Final Report

B777-300ER (9V-SWH)
Low on Final Reserve Fuel

25 October 2022

TIB/AAI/CAS.209

Transport Safety Investigation Bureau

Ministry of Transport
Singapore

25 September 2023
The Transport Safety Investigation Bureau of Singapore

The Transport Safety Investigation Bureau (TSIB) is the air, marine and rail
accidents and incidents investigation authority in Singapore. Its mission is to promote
transport safety through the conduct of independent investigations into air, marine and
rail accidents and incidents.

The TSIB conducts air safety 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 sole objective of TSIB’s air safety investigations is the prevention of aviation
accidents and incidents. The safety investigations do not seek to apportion blame or
liability. Accordingly, TSIB reports should not be used to assign blame or determine
liability.

© 2023 Government of Singapore

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 Table of Contents

ABBREVIATIONS iv
SYNOPSIS 1
1 Factual information 2

1.1 History of the flight 2

1.2 Injuries to persons 8

1.3 Damage to aircraft 9

1.4 Personnel information 9

1.5 Aircraft information 10

1.6 Meteorological information 11

1.7 Aids to navigation 16

1.8 Flight recorders 16

1.9 Organisational and management information 17

1.10 Other Information 20

2 Analysis 23

2.1 Flight crew’s decision making 23

2.2 Information on autoland for Runway 04 of Batam Airport 25

2.3 Understanding of minimum fuel 27

3 Conclusions 29
4 Safety actions 30
5 Safety recommendations 32

© 2023 Government of Singapore

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ABBREVIATIONS

AFDS Autopilot Flight Director System

AGL Above Ground Level

AMC Apron Movement Control

ATC Air Traffic Control

ATIS Automatic Terminal Information Service

EAT Estimated Approach Time

FCOM Flight Crew Operations Manual

FMC Flight Management Computer

FRF Final Reserve Fuel

GPWS Ground Proximity Warning System

ILS Instrument Landing System

ICAO International Civil Aviation Organisation

PF Pilot Flying

PFD Primary Flight Display

PM Pilot Monitoring

SAC Singapore Approach Control

TAF Terminal Aerodrome Forecast

TPAC Tanjung Pinang Approach Control

VOR Very High Frequency Omni-Directional Range

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SYNOPSIS

On 25 October 2022 at about 0820UTC, a B777-300ER aircraft was diverted to

Batam Airport due to inclement weather over Changi Airport. After three unsuccessful
attempts to land, the aircraft eventually landed on the fourth attempt with low final reserve
fuel.

The Transport Safety Investigation Bureau classified this occurrence as an

incident.

AIRCRAFT DETAILS

Aircraft type : B777-300ER

Operator : Singapore Airlines
Aircraft registration : 9V-SWH
Numbers and type of engines : 2 x GE90-115B
Engine hours/cycles since new : Engine 1 58683 hours / 7448 cycles
Engine 2 67120 hours / 8379 cycles
Engine hours/cycles since
last shop visit : Engine 1 2080 hours / 269 cycles
Engine 2 7805 hours / 1048 cycles
Date and time of incident : 25 October 2022 0919 hrs (UTC)
Location of occurrence : Hang Nadim International Airport Runway 22
Type of flight : Scheduled
Persons on board : 280

© 2023 Government of Singapore

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1 FACTUAL INFORMATION

All times used in this report are Coordinated Universal Time (UTC) unless
otherwise stated.

1.1 History of the flight

1.1.1 On 24 October 2022, a Boeing 777-300ER was scheduled to depart London

Heathrow Airport at 1950 hrs and arrive in Singapore Changi Airport at 0855 hrs
on 25 October 2022. The planned alternate destination airports were Paya
Lebar Air Base in Singapore, Kuala Lumpur International Airport and Senai
International Airport in the state of Johor in Malaysia. The First Officer was the
Pilot Flying (PF) and the Pilot-in-Command (PIC) the Pilot Monitoring (PM)1.

1.1.2 Prior to departure, the flight crew reviewed the documents provided by the flight
dispatcher. The Terminal Aerodrome Forecast2 (TAF) for Changi Airport
indicated that there could be temporary light to moderate thunderstorms with
rain in the vicinity of Changi Airport for periods of 30 minutes or more but less
than 60 minutes. The flight crew accepted the fuel plan provided by the flight
dispatcher, with 106,164 kg of fuel at departure. They considered the following
factors and were satisfied that there was no requirement to uplift additional fuel:

(a) There was no forecasted large weather system along the planned flight
route that required large deviation.

(b) The forecasted weather situation at Changi Airport around the

scheduled time of arrival was above the landing minimas.

