INCIDENT REPORT

Runway Excursion Incident

Boeing 777-200 Registration 9V-SRG

Singapore Changi Airport

24 January 2004

AIB/AAI/CAS.016

Ministry of Transport
Singapore

26 April 2005
The Air Accident Investigation Bureau of Singapore

The Air Accident Investigation Bureau (AAIB) is the investigation authority in

Singapore responsible to the Ministry of Transport for the investigation of air
accidents and incidents to Singapore and foreign civil aircraft in Singapore.
The AAIB also participates in overseas investigations of accidents and
incidents involving Singapore aircraft or aircraft operated by a Singapore air
operator.

The mission of the AAIB is to promote aviation safety through the conduct of
independent and objective investigations into air accidents and incidents
consistent with Annex 13 to the Convention on International Civil Aviation.

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.

The investigation process involves the gathering, recording and analysis of all
available information on the accidents and incidents; determination of the
causes and/or contributing factors; identification of safety issues; issuance of
safety recommendations to address these safety issues; and completion of
the investigation report.

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.”

1
 CONTENTS

Page

Glossary of Abbreviations 3

Synopsis 5

1 Factual Information 6
1.1 History of Flight 6
1.2 Injuries to persons 8
1.3 Damage to aircraft 8
1.4 Other damage 8
1.5 Personnel information 9
1.6 Aircraft information 9
1.7 Meteorological information 10
1.8 Aids to navigation 11
1.9 Communications 11
1.10 Aerodrome information 11
1.11 Flight recorders 13
1.12 Wreckage and impact information 13
1.13 Medical and pathological information 13
1.14 Fire 13
1.15 Survival aspects 13
1.16 Tests and research 13
1.17 Organisation and management information 14
1.18 Additional information 14
1.19 Useful or effective investigation techniques 15

2 Analysis 16
2.1 Wind condition and crew action 16
2.2 Draining of water off runway 16
2.3 Aquaplaning 17

3 Conclusions 18
3.1 Findings 18
3.2 Significant Factors 18

4 Safety Recommendations 19

5 Safety Action 20

6 Appendices 21
Appendix 1 22
Appendix 2 23

2
 GLOSSARY OF ABBREVIATIONS

ATC Air Traffic Control

ATIS Aerodrome Terminal Information Service
CAS Calibrated Air Speed
CRM Crew Resource Management
DFDR Digital Flight Data Recorder
FO First Officer
IAS Indicated Airspeed
ILS Instrument Landing System
ICAO International Civil Aviation Organisation
PIC Pilot-In-Command
SARP Standard and Recommended Practices
SOP Standard Operating Procedures
UTC Coordinated Universal Time
VFR Visual Flight Rules
Vref Minimum speed based on a percentage of the stall
speed of aircraft

3
BOEING 777-200, 9V-SRG

Classification : Incident
Aircraft type : Boeing 777-200
Registration : 9V-SRG
Number and Type of Engines : Two Rolls Royce Trent 800
Place : Singapore Changi Airport
Date & Time (Local Time) : 24 January 2004, 2035 hours
Type of Flight : Public Transport (Passenger)
Persons on Board : 269
Point of Departure : Brisbane, Australia
Destination : Singapore Changi Airport

4
SYNOPSIS

A Boeing 777-200 aircraft was landing in rain at the Singapore Changi

Airport on 24 January 2004, when its left hand landing gear momentarily
departed the paved surface of Runway 02L and went onto the soft grass
verge before returning to the paved runway surface. Subsequently, the
aircraft taxied on its own to the designated passenger gate. All occupants
disembarked unassisted using the aerobridge. There was no injury.

All six tyres of the left hand landing gear showed evidence of reverted
rubber aquaplaning and three of the tyres were deflated. The forward and aft
junction boxes under the landing gear truck were damaged and separated
from their attachments.

5
1. FACTUAL INFORMATION

All times used in this report are Singapore times. Singapore time is
eight hours ahead of UTC.

1.1 History of flight

1.1.1 The Boeing 777-200 aircraft was operating a scheduled service

from Brisbane, Australia to Singapore. The flight was normal until
the landing at 2035 hours at the Singapore Changi Airport. The first
officer (FO) was the pilot flying (PF) the aircraft.

