Non-normal procedures in Airplane Flight Manual ................................ 8
1.5.2 Service Bulletin 700-1A11-22-002 ......................................................... 8
1.5.3 Operator’s windshear training for pilots ................................................. 8

2 DISCUSSION ...................................................................................................... 9
2.1 Awareness and response to windshear caution and warning ........................... 9
2.2 Response to windshear warning ....................................................................... 9

3 CONCLUSION .................................................................................................. 10

4 SAFETY ACTIONS .......................................................................................... 11

5 SAFETY RECOMMENDATIONS ................................................................... 12

© 2014 Government of Singapore 2

 GLOSSARY OF ABBREVIATION

ACARS Aircraft Communications Addressing and Reporting System

ATC Air Traffic Control
CVR Cockpit Voice Recorder
FDR Flight Data Recorder
fpm Feet per minute
ft Feet
GS Ground Speed
KIAS Indicated Airspeed in knots
kts knots
MSL Mean sea level
ND Navigation Display
NM Nautical miles
PF Pilot Flying
PFD Primary Flight Display
PIC Pilot-in-command
PIREP Pilot Report
PM Pilot Monitoring
QAR Quick Access Recorder
QNH Altitude above mean sea level based on local station pressure
RA Radio Altitude
SIGMET Significant Meteorological Information
UTC Coordinated Universal Time
VFR Visual Flight Rule

© 2014 Government of Singapore 3

SYNOPSIS

On 16 June 2013, a Bombardier BD-700 private jet while landing at Runway

21 of Seletar Airport, experienced a strong gust of cross wind causing it to drift off
and touch down on the left side of the runway. Both nose and left main gears
touched down on the grass patch while the right main gear touched down on the
edge of the paved runway. After touching down, the Pilot Flying manoeuvred the
aircraft back onto the runway and subsequently taxied the aircraft to its parking bay.
As a result of the runway excursion, two signboards on the left of the runway were
damaged due to contact by the aircraft.

The aircraft sustained damages to its left flaps, left flap track fairings, left
landing gear door and left thrust reverser lower clamshell door. There was no injury
to any person.

The Air Accident investigation Bureau of Singapore classified this occurrence

as an accident and instituted an investigation.

AIRCRAFT DETAILS

Aircraft type : Bombardier BD-700-1A11

Operator : Capital Investment Worldwide Inc.
Aircraft registration : M-YSAI
Manufacturer’s Serial number : 9166
Numbers and type of engines : 2 x Rolls Royce BR 700-710A2-20 Turbofan
Type of flight : Private flight
Persons on board :5

© 2014 Government of Singapore 4

1 FACTUAL INFORMATION

All times used in this report are Singapore times. Singapore time is eight
hours ahead of Coordinated Universal Time (UTC).

1.1 History of the flight

1.1.1 The Bombardier BD 700 flew from Delhi, India to Seletar Airport in
Singapore on 16 June 2013. The pilot-in-command, seated on the left
seat, was the Pilot Flying (PF) while his co-pilot, seated on the right seat,
was the Pilot Monitoring (PM).

1.1.2 Seletar Airport was a Visual Flight Rule (VFR) airfield and had a single
runway (Runway 3/21). The aircraft was to land on Runway 21.

1.1.3 At 22:05:35, the aircraft was 6 NM from the runway. After confirming with
the PF1, the PM informed the tower controller that they had the runway in
sight. The tower controller then cleared the aircraft to continue the
approach. According to the PM, the weather was clear without rain or
visual obstruction and the conditions were good for visual approach
landing at that instance. The aircraft’s weather radar display showed that
the weather was clear in the approach path but there was heavy
precipitation about 5-7 NM to the right of the runway. According to the
tower controller and watch manager, the visibility at that point was good
as they were able to see the landing lights of the aircraft.

1.1.4 At 22:05:42, the tower controller asked if the flight crew was able to sight
the obstacle (a steel structure) located 2 NM from the runway. The PM
replied in the affirmative, adding that they were familiar with the airport.
The controller then cleared the flight to continue the approach to Runway
21.