(c) There was no reported defect with the aircraft systems.

(d) Air traffic control would typically shorten the flight track of the aircraft
through European airspace.

1.1.3 At 0801 hrs on 25 October 2022, while the aircraft was in the Kuala Lumpur
Flight Information Region, Singapore Approach Control (SAC) informed the
flight crew to expect to land on Runway 20R at Changi Airport. According to the
flight crew, at that point, the flight management computer (FMC) indicated that

1 The flight was operated by an augmented crew comprising two Captains and one First Officer. The second Captain
was not in the flight deck at the time of occurrence, as this was not the operator’s requirement.
2 The TAF is an aerodrome forecast that consists of a concise statement of the expected meteorological conditions at

the aerodrome for a specified period.

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 their estimated fuel on landing was 7,000 kg, which was above the Final
Reserve Fuel (FRF)3 requirement of 3,024 kg.

1.1.4 At 0805 hrs, SAC instructed the aircraft to hold over waypoint PASPU because
of a tailwind on Runway 20R. A minute later, SAC informed all traffic on the
Approach frequency to expect delay as the tailwind on Runway 20R was in
excess of 10 kts. The PM indicated that, while in hold, the weather radar system
on the aircraft showed that there was heavy precipitation over Changi Airport
and the two alternate destination airports (Paya Lebar Air Base and Senai
International Airport) and that the weather appeared fine over Hang Nadim
International Airport in Batam, Indonesia (Batam Airport).

1.1.5 At 0810 hrs, SAC updated all traffic on the Approach frequency that the runway
in Changi Airport to be used for landing had been changed to Runway 02L.
Shortly after this, SAC informed the aircraft that the landing runway would be
Runway 02L.

1.1.6 At 0822 hrs, the flight crew established contact with Singapore Arrival Control
(hereinafter referred to as Arrival Control). Over the next six minutes, Arrival
Control vectored the aircraft towards Runway 02L and informed the flight crew
that there was heavy rain over Changi Airport and the visibility was reduced to
2 NM. During this period, the weather condition continued to deteriorate with the
visibility reducing further to 500 m while the heavy rain persisted. By 0827 hrs,
Singapore air traffic control services decided to hold off arrival traffic landing at
Changi Airport, to assess the overall weather condition at that time taking into
consideration that:

(a) Changi Tower had just initiated coordination with SAC to change the
runway configuration from the 20 to 02 direction by repositioning all
departure and arrival traffic for Runway 02R and Runway 02L
respectively, yet the wind direction had shifted back to the reciprocal
direction.

(b) The inclement weather had deteriorated further affecting the path for
both northern and southern approaches.

(c) The erratic surface wind condition and poor visibility had resulted in two

3The FRF quantity for an aircraft with turbine engine is the mass of fuel on arrival at the destination aerodrome that is
equivalent to the amount of fuel required for the aircraft to fly for 30 minutes at holding speed at 1500 feet above
aerodrome elevation in standard conditions.
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 aircraft performing go-arounds while attempting to land on Runway 02L
while another aircraft requested to discontinue its approach for Runway
02L.

1.1.7 At around 0829 hrs, Arrival Control informed all traffic on the Arrival frequency
to expect a five-minute delay and that further updates on the weather situation
over Changi Airport would be provided. The flight crew were instructed to
proceed to waypoint SAMKO and hold4. While enroute to SAMKO, the flight
crew obtained the Batam Airport Automatic Terminal Information Service5
(ATIS) which indicated clear weather in the vicinity of Batam Airport at that time,
and informed Arrival Control at 0831 hrs that they could perform only one hold6
and would be down to emergency fuel7. As the aircraft entered the hold at
around 0833 hrs, Arrival Control updated all traffic on the Arrival frequency that
the visibility for Runway 02L had deteriorated to less than 500 m.

1.1.8 In view that there was no sign of weather improvement over Changi Airport,
SAC informed Tanjung Pinang Approach Control (TPAC) in Indonesia at 0834
hrs that the flight might request to divert to Batam Airport and initiated
coordination with TPAC for a potential diversion.

1.1.9 While the aircraft was in hold and given that Changi Airport, Paya Lebar Air Base
and Senai International Airport were still affected by inclement weather whereas
the weather over Batam Airport was fine, the flight crew contemplated a
diversion to Batam Airport. The flight crew were mindful that, as the aircraft was
about the same distance to Batam Airport as to Changi Airport, a diversion to
Batam Airport would not aggravate the fuel situation.