1.1.2 The weather information broadcast by ATIS1 ‘O’ at 1930 hours was
rain over the airfield with braking action on Runway 02L reported as
medium, wind calm and visibility of 6 km. This was updated by
another ATIS ‘P’ at 2006 hours and the changes were highlighted
by the Pilot-in-Command (PIC) to the PF during the descent. The
crew intended to land with an autobrake setting of 3 and the use of
full reverse thrust on a wet runway was also discussed.

1.1.3 During the descent both pilots were concerned about the weather
and commented on the weather radar showing ‘all red’ (clouds with
high water content). The crew obtained a deviation to avoid the
weather.

1.1.4 On initial contact with Changi control tower, the crew were advised
of rain over the airfield and strong low level windshear. The crew
were also advised of medium to poor braking action reported by a
preceding arrival aircraft.

1.1.5 At about 1,800 ft, Changi control tower advised the flight to continue
its approach and that there was strong crosswind, but no windshear
reported by the preceding arrival aircraft. At this point, the PF
indicated that he would conduct an automatic landing (autoland).
The PIC concurred, saying that they ‘might as well do an autoland’
as they ‘would not be able to see the runway until a few hundred
feet’.

1.1.6 Shortly after, a landing clearance was given by the tower with the
surface wind reported at 140 degrees and 15 knots.

1.1.7 When the PF sighted the runway about 45 seconds later (about 600
ft above ground level) he requested to land the aircraft manually
instead of using the autoland. The PIC agreed with the PF’s
request. The PF disengaged the autopilot at about 520 ft.

1
ATIS (Aerodrome Terminal Information Service) is an automatic broadcast service provided by the airport
authority. The broadcast is carried out at regular intervals and each broadcast is identified by a letter of the
alphabet, until the following update when a new letter is assigned.

6
1.1.8 In order to counter the crosswind, and maintain the desired ground
track, the autopilot was maintaining a crab angle of 5 degrees into
the wind. The aircraft’s heading was 28 degrees and the ground
track was 23 degrees.

1.1.9 After the autopilot was disengaged, the PF used the cross control
technique, of applying left rudder while lowering the right wing, to
counter the crosswind. The aircraft maintained the glideslope at a
descent rate of about 750 ft per minute with an indicated airspeed
of about 135 knots. The Vref was about 128 knots.

1.1.10 In response to changing wind conditions, the PF made frequent

aileron and rudder adjustments to maintain the aircraft on the
localizer of the Instrument Landing System (ILS).

1.1.11 At about 200 ft above ground, the aircraft started to deviate to the
right of the localizer with the right wing low. At about 150 ft above
ground, the aircraft was indicating 0.1 dot to the right of the localizer
while the right wing went lower to about 2 degrees.

1.1.12 During descent from 100 to 38 ft, the PF further applied corrective
actions to return the aircraft to the localizer. At about 80 ft, the right
wing low became a left wing low of more than 3 degrees.

1.1.13 The aircraft moved from 0.1 dot on the right of the localizer at 26 ft
to 0.1 dot left of the localizer at about 10 ft with the left wing
remaining low at 2.85 degrees.

1.1.14 At one second before touchdown, the aircraft pitch attitude was 1.2
degrees nose up. At touchdown, the aircraft pitched nose up at 1.4
degrees, whereas the normal nose pitch should be about 2.5
degrees. The aircraft landed firm at 1.6 g at 0.1 dot to the left of the
localizer which is about 4 m to the left of runway centreline at an
indicated airspeed of 131 knots (ground speed of 148 knots) with
the left wing low at 1.1 degrees. According to the crew the aircraft
skidded to the left on touchdown.

1.1.15 The left hand landing gear of the aircraft departed the runway for
about six seconds. From the wheel tracks in the soft ground, it was
determined that the left hand landing gear had rolled about 360 m
on the grass verge with the maximum displacement of about 6.2m
from the runway edge (see Appendix 1).

1.1.16 DFDR data showed the landing gear “Not Tilt”2 indication (indicating
that the aircraft had touched down) for about four seconds. After
that, the “Not Tilt” indication was changed to a “Not Valid” indication.