1.1.5 At 22:06:01, the tower controller provided wind information of 260° at 4

knots. The PM acknowledged the information.

1.1.6 At 22:06:19, the tower controller gave the clearance to land. The PM
acknowledged the clearance to land.

1.1.7 At 22:08:16, the tower controller informed the crew of severe low level
windshear2 that was observed in the vicinity of Seletar Airport3. The
tower controller also informed that there was rain over the airfield and
that the runway was wet. The PM acknowledged the information4 and
informed the controller that they were at that moment flying over the
water (Straits of Johor). Then the crew encountered rain, which
intensified as they flew over the Singapore shoreline but the runway was
still in sight. Both pilots assessed the weather condition to be adequate

1
According to the PF, he was unable to sight the runway initially. The PM pointed out the runway to him.
2
This was detected by the airport’s Low Level Windshear Alert System (LLWAS).
3
Prior to this transmission, there was no report of any adverse weather condition.
4
The PF said after the occurrence that he could not recall hearing the controller providing the windshear
warning.

© 2014 Government of Singapore 5

 and they continued with the approach.

1.1.8 In the subsequent one and half minutes, the tower controller provided the
following wind information:

• At 22:08:41, 250° at 11 knots

• At 22:09:00, 260° with gusting wind of 15 knots
• At 22:09:46, 290° at 25 knots

1.1.9 At 22:10:09, when the aircraft was 220 ft above ground, the aircraft’s
Enhanced Ground Proximity Warning Computer (EGPWC) 5 generated a
windshear caution.

1.1.10 At 22:10:17, at 108 ft above ground, the EGPWC generated a windshear

warning6.

1.1.11 The PF did not notice any windshear caution or windshear warning. The
PM momentarily heard a windshear aural warning before touchdown.
However, he did not initiate a go-around as required by the procedure in
the Airplane Flight Manual.

1.1.12 At 50 ft, the PM noticed that the aircraft started to pitch up and he asked
the PF to increase engine power, which the PF did. The aircraft then
started to drift towards the left side of the runway. As the aircraft flared
over the left side of the runway, the PM noticed that the right wing tip
started to drop towards the runway7 but did not strike the runway.

1.1.13 The aircraft landed at 22:22:00, with the right main gear touching down
first, on the runway pavement and close to the left edge of the runway.
This was followed by the left main gear touching down on the grass patch
left of the runway edge. The PF stated that the aircraft was “blown” off to
the left side of the runway before touchdown. The PM noted that the
aircraft started to drift to the left of the runway centreline just before
touchdown. The PF applied slight right aileron8 and full right rudder
pedal to try to bring the aircraft back to the runway, but he stated that the
aircraft did not respond. The PM also instinctively applied right rudder
but became aware that the PF had already applied maximum right rudder
input.

1.1.14 Data from the FDR indicated that the aircraft continued to drift to the left
after the PF’s attempt to bring the aircraft back to the runway. However,
the magnetic heading data indicated that the aircraft had turned towards
the right in response to the PF’s input.

1.1.15 After the nose gear had touched down, the PF was then able to steer the
5
Windshear caution alert is indicated by amber “WINDSHEAR” alert message on the cockpit’s Primary Flight
Display (PFD), which provides information that can assist the pilot in managing his flight in the vertical
plane (e.g. airspeed, attitude, altitude).
6
The windshear warning consists of a red “WINDSHEAR” indication on the PFD, a boxed “WINDSHEAR”
annunciation in large font on the Head-Up-Display (HUD) accompanied by a brief siren and a
“WINDSHEAR-WINDSHEAR-WINDSHEAR” aural warning.
7
The right wing dipped because the PF applied right aileron to try to bring the aircraft back to the runway.
8
According to the PF, too much right aileron application may cause a wing tip strike.

© 2014 Government of Singapore 6

 aircraft back onto the runway. According to the PF, it took about 4-5
seconds before the aircraft responded to his directional input and started
to steer back to the runway. He believed the aircraft responded after the
crosswind had abated and the aircraft had slowed down following thrust
reverser deployment.