1.1.10 At 0836 hrs, as the aircraft was about to complete the first hold over SAMKO,
the PM asked Arrival Control if there was any update to the situation. Upon being
informed that there was no update, the PM informed Arrival Control that they
were able to perform one more hold and that if they still could not have the
clearance to commence approach to land at Changi Airport thereafter, they
would need to divert to Batam Airport. Arrival Control informed the flight crew

4 An aircraft flies an oval course at a designated waypoint while in hold when awaiting further air traffic control
instructions (e.g. clearance to land).
5 ATIS is a continuous broadcast of recorded aeronautical information pertaining to an aerodrome that includes

essential information such as weather condition, active runways etc.

6 Flying one hold means flying one circuit of the oval course at the designated waypoint.
7 The flight crew used the term “emergency fuel” which is not a term in pilot-air traffic control communication

phraseology. Air traffic control would typically recognise only “Mayday Fuel” as a fuel emergency situation.
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 that it could help with the coordination for a diversion to Batam Airport.

1.1.11 At around 0839 hrs and while the aircraft was in the first hold, the PM informed
Arrival Control again that they could perform one more hold, as mentioned in
their earlier communication. Arrival Control acknowledged the flight crew’s plan
for a second hold and continued with its coordination with TPAC for the aircraft’s
diversion to Batam Airport.

1.1.12 At 0842 hrs, the flight crew informed Arrival Control that they were approaching
SAMKO to complete their second hold. They were instructed by Arrival Control
to fly heading 180°. The PM queried Arrival Control why the aircraft was being
vectored in a direction away from both Changi and Batam Airports. Arrival
Control explained to them that Changi Airport was still unable to accept arrivals
and that TPAC had not yet approved the aircraft’s diversion to Batam Airport.
The PM then offered to perform an orbit8 (instead of a third hold) over SAMKO,
which Arrival Control approved.

1.1.13 At 0844 hrs, the PM informed Arrival Control that they needed to divert to Batam
Airport9. This was the fourth flight to make the decision to divert to alternate
airport while three other flights had earlier elected to divert to alternate airports.
At this point, the PIC, who had been the PM, took over as the PF while the First
Officer, who had been the PF, became the PM. The flight crew made the
decision to divert as there was no certainty that they could land at Changi Airport
and as they assessed that the flight could divert to Batam Airport and land while
complying with the FRF requirement. Arrival Control acknowledged the flight
crew’s requirement for a diversion and instructed the flight crew to fly heading
180° so as to position the aircraft for landing on Runway 22 at Batam Airport.

1.1.14 A minute later, the PM queried Arrival Control again if Changi Airport was
accepting arrivals. Arrival Control replied that that Changi Airport was still not
accepting arrivals.

1.1.15 At 0846 hrs, Arrival Control informed the flight crew that approval for their
diversion to Batam Airport was still pending. Arrival Control instructed the flight
crew to fly heading 120° and thereafter 90°. At 0848 hrs, Arrival Control
transferred the flight to SAC. SAC vectored the aircraft towards the boundary of
its control area with the intention for the eventual hand-over of the aircraft to

8 An orbit refers to a 360° circular course at a holding point.

9 The orbit which the PM offered to perform earlier was eventually not executed.
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 TPAC to occur at a position as close to Runway 22 of Batam Airport as possible.
The PM informed SAC that they were down to minimum fuel10. Two minutes
later, SAC informed the flight crew that clearance from Batam Airport was still
pending.

1.1.16 The PF declared “Mayday Fuel” at 0853 hrs when the estimated fuel on landing
at Batam Airport was at the FRF. At that point, the aircraft was approximately
13 NM south-east of Batam Airport. SAC vectored the aircraft to an initial
heading of 360° and instructed the crew to contact TPAC11.

1.1.17 By 0855 hrs, the flight crew had established contact with TPAC and were
informed that they had priority for the landing. The PF was also performing
communication duties while the PM was configuring the aircraft systems and
providing information to the PF, in preparation for the landing at Batam Airport.
According to the flight crew, the documents they referred to included the
following:

(a) Batam Runway 22 Very High Frequency Omni-Directional Range (VOR)

approach chart

(b) Batam Runway 04 Instrument Landing System (ILS) approach chart

(c) Operator’s Airport Briefing for Batam Airport

1.1.18 At around 0900 hrs as the aircraft was on the approach path for Runway 22, the
flight crew were informed by TPAC that there was a tailwind of 14 kts gusting
up to 30 kts. The PF opted to discontinue the approach at around 1,600 feet
above ground level (AGL) and requested to reposition for another approach onto
Runway 04.