2
The two main landing gears of the B777 aircraft are tilted when the aircraft is in the air. When the aircraft lands the
landing gears are levelled and “not tilt” data are recorded for the gears.

7
1.1.17 The PIC took over the control of the aircraft with full right rudder
application and brought the aircraft back on the paved surface of
the runway.

1.1.18 Some antiskid system fault messages appeared on the EICAS

(Engine Indication and Crew Alerting System) display during the
excursion. These messages were most likely the result of damage
sustained on the left hand landing gear after it departed from the
paved runway surface.

1.1.19 The PIC taxied the aircraft to the assigned passenger gate after
assessing it was safe to do so. The persons on board disembarked
normally from the aircraft through the aerobridge.

1.2 Injuries to persons

Nil

1.3 Damage to aircraft

1.3.1 The aircraft sustained the following minor damage:

• The forward junction box mounted below the left landing gear
truck beam, between the front and rear axles, was torn off.
• The aft junction box on the left landing gear was dislodged
slightly from its position.
• Some conduit clamps on the landing gear shock strut were adrift.
• All six tyres on the left hand landing gear suffered rubber
reversion. Tyres number 1, 2 and 5 were deflated. (See
Appendix 2)
• Two wing-to-body fairing panels aft of the wheel well were
damaged.
• One body fairing had a crack of approximately 45 cm.
• The leading edge of the left hand horizontal stabilizer had a dent
of about 10 cm by 8 cm.

1.3.2 One large metal piece and other smaller fibreglass pieces (from the
body fairing panels) were found on the runway. Pieces of the
junction box parts were found on the grass verge.

1.4 Other damage

1.4.1 There was no damage to the runway surface. Five runway edge
lights along the western side of Runway 02L between Taxiways W9
and W7 were damaged.

1.4.2 The wheel tracks on the soft ground started near the runway edge
light No.132 which was about 700 m from the start of the threshold
of Runway 02L and ended at runway edge light No.120. The wheel

8
 tracks were about 360 m long and about 6.2 m at their furthest from
the edge of the runway. Only the left landing gear had departed the
runway.

1.5 Personnel Information

1.5.1 Pilot-in-command
Age : 36 years (Male)
Licence : Airline Transport Pilot’s Licence
issued by the Civil Aviation Authority
of Singapore
Aircraft ratings : B747-300, B747-400 and B777
Total flying experience : 8558 hours
Flying experience on type : 937 hours
Last Base Check : 13 October 03
Last line check 777-200 : 19 September 2003
Last simulator check : 08 July 2003
Last medical check : September 2003
Flight time (last 24 hours) : 7 hours 15 minutes
Flight time (last 30 days) : 67 hrs 13 minutes
Flight time (last 90 days) : 176 hours 07 minutes
Rest period before flight : 33 hours

1.5.2 First Officer

Age : 32 years (Male)
Licence : Airline Transport Pilot’s Licence
issued by the Civil Aviation Authority
of Singapore
Aircraft ratings : Baron Be 58, Learjet L45, A310 and
B777
Total flying experience : 1467 hours
Flying experience on type : 688 hours
Last Base Check date : 1 November 2003
Last line check 777-200 : 28 December 2003
Last simulator check : 1 November 2003
Last medical check : August 2003
Flight time (last 24 hours) : 07 hours 15 minutes
Flight time (last 30 days) : 34 hours 23 minutes
Flight time (last 90 days) : 171 hours 42 minutes
Rest period before flight : 33 hours

1.6 Aircraft Information

1.6.1 The aircraft was serviceable and had a valid Certificate of

Airworthiness.

1.6.2 The estimated landing weight of the aircraft (including about 8,300
kg of fuel) was about 179,200 kg. This weight was within the
maximum allowable landing weight of 208,652 kg.

9
1.6.3 The aircraft has two main landing gears and a nose landing gear.
Each main landing gear has three axles with two wheels mounted
on each axle, making a total of six wheels per gear. The wheels
are each fitted with a hydraulically operated multi-disc carbon brake
unit which provides the primary means of stopping the aircraft.