1.1.16 After the aircraft stopped on the runway, it had to do a 180° turn on the
runway to taxi to its parking stand. Both the PF and PM commented that
during the 180° turn, the rain was so heavy that they could hardly see
anything through the windshield except for the runway edge lights. They
informed ATC that they had drifted off the runway and suggested that the
runway be inspected for any possible debris.

1.1.17 According to the tower controller, he saw the rain move in from the shore
towards the threshold of Runway 21 and described the rain as a very
short and heavy downpour.

1.1.18 Due to the low light condition and rain, both the tower controller and the
watch manager were unable to see if the aircraft had landed off the
runway. They did not notice anything wrong with the landing until they
were informed by the pilots.

1.2 Injuries to persons

1.2.1 There was no injury to any person.

1.3 Personnel information

1.3.1 Pilot and Co-pilot

Pilot Co-pilot
Gender Male Male
Age 58 59
Licence Airline Transport Pilot Licence Air Transport Pilot Licence
issued by the Federal Aviation issued by the Federal
Administration with BD-700 Aviation Administration with
rating, validated by the State BD-700 rating, validated by
of Registry the State of Registry
(expiry on 16 May 2014) (expiry on 6 Sep 2014)
Total on BD-700 275 hr 1842 hr
Flying in last 24 hours 5 hr 30 min Nil
Flying in last 7 days 13 hr 10 hr 14 min
Flying in last 90 days 104 hr 30 min 79 hr

1.3.2 Toxicology tests performed on both flight crew members did not show
any anomaly.

1.3.3 While the PM was familiar with Seletar Airport, the PF had flown into
Seletar Airport only a few times, and the occurrence flight was his first
night landing as a PF.

© 2014 Government of Singapore 7

1.4 Flight recorders

1.4.1 The aircraft’s digital flight data recorder (FDR) and cockpit voice recorder
(CVR) were removed by the operator’s technical handling agent and
handed over to the AAIB.

1.4.2 The CVR consists of four individual tracks, of which only the area
microphone recording contained information relevant to the occurrence.
The other three tracks (left hand seat, right hand seat and first observer
seat) were recorded over as the CVR was not deactivated after aircraft
arrived on the parking bay. The area microphone recordings were useful
for the investigation as it captured the windshear aural warning. There
was no verbal communication between the flight crew after the windshear
aural warning sounded.

1.4.3 The FDR data were downloaded successfully and useful for the
investigation.

1.5 Additional Information

1.5.1 Non-normal procedures in Airplane Flight Manual

1.5.1.1 The operator adopted the manufacturer’s Airplane Flight Manual for its
operation. The manual stated that go-around should be initiated when a
windshear caution or warning is encountered.

1.5.2 Service Bulletin 700-1A11-22-002

1.5.2.1 The aircraft manufacturer had issued Service Bulletin 700-1A11-22-002

on 12 December 2012 to offer a Windshear Escape Guidance (WEG)
option as part of the automatic flight control system, which, when a
windshear condition is detected, will provide windshear escape guidance
consisting of lateral and vertical movement commands. If the auto-
throttle is engaged, the WEG will also cause the throttle lever to be
automatically advanced fully forward to provide maximum thrust.

1.5.2.2 At the time of the occurrence, the aircraft had not incorporated this
Service Bulletin.

1.5.3 Operator’s windshear training for pilots

1.5.3.1 Simulator training for the operator’s pilots was contracted out to an
external flight training school. The simulator training did not include
windshear simulations.

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2 DISCUSSION

2.1 Awareness of windshear caution and warning

2.1.1 The ATC had alerted the flight crew to the presence of severe low level
windshear in the vicinity of Seletar Airport and this was acknowledged by
the PM.

2.1.2 Despite being alerted by the ATC of a possible windshear encounter,

both pilots did not notice the windshear caution while only the PM
recalled hearing the “WINDSHEAR-WINDSHEAR-WINDSHEAR” aural
warning when the windshear warning was activated. One would expect
the flight crew to have heightened awareness of a possible windshear
encounter after receiving the low level windshear warning issued by the
ATC.

2.1.3 As it was the first time that the PF was performing a night landing at
Seletar Airport, he might have been fixated on landing the aircraft safely
in deteriorating weather conditions, resulting in him not noticing the
windshear caution and warning.