1.1.19 Over the next few minutes, the PF manoeuvred the aircraft to avoid the weather
and repositioned the aircraft with the intention to perform an autoland using the
Instrument Landing System (ILS) on Runway 04. At around 0905 hrs, the PM
informed TPAC that he had Runway 04 in sight. TPAC instructed the flight crew
to contact Nadim Tower (the control tower at Batam Airport) on tower frequency
of 118.7 MHz and the PM read back the frequency correctly.

10 See 1.10.2 for information on minimum fuel declaration.

11 Earlier at 1647 hrs, TPAC had informed that should the flight declare an emergency, SAC could proceed to route the
aircraft directly to Batam Airport.
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1.1.20 Shortly after the last communication with TPAC, the PF disengaged the autopilot
system when the aircraft was 1,195 feet AGL. The PF recalled that he attempted
to manually fly the aircraft to capture the glideslope and localiser signals with
the intention to perform an autoland.

1.1.21 At around 0906 hrs, Nadim Tower informed TPAC that the flight crew had not
made contact on the tower frequency and the tower controllers did not have the
aircraft in sight because of heavy rain and the visibility for Runway 04 was 500
m. Nadim Tower did not issue any landing clearance for the aircraft as the flight
crew did not contact Nadim Tower.

1.1.22 At around this time, the PF managed to position the aircraft on the localiser final
approach course for Runway 04 and armed the autopilot Approach mode. The
lateral and vertical mode of the aircraft’s autopilot flight director system
managed to capture the localiser and glideslope mode respectively. The PF
engaged the autopilot system when the aircraft was 668 feet AGL but was met
with a “NO AUTOLAND” message on the Primary Flight Display (PFD).
According to the PF, he was startled by the appearance of the “NO AUTOLAND”
message and shortly after, he noticed that the localiser and glideslope deviation
pointers were showing almost a full-scale deflection on his PFD, indicating that
the aircraft was away from the centreline and glidepath of the runway. The PF
disengaged the autopilot and, 20 seconds later, executed a go-around when the
aircraft was 132 feet AGL.

1.1.23 At 0907 hrs, Nadim Tower informed TPAC that there was an aircraft going
around at Runway 04. Three seconds after this communication, the PF informed
TPAC that he was executing a go-around.

1.1.24 At 0909 hrs, while the PF was repositioning the aircraft for another attempt to
land on Runway 04, he requested TPAC for information on the tailwind at
Runway 22. TPAC had to relay this request to Nadim Tower and was only able
to reply to the flight crew 90 seconds later, informing that the visibility for Runway
04 and Runway 22 was 500 m and six kilometres respectively and that wind
information was 340° at seven knots.

1.1.25 In response, the PF informed TPAC that the aircraft did not have sufficient fuel
to be repositioned for Runway 22 and that his next landing attempt on Runway
04 had to be successful. At that point, the aircraft was approximately abeam the
threshold of Runway 04 and the flight crew was about to commence a right turn
for the final approach to Runway 04.
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1.1.26 At about 0911 hrs, TPAC informed the flight crew that the visibility for Runway
04 was 800 m and that the flight crew had the discretion to continue the
approach. The PF confirmed to TPAC that he would maintain his original
intention to land on Runway 04.

1.1.27 Over the next two minutes, TPAC and Nadim Tower coordinated the
movements of other traffic to keep the runway clear. TPAC continued to relay
information between the flight crew and Nadim Tower, which included the
landing clearance.

1.1.28 According to the PF, when the aircraft broke cloud cover on the second
approach to Runway 04, the aircraft was above the glidepath and offset to the
left of the extended centreline of the runway. The PF increased the descent rate
in an attempt to position the aircraft on the glidepath and extended centreline of
the runway. However, the Ground Proximity Warning System (GPWS)
generated a warning for excessive sink rate when the vertical speed exceeded
-1,400 feet per minute. At 0914 hrs, the PF initiated another go-around in
response to the GPWS warning, in line with the operator’s procedures, when
the aircraft was at about 212 feet AGL.

1.1.29 At around 0915 hrs, the PF informed TPAC that they were going around and
would perform a teardrop turn to reposition the aircraft to perform a visual
landing on Runway 22. Subsequently, TPAC gave wind information as wind
direction 330° at 15 kts to the fight crew. The PF was aware that the aircraft’s
tailwind certification limit was 15 kts for landing and the operator’s procedure
was not to land with a tailwind exceeding 10 kts. Considering that the remaining
fuel quantity had reached critically low level, the PF decided to proceed with the
approach to land on Runway 22.

1.1.30 The aircraft subsequently landed at Batam Airport and taxied to a parking bay.
The aircraft touched down at Batam Airport at 0919 hrs with fuel remaining
significantly below the FRF of 3,024 kg.