1.6.4 The aircraft is equipped with two Rolls Royce Trent 800 engines.
Each engine has a hydraulically operated thrust reverser. The
thrust reverser system is used after aircraft touchdown to slow
down the aircraft by re-directing the airflow from the engine forward,
creating a reversal in thrust. The purpose of the system is to
reduce the stopping distance by supplementing the aircraft brake
system.

1.6.5 The aircraft is equipped with an autobrake system designed to

optimise braking performance and reduce tyre wear. There are five
positions, namely Settings 1 to 4 and RTO (Rejected Take-Off), on
the autobrake system that provide different deceleration rates.
RTO is only used during the take-off roll. Setting 1 provides the
least hydraulic pressure on the brake units giving the lowest
deceleration to the aircraft while Setting 4 provides the maximum
hydraulic pressure. Manual input of the brake pedal will cancel the
autobrake system automatically.

1.6.6 Maintenance records showed no pre-existing fault in the antiskid

system or the autobrake system. DFDR data showed the
autobrake pressure increased normally following touchdown.

1.7 Meteorological Information

1.7.1 The incident happened during rain. Weather information provided

by the Meteorological Service Division of the Singapore National
Environment Agency is incorporated in the broadcasts of Changi
Airport Aerodrome Terminal Information Service (ATIS). The
meteorological conditions, broadcast as ATIS ‘O’, at 19:30 hours
were as follows:
• Light rain over airfield
• Runway surface wet
• Braking action Runway 02L reported as medium
• Wind calm
• Visibility 6 km
• Scattered clouds at 700 ft and 1,200 ft
• Temperature/dew point at 24 degrees Celsius
• QNH 1009
• Recent moderate rain
• No significant change expected

10
1.7.2 On initial contact with Changi control tower, the crew was advised
of:
• Rain over the airfield
• Reported strong low level windshear
• Braking action reported as medium to poor

1.7.3 A minute and a half later, Changi control tower advised the crew of
the following:
• Strong crosswind
• No windshear

1.7.4 From the DFDR records, from 150 ft to touchdown, the wind speed
had changed rapidly from about 16.5 knots to 11 knots in 5 seconds,
and 8 seconds later increased to about 20.5 knots just before
touchdown. The surface wind at the time of the landing was from
the southeast. This would mean a quartering tailwind (a crosswind
experienced from the rear right quarter).

1.8 Aids to navigation

1.8.1 Navigation aids at Changi Airport required for aircraft operations

were working normally at the time of the incident.

1.9 Communications

1.9.1 The aircraft was in contact with Flow Control of the Singapore Air
Traffic Control Centre (SATCC) on 124.05 MHz and then with
Arrival Control of SATCC on 119.3 MHz. It was in contact with
Changi control tower on 118.6 MHz at the time of the incident.

1.9.2 The crew did not report any communication problem with the air
traffic control on these frequencies.

1.10 Aerodrome information

1.10.1 Runway 02L is 4,000 m long and 60 m wide. The surface of the
runway is paved with bituminous concrete and is constructed with
transverse slope of 1.5 percent to permit the rapid drainage of water.
The shoulders on the sides of the runway are flush with the runway,
3 m wide, and sloped at less than 2.5 percent. On both sides of the
runway are flat grass areas that drain into a large drainage system
about 130 m away from the edge of Runway 02L. These grass
areas are sloped at 2.5 percent.

1.10.2 Singapore aerodrome operators must comply with the Singapore

Manual of Aerodrome Standards as required by paragraph 67B of
the Air Navigation Order.

11
1.10.3 The Singapore Manual of Aerodrome Standards adopts the ICAO
Standards and Recommended Practices (SARPs) on aerodrome
design and operations contain in Volume 1 of Annex 14 to the
Chicago Convention. Hence, complying with the requirements of
the Singapore Manual of Aerodrome Standards would meet ICAO
SARPs of Annex 14.

1.10.4 The Singapore Manual of Aerodrome Standards recommendations

for runway transverse slopes and runway shoulder slopes are
stated in paragraph 7.2.1.183 “Transverse slopes” and paragraph
7.2.24 “Runway shoulders” respectively. These slopes are not to
exceed 1.5 percent and 2.5 percent respectively.