2.1.4 The pilots’ simulator training did not include windshear simulations.
Thus, the pilots might not have been familiar with the windshear related
cautions and warnings and might have missed noticing the visual
indications related to the windshear condition.

2.1.5 Relevant simulator training should benefit flight crews in becoming more
familiar with the windshear related cautions and warnings.

2.2 Response to windshear warning

2.2.1 The PM did not call out the warning to alert the PF of the warning. The
procedures in the Airplane Flight Manual did not require the PM to call
out windshear cautions and warnings. Although not required by the
procedures, acknowledgement of a windshear caution or warning by
calling out is a useful crew resource management practice in ensuring
that both pilots are aware of the situation.

2.2.2 The procedures in the Airplane Flight Manual required a go-around to be

initiated when windshear warning is activated. The PM, after hearing the
warning, observed that the vertical speed of the aircraft increased slightly
but not to an extent of concern. In addition, he observed that the aircraft
was responding to the PF’s input. As such, he did not see a need to
initiate a go-around.

2.2.3 It would have been prudent for the PM to initiate a go-around when he
heard the aural warning, as it is a requirement under the Aircraft Flight
Manual.

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3 CONCLUSION

From the information gathered, the following findings are made. These
findings should not be read as apportioning blame or liability to any
particular organisation or individual.

3.1 The air traffic controller had informed the flight crew of a low level
windshear warning indicating the presence of windshear activity in the
aerodrome. As the aircraft approached the runway, the weather
conditions deteriorated and this was detected by the aircraft’s windshear
detection system.

3.2 The windshear caution was generated by the aircraft’s windshear

detection system but the visual indication was not noticed by both pilots.
When the windshear warning was generated later, the PF did not notice
the visual and aural indications related to this warning and the PM
noticed only the aural indication.

3.3 Although the PM heard the aural warning, he did not initiate a go-around,
which was required by the Airplane Flight Manual.

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4 SAFETY ACTIONS

During the course of the investigation and through discussions with the
investigation team, the following safety actions were initiated by the
operator.

4.1 The operator has introduced a safety management system. As part of

this system, the operator uses a risk assessment tool in the evaluation,
for each planned flight, of the risks associated with equipment, operating
environment, pilot qualifications and experience. If the operator deems
the risk for a particular flight to exceed the tolerable limit, that flight will
not be performed.

4.2 The operator has made diverting to an alternate aerodrome upon receipt
of windshear warning from the air traffic control during approach a
standard operating procedure.

4.3 The operator has incorporated the aircraft manufacturer’s Service

Bulletin 700-1A11-22-002 on installation of the Windshear Escape
Guidance (WEG) as part of the automatic flight control system9.

4.4 The operator has required its pilots to conduct at least 10 landings into a
visual flight rule (VFR) airport, of which five must be conducted at night,
before being allowed to carry passenger into that VFR airport. In the
meantime, the operator has suspended night landings into Seletar
Airport.

4.5 The operator has incorporated windshear training as part of its recurrent
simulator trainings.

9
Once a windshear warning condition is detected, the active WEG will be enabled. This will result in
the flight director Windshear Escape Guidance mode (WSHR) being activated and in the flight
director providing escape guidance, based on aircraft performance, consisting of lateral and vertical
commands. The WSHR mode cannot be cancelled when a windshear warning is active. If the
autothrottle is engaged, the WSHR mode will also cause the throttle lever to be automatically
advanced fully forward to provide maximum thrust.

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5 SAFETY RECOMMENDATIONS

A safety recommendation is for the purpose of preventive action and

shall in no case create a presumption of blame or liability.

It is recommended that:

5.1 The operator review its procedure to require flight crew to acknowledge
any flight deck annunciations by calling out the cautions or warnings to
enhance crew resource management. [AAIB Recommendation R-2014-
004]

5.2 The operator review its operating procedures to ensure that, following an
accident or a serious incident, flight recorders are de-activated
immediately upon completion of the flight, so as to preserve the records
of every flight recorder. [AAIB Recommendation R-2014-005]

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