1.2 Injuries to persons

1.2.1 There was no injury to any person in this incident.

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1.3 Damage to aircraft

1.3.1 There was no damage to the aircraft.

1.4 Personnel information

1.4.1 PIC

Age 55
Licence type Air Transport Pilot License
Issuing authority Civil Aviation Authority of Singapore
Licence validity date 10 January 2020
Medical certificate Class One
Medical certificate validity Date of expiry: 31 January 2023
Medical operational proviso Corrective lenses for near vision
Last Base Check date 24 March 2022
Last Line Check date 14 March 2022
Total flying hours 14,371.5
Aircraft types flown B747, B777
Total hours on type 10,075.6
Flying in last 90 days 246hr 32min
Flying in last 7 days 40hr 10min
Flying in last 24 hours 13hr 44min
21hr 13min
(Comprising 5hr 59min on standby
Duty time in last 48 hours
on 23 October 2022, and 15hr 14min
on SQ319)
Rest from 22 October 2022 1556z to
24 October 2022 1850z (except
Rest period in last 48 hours
standby period on 23 October 2022
as stated above)

1.4.2 FO

Age 31
Licence type Air Transport Pilot License
Issuing authority Civil Aviation Authority of Singapore
Licence validity date 18 April 2022
Medical certificate Class One

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 Medical certificate validity 30 April 2023
Medical operational proviso Corrective lenses for distant vision
Last Base Check date 12 June 2022
Last Line Check date 20 January 2022
Total flying hours 2,261.9
Aircraft types flown B777
Total hours on type 2,261.9
Flying in last 90 days 203hr 25min
Flying in last 7 days 27hr 40min
Flying in last 24 hours 13hr 44min
21hr 13min
(Comprising 5hr 59min on standby
Duty time in last 48 hours
on 23 October 2022, and 15hr 14min
on SQ319)
Rest from 22 October 2022 1556z to
24 October 2022 1850z (except
Rest period in last 48 hours
standby period on 23 October 2022
as stated above)

1.5 Aircraft information

1.5.1 Autopilot Flight Director System (or autopilot system)

1.5.1.1 The Autopilot Flight Director System (AFDS) has these two purposes:

(a) To automatically control the airplane attitude when the autopilot is

engaged.

(b) To supply indications so the flight crew can manually control the
airplane attitude.

1.5.1.2 When the Approach (APP) switch on the mode control panel is pushed, it arms
the localiser in roll mode and glideslope in pitch mode. Once the localiser and
glideslope signs are captured, the approach mode becomes engaged.

1.5.1.3 In the approach mode of the AFDS, the aircraft automatically captures and
tracks the localiser and glideslope signals. If the autopilot approach continues
and certain criteria are met by the aircraft systems and aerodrome

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 infrastructure12, the aircraft is able to land automatically as the glideslope signals
guides the aircraft along the descent path to the touchdown point on the runway
while the localiser signal guides the aircraft along maintain a lateral path that is
centred along the extended centreline of the runway.

1.5.1.4 The AFDS provides inputs to control the elevators, ailerons, flaperons and
spoilers. During approach and landing, the AFDS would also provide inputs to
control the rudder. After an automatic landing, the AFDS also provide inputs to
control the nose wheel steering and rudder to follow the localiser signal.

1.5.1.5 According to the aircraft manufacturer, some of the situations where the “NO
AUTOLAND” message may be shown on the PFDs include:

(a) If the APP switch has been selected but the engaged status has not
been annunciated by 600 feet AGL.

(b) If the AFDS is in approach mode and the aircraft track is not aligned with
the runway heading that is stored in the flight management computer’s
navigation database.

1.6 Meteorological information

1.6.1 According to meteorological records, there was a thunderstorm on 25 October

2022 at 0800 hrs north of Changi Airport. The thunderstorm moved southwards
and affected the aerodrome between 0815 hrs and 0915 hrs. During this period,
the thunderstorms continued to develop and intensified over the southern parts
of Singapore as well as the eastern side of the Batam island, where Batam
Airport was located.

1.6.2 The summary of the Meteorological Aerodrome Reports (METARs) for Changi
Airport around period of occurrence is provided in Table 1.