1.10.5 As for the grass verge (runway strips), Singapore Manual of

Aerodrome Standards’ recommended slope is not to exceed 2.5
percent (paragraph 7.2.3.145 “Transverse slopes”)

1.10.6 The day after the incident, the investigators noticed that even
though it was not raining heavily, rain water accumulated at some
areas on the paved runway shoulder up to about 3 m from the grass
edge and about 100 mm in depth. In some places, the grass had
grown higher than the level of the runway shoulder. Dead grass
gathered at the edge of the runway shoulder also obstructed the
drainage of rain water.

1.10.7 The airport operator carried out runway friction tests on Runway
02L-20R on 25 January 2004 (the day after the incident) between
1620 to 1725 hours. A Saab Friction Tester (SFT) equipped with a
special self-wetting measuring wheel mounted behind the rear axle
was used to perform the friction test. The measuring wheel was
towed at a speed of 95 km per hour. Measurements of friction
coefficients with 1 mm thick film of water were recorded over each

3
7.2.1.18 Transverse slopes
Recommendation – To promote the most rapid drainage of water, the runway surface should, if practicable, be
cambered except where a single cross fall from high to low in the direction of the wind most frequently associated
with rain would ensure rapid drainage. The transverse slope should ideally be:
- 1.5 percent where the code letter is C,D, E or F; and
- 2 percent where the letter code is A or B;
but in any event should not exceed 1.5 percent or 2 percent as applicable, nor less than 1 percent except at
runway or taxiway intersections where flatter slopes may be necessary. (Note: The code letter for Changi Airport
Runway 02L/20R is E.)
(Corresponding reference in the ICAO Volume 1 of Annex 14: para 3.1.18)
4
7.2.2 Runway shoulders – Slopes on runway shoulders
7.2.2.4 Standard – The surface of the shoulder that abuts the runway should be flush with the surface of the runway
and its transverse slope should not exceed 2.5 percent. (Corresponding reference in the ICAO Volume 1 of Annex
14: para 3.2.4)
5
7.2.3.14 Transverse slopes
Recommendation – Transverse slopes on that portion of a strip to be graded should be adequate to prevent the
accumulation of water on the surface but should not exceed:
- 2.5 percent where the code number is 3 or 4; and
- 3 percent where the code number is 1 or 2;
except that to facilitate drainage the slope for the first 3 m outward from the runway, shoulder or stopway edge
should be negative as measured in the direction away from the runway and may be as great as 5 percent. (Note:
The code number for Changi Airport runway strips adjacent to Runway 02L/20R is 4.)
(Corresponding reference in the ICAO Volume 1 of Annex 14: para 3.3.14.)

12
 third of the runway’s length and at 3, 6 and 9 metres from the
runway centreline. The average coefficients for each third of the
runway (starting from the end of Runway 02L) were 0.65, 0.58 and
0.62. These values were above the maintenance friction level of
0.47 recommended in Table 14-1of the Singapore Manual of
Aerodrome Standards, a level below which corrective maintenance
action will have to be initiated.

1.11 Flight Recorders

1.11.1 Solid State Flight Data Recorder

1.11.1.1 The aircraft was equipped with a solid state flight data recorder
(part number 980- 4700-042; serial number 08735) manufactured
by Honeywell. The recorded parameters were useful to the
investigation.

1.11.1.2 The landing gear data had a “Not Tilt” indication which appeared for
about four seconds before it changed to the “Not Valid” indication
together with the loss of other parameters related to the landing
gear.

1.11.2 Solid State Cockpit Voice Recorder

1.11.2.1 An AlliedSignal solid state cockpit voice recorder (part number: 980-
6022-001 and serial number 0576), with a duration of two hours
was installed on the aircraft. The recorder was removed intact from
the aircraft for downloading and reading out.

1.11.2.2 The outputs of the microphones of the PIC, PF, observer and the
cockpit area were recorded on four separate tracks. The quality of
the recording was satisfactory.

1.12 Wreckage and impact information

1.12.1 Not applicable.

1.13 Medical and pathological information

1.13.1 Not applicable.

1.14 Fire

1.14.1 There was no fire.

13
1.15 Survival aspects

1.15.1 This was a survivable incident.

1.16 Test and research

1.16.1 Nil.

1.17 Organisational and management information

1.17.1 Nil

1.18 Additional information

1.18.1 All six tyres on the left hand landing gear had rubber reversion6,
indicating reverted rubber aquaplaning had occurred. Three of the
six tyres at positions 1, 2 and 5 were deflated. Below is a sketch
showing the layout of the main landing gear tyres of the Boeing 777
aircraft.

1 2 3 4

5 6 7 8

9 10 11 12

Left Hand Right Hand

Landing Landing
Gear Gear

Notes: Number in the box is the wheel position number.

Deflated tyres are shown shaded in the sketch above.

6
Rubber reversion occurs when rubber of the tyre is superheated by steam caused by friction between tyre and
water. This friction is most commonly brought about by aquaplaning.

14
1.18.2 Two tyres fitted at the No.1 and No.9 positions were sent to the tyre
manufacturer, by the operator, for examination and analysis. The
report from the tyre manufacturer indicated that both tyres had
severe flat spotting and exposed belt plies. The damage appeared
to have been initiated by reverted-rubber aquaplaning. The level of
abrasion on the tyres also indicates that the tyres were blocked
from rolling for some period, while in contact with the runway
surface.

1.18.3 The report also indicated that the tread wear pattern of No.1 tyre
showed an overload condition or partial or full loss of pressure,
which resulted in the shoulder areas abrading more than the centre
tread area. This tyre was apparently blocked from rolling for a
greater distance than the No.9 tyre as the amount of tread rubber
abrasion was much more.

1.18.4 No. 9 tyre’s tread has a flat spot consistent in size with its normal
load bearing, contact area. The tyre has worn in the centre rib area
exposing the steel protector ply and two layers of belt ply. The
wear was not sufficient to cause any loss of pressure. The slightly
more central wearing (compared to the shoulders) is consistent with
normal loading of that wheel.

1.18.5 There were no signs of rubber reversion or abrasion on any of the

six tyres of the right hand landing gear.

1.19 Useful or effective investigation techniques

Nil

15
2 ANALYSIS

The investigation team’s analysis covered the following areas:

a) Wind condition and crew action

b) Draining of water off the runway
c) Aquaplaning

2.1 Wind condition and crew action

2.1.1 At about 1,800 ft, after being advised by the tower of the latest
weather condition over the airfield, the crew discussed the situation
and decided to conduct an automatic landing as they expected the
aerodrome only to be sighted at a low altitude “of a few hundred
feet.” At about 600 ft, they changed their decision and reverted to
landing the aircraft manually. DFDR data showed that the wind
direction and speed from 200 ft to touchdown were constantly
changing. This resulted in the PF having to make constant
adjustments of the control surfaces to maintain the ILS for
approximately the last 48 seconds of flight (the rate of descent was
an average of 750 ft per min). It cannot be determined whether the
crew had enough time to appreciate the wind conditions
experienced in the situation, i.e. quartering tailwinds, before the
landing.

2.1.2 The weather conditions, as reported by the tower, were strong low
level windshear, medium to poor braking action, and strong
crosswinds. Although the wind direction and speed were variable,
the wind conditions were within the flight envelope of the autopilot,
and the autopilot system would be able to control the drift. The use
of the autopilot system could have helped to lessen the workload for
the crew and allowed them more time to monitor the approach and
landing.

2.2 Draining of water off runway

2.2.1 Although the runway surface, runway shoulders and runway strips
of Runway 02L meet the slope recommendations of the Singapore
Manual of Aerodrome Standards and ICAO SARPs for the drainage
of water, this incident shows that meeting these slope
recommendations may not necessarily ensure that rain water will be
drained away fast enough from the runway shoulder in heavy rain.
The water pooling could be worse in heavier rain. The chances of
aircraft aquaplaning increase with the extent of water pooling.
There may be a need to review the overall design of the runway
shoulder and grass area to ensure effective drainage.