12 The runways at Changi Airport are equipped for Category II ILS operation. Based on Singapore Air Traffic Services’
procedures, Category II ILS approaches can be made available in times of prolonged periods of reduced visibility and
forecasted to deteriorate further. Pilots can request to perform a Category II ILS approach but Changi Airport will require
one hour for all stakeholders to prepare the aerodrome to ensure that glideslope and localiser signals are protected to
accurately guide the aircraft to the touchdown point on the runway. The visibility around the period of the incident flight’s
arrival did not deteriorate to the criteria of Category II ILS operation, it was the unstable wind conditions that had resulted
in temporary holding off of arrival flights.
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 Time (UTC) METAR

0800 METAR WSSS 250800Z 16007KT 9999 VCSH FEW014 FEW016CB

FEW017TCU SCT040 30/25 Q1008 TEMPO TL0930 4500 TSRA=

Summary: Mean winds of 7 kts blowing from the south-southeast

direction were reported and no significant weather was observed.
Moderate thunderstorm with precipitation and a prevailing
visibility of 4500 m was forecasted until 0930 hrs.

0807 SPECI13 WSSS 250807Z 14005KT 020V170 9000 -TSRA FEW014

FEW016CB SCT017TCU 29/25 Q1008 TEMPO TL0930 3000 TSRA=

Summary: Mean winds of 5 kts blowing from the southeast

direction were reported. Light thunderstorm with a prevailing
visibility of 9000 m was observed. Moderate thunderstorm with
precipitation and a prevailing visibility of 3000 m was forecasted
until 0930 hrs.

0811 SPECI WSSS 250811Z 33010KT 300V360 9000 4000E -TSRA

FEW014 FEW016CB SCT017TCU 29/23 Q1008 TEMPO TL0930 3000
TSRA=

Summary: Mean winds of 10 kts blowing from the northwest

direction were reported. Light thunderstorm with a prevailing
visibility of 9000 m and minimum visibility of 4000 m to the east
was observed. Moderate thunderstorm with precipitation and a
prevailing visibility of 3000 m was forecasted until 0930 hrs.

0815 SPECI WSSS 250815Z 26008KT 230V300 3500 TSRA FEW012

FEW014CB BKN015TCU 26/22 Q1009 TEMPO TL0930 2000 +TSRA=

Summary: Mean winds of 8 kts blowing from the west-southwest

direction were reported. Moderate thunderstorm and a prevailing
visibility of 3500 m was observed. Heavy thunderstorm with
precipitation and a prevailing visibility of 2000 m was forecasted
until 0930 hrs.

13 SPECI is a special weather report issued beyond the normal update frequency of the METAR, when there is
significant deterioration or improvement in airport weather conditions.
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 0830 METAR WSSS 250830Z 32009KT 230V360 1000 R02L/P2000N
R02R/P2000N +TSRA FEW008 FEW014CB BKN015TCU 24/22
Q1009 BECMG FM0900 TL0915 4500 TSRA BECMG FM1000 6000
NSW=

Summary: Mean winds of 9 kts blowing from the northwest were

reported. Heavy thunderstorm with a prevailing visibility of 1000
m was observed. The observed weather conditions were
forecasted to last until 0900 hrs and expected to gradually
improve from 0900 hrs to 0915 hrs to moderate thunderstorm with
precipitation and a prevailing visibility of 4500 m.

0900 METAR WSSS 250900Z 20005KT 170V260 1500 +TSRA FEW008

FEW014CB SCT015TCU BKN130 23/23 Q1009 BECMG TL0930 4500
TSRA BECMG FM1000 TL1030 6000 NSW=

Summary: Mean winds of 5 kts blowing from the south-southwest

direction were reported. Heavy thunderstorm with a prevailing
visibility of 1500 m was observed. The observed weather
conditions were forecasted to improve to moderate thunderstorm
with precipitation and a prevailing visibility of 4500 m by 0930 hrs.

Table 1: Summary of METAR for Changi Airport

1.6.3 The summary of the METARs for Batam Airport around period of occurrence is
provided in Table 2.

Time (UTC) METAR

0800 METAR WIDD 250800Z 18004KT 9999 FEW013CB SCT014

30/24 Q1010 NOSIG RMK CB TO NW DUPE=

Summary: Mean winds of 4 kts blowing from the south direction

were reported. Cumulonimbus clouds were observed in the
north-west direction.

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 0830 METAR WIDD 250830Z 17004KT 9999 FEW013CB SCT014
30/24 Q1010 NOSIG RMK CB TO N AND NW=

Summary: Mean winds of 4 kts blowing from the south direction

were reported. Cumulonimbus clouds were observed in the north
and north-west direction.

0900 METAR WIDD 250900Z 04010KT 9999 FEW013CB BKN014

30/23 Q1010 NOSIG RMK CB TO N AND NW=

Summary: Mean winds of 10 kts blowing from the north-east

direction were reported. Cumulonimbus clouds were observed in
the north and north-west direction.