16
2.3 Aquaplaning

2.3.1 The surfaces of all six tyres of the left hand landing gear had
evidence of reverted rubber aquaplaning.

2.3.2 At touch down, the pitch attitude was recorded as 1.4 degrees nose
up which is less than the normal pitch attitude of about 2.5 degrees.
The roll attitude was left wing low at about 1.1 degrees and 4
metres left of the centreline. The aircraft was drifting sideways to
the left while touching down firm at 1.6g on the left hand landing
gear at a ground speed of 148 knots. The combination of all these
factors could have caused an overload condition when the left hand
landing gear wheels contacted the wet runway surface, and induced
reverted-rubber aquaplaning.

2.3.3 Runway overruns or excursions on water-affected runways remain

relatively common. The industry currently lacks a means to
measure runway coefficient of friction in an actual runway
contamination situation. Such measurement will provide
information for crews to make better landing decision.

2.3.4 From the DFDR records, the ‘Not-Tilt’ indication (which indicated
that the landing gear had touched the runway) lasted four seconds
after which it was changed to the ‘Not Valid’ indication. The ‘Not
Valid’ indication is most likely due to the junction box having been
damaged after the left hand landing gear skidded off the runway.

17
3 CONCLUSIONS

3.1 Findings

3.1.1 The aircraft was airworthy and there were no pre-existing system
deficiencies that could have contributed to the incident.

3.1.2 The crew was properly qualified and rested to operate the flight.

3.1.3 The continuously changing wind conditions near touchdown made it

difficult for the PF to make accurate adjustments to land the aircraft
on the centreline with the correct flare. Consequently the aircraft
landed about 4 m to the left of the centreline of Runway 02L and
touched down firm at 1.6 g with the left wing low.

3.1.4 The wet runway, rain, and changing wind conditions contributed to
the skidding and reverted rubber aquaplaning experienced by the
aircraft, which resulted in it leaving the paved surface of the runway.

3.1.5 The transverse slopes of Runway 02L, the runway shoulders and
the runway strips (adjacent grass verge) of Changi Airport meet the
relevant recommendations of the Singapore Manual of Aerodrome
Standards and ICAO SARPs for water drainage.

3.2 Significant Factors

The following significant factors were identified:

3.2.1 The crew were aware of the changing weather conditions over the
airfield. With the complications of strong crosswind and rain over
the airfield, landing the aircraft with the autopilot could have
lessened the workload of the crew and allowed them more time to
monitor the approach and landing.

3.2.2 The aircraft was not adequately maintained on the desired ground
track and aircraft attitude, owing to the changing wind conditions at
low altitude.

3.2.3 Though the transverse slopes of Runway 02L have been

constructed in accordance with the requirements stipulated in the
Singapore Manual of Aerodrome Standards, rain water did not drain
away fast enough from the shoulders of the runway.

18
4 SAFETY RECOMMENDATIONS

It is recommended that:

4.1 The airline enhance its crews’ awareness of the hazards of

aquaplaning and review its crew training on crosswind landing in
heavy rain. (AAIB Recommendation R-2005-008)

4.2 The airport operator improve the drainage of water from Runway
02L shoulders to prevent water accumulation on the runway
shoulders in heavy rain. (AAIB Recommendation R-2005-009)

4.3 ICAO review its Standards and Recommended Practices on runway

construction to allow better drainage of water from runways in
airports where heavy rain is frequently encountered. (AAIB
Recommendation R-2005-010)

19
5 SAFETY ACTION

5.1 Arising from a previous accident investigation conducted by the

AAIB, a safety recommendation was made to ICAO suggesting
ICAO to encourage research that could lead to the production of
equipment that can accurately measure the braking action of
runways under all conditions of surface contamination.

5.2 ICAO informed the AAIB in December 2004 that the development of
a friction measuring device is an industry prerogative, that ICAO is
currently monitoring an international effort to develop means to
correlate the friction values measured by different equipment with
the friction that an aircraft would experience and that ICAO will
consider setting up a working group under the Aerodrome Panel to
review the results and recommend future action.

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6 APPENDICES

Appendix 1: Schematic of Runway 02L edge lights damaged by

the aircraft

Appendix 2: Photographs showing damage to the tyres

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Appendix 1

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 Appendix 2
PHOTOGRAPHS SHOWING DAMAGE TO THE TYRES

Tyre No. 1 Tyre No. 2

Tyre No. 5 Tyre No. 6

Tyre No. 9 Tyre No. 10

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