0930 METAR WIDD 250930Z 35004KT 6000 -TSRA FEW013CB

BKN014 26/23 Q1011 NOSIG RMK CB TO N AND SE AND NW=

Summary: Mean winds of 4 kts blowing from the north direction

were reported. Light thunderstorm and a prevailing visibility of
6000 m was observed. Cumulonimbus clouds were observed in
the north, south-east and north-west direction.

1000 METAR WIDD 251000Z 29006KT 8000 -TSRA FEW013CB

BKN014 25/23 Q1011 NOSIG RMK CB TO SE AND S AND NW=

Summary: Mean winds of 6 kts blowing from the west-northwest

direction were reported. Light thunderstorm and a prevailing
visibility of 8000 m was observed. Cumulonimbus clouds were
observed in the south-east, south and north-west direction.

1030 METAR WIDD 251030Z 30004KT 9000 -TSRA FEW013CB

BKN014 25/24 Q1011 NOSIG RMK CB TO SE AND S AND NW=

Summary: Mean winds of 4 kts blowing from the north-west

direction were reported. Light thunderstorm and a prevailing
visibility of 9000 m was observed. Cumulonimbus clouds were
observed in the south-east, south and north-west direction.

Table 2: Summary of METAR for Batam Airport

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1.6.4 The rain intensity over both Changi and Batam Airports from the time the aircraft
entered the hold over SAMKO until it landed in Batam Airport is shown in Figure
1.

Figure 1: Rain intensity over Changi and Batam Airports

1.6.5 Changi Airport was affected by heavy rain during the period when the aircraft
was vectored towards Runway 02L. During the period when the flight was
holding over SAMKO, there was no rain over Batam Airport but the weather
system was moving south from Singapore towards Batam.

1.6.6 The weather system moved south towards Batam Airport, located approximately
16 NM south-east of Changi Airport. Weather radar records showed that light
rain was observed in the vicinity of Batam Airport at 0850 hrs. The rain continued
to develop and intensify during the period when the flight diverted and made the
landing attempts. When the flight crew declared “Mayday Fuel”, the weather
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 condition over Batam Airport had deteriorated with a wider spread of moderate
rain intensity.

1.6.7 By 0900 hrs, when the flight arrived for the first approach on Runway 22, there
was moderate to heavy rain over Batam Airport. Over the next 20 minutes where
the PIC attempted thrice to land the aircraft, the weather deteriorated with the
rain intensity increasing and becoming more widespread.

1.7 Aids to navigation

1.7.1 For the approach to Runway 04 of Batam Airport, an ILS is available. The
localiser frequency of the ILS is 110.1 MHz with the identifier IBTM. The heading
for the final approach course of the localiser signal is 41°, a 1° offset from the
heading of Runway 04 which is 42°. According to the aircraft manufacturer, this
difference is likely the result of the two magnetic courses being surveyed at
different times and the aircraft would have been able to follow the localiser signal
and perform an autoland if certain criteria are met by the aircraft systems and
aerodrome infrastructure. Nevertheless, the operator’s procedures (refer to
Para 1.9.2) indicate that its flight crew should not attempt an autoland if the
published approach charts indicate that there is an offset.

1.7.2 Even in situations where autoland is not available, the ILS localiser and
glideslope signals can be used by the AFDS to guide the aircraft along the
appropriate vertical descent and lateral profile for the approach. As they
approach the decision altitude14, they can disconnect the autopilot and land the
aircraft manually.

1.8 Flight recorders

1.8.1 The aircraft was installed with a Cockpit Voice Recorder (CVR) and a Flight Data
Recorder (FDR). After the aircraft arrived at the parking bay at Batam Airport,
the flight crew shut down the engines but left the auxiliary power unit (APU)
running to provide conditioned air to the aircraft cabin when the passengers
waited for the aircraft to take off again for Changi Airport. The flight crew did not
deactivate the CVR and FDR.

1.8.2 As the CVR had a recording capacity of only two hours, audio data around the

14Decision altitude is a specific altitude during a precision approach where the pilot must discontinue the approach if
the required visual reference to continue the approach has not been established.
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 time of the diversion occurrence was over-written and was not available for
analysis by the investigation team.

1.8.3 Fight data from the FDR, which had a recording capacity of 25 hours, was
downloaded and analysed. The data around the time of the diversion
occurrence was available and used for analysis by the investigation team.

1.8.4 The FDR data was reviewed by the aircraft manufacturer. It was observed that
in the first approach to Runway 04, the aircraft intercepted the localiser signal
at a 15° angle slightly less than 2 NM from the runway threshold. The autopilot
was engaged just as the aircraft crossed the centre of the localiser beam and
the aircraft passed through the localiser beam before it could turn to align with
the localiser given the short range. The AFDS identified the increasing localiser
deviation and set the “NO AUTOLAND” message to indicate that the aircraft
track was out of alignment with the runway heading and that autoland could not
be engaged.

1.9 Organisational and management information

1.9.1 Operator’s fuel policy

1.9.1.1 The operator’s fuel policy contained within the operations manual states that:

(a) The PIC shall request delay information from ATC when unanticipated
circumstances may result in landing at the destination airport with less
than the FRF plus any fuel required to proceed to an alternate airport or
the fuel required to operate to an isolated airport.

(b) When the maximum delay or an Estimated Approach Time (EAT) is

known, the flight may continue to hold, as long as landing at destination
is assured and the fuel remaining at touchdown is not less than the FRF.

(c) The PIC shall advise ATC of a minimum fuel state by declaring
“minimum fuel” when, having committed to land at a specific airport, the
pilot calculates that any change to the existing clearance to that airport
may result in landing with less than FRF.

(d) The declaration of “minimum fuel” informs ATC that all planned airport
options have been reduced to a specific airport of intended landing and
any changes to the existing clearance may result in landing with less

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 than FRF. This is not an emergency situation but an indication that an
emergency situation is possible should any additional delay occur.

(e) The PIC shall declare a situation of fuel emergency by broadcasting

“mayday, mayday, mayday, fuel” when the calculated usable fuel
predicted to be available upon landing at the nearest airports where a
safe landing can be made is less than the FRF.

1.9.2 Operator’s autoland policy

1.9.2.1 The operator’s flight crew operations manual (FCOM) states that:

An autoland should not be attempted unless the localiser final approach

course is aligned with the runway centreline, except for runways that have
CAT II or III ILS charts published.

1.9.2.2 In the published approach charts available to the flight crew, there is no explicit
mention that an autoland should not be attempted. During the occurrence, the
flight crew had made reference to the Batam Runway 04 ILS and Batam Runway
22 VOR approach charts. They would have looked at specific areas of both
charts (see Figure 2) to recognise that the heading for the final approach course
of the localiser signal is 41°, which is a 1° offset from the heading of Runway 04
which is 42° to arrive at the conclusion that an autoland should not be attempted.

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 Figure 2: (Left) ILS chart indicating 41° heading for the localiser signal
(Right) VOR chart showing 42° heading for Runway 04

1.9.3 Airport briefing document

1.9.3.1 The operator provides, in respect of every airport that it operates to, an airport
briefing document to provide useful operational information (e.g. common
hazards, ground movement/parking limitations) to its flight crew about the
specific airport that they are operating into. The airport briefing is a value-add
initiative by the operator that is over and above the regulator’s requirements.

1.9.3.2 For some airports where autoland is not permitted because the localiser signal
is not aligned to the runway heading, this information is reflected in the critical
section of the airport briefing document, as shown in Figure 3 for Phuket Airport.

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 Figure 3: Information showing autoland is not permitted on Runway 27 of
Phuket Airport

1.9.3.3 In the case of the critical section of operator’s airport briefing for Batam Airport,
there is no information reflecting autoland is not permitted for Runway 04, as
shown in Figure 4.

Figure 4: No information in the critical section of Batam Airport briefing

1.9.3.4 The operator indicated that information within the airport briefing documents is
derived from several formal and informal sources, including crew and ATC
feedback. According to the operator, the inclusion or omission of any information
in the airport briefings is not intended to supplement or detract from its published
policies, hence the level of details in one airport brief document may defer from
another.

1.10 Other Information

1.10.1 Diversion Coordination

1.10.1.1 When SAC first initiated diversion coordination with TPAC at 0834 hrs for the
aircraft to divert to Batam Airport, the flight crew had not indicated that it was in
a “Mayday Fuel” situation. The coordination between both SAC and TPAC was
based on the procedures to coordinate the normal movement of an arrival
aircraft in a non-emergency situation. A typical coordination process usually
takes between 10 and 20 minutes and it involves:

(a) SAC contacting TPAC and providing details of the diverting aircraft and
the abbreviated flight plan.

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 (b) TPAC informing Nadim Tower on the diversion request.

(c) Nadim Tower coordinating with Batam apron movement control (AMC)
on the diversion request. Factors that both Batam Tower and Batam
AMC have to consider if they can accept the arrival of aircraft include,
but not limited to:

(i) If the aerodrome is certified to support the operation of the aircraft

type

(ii) If the aerodrome rescue and firefighting services can support

emergency response involving a particular aircraft type

(iii) The availability of parking area for the unscheduled arrival aircraft

(iv) Manoeuvring space for the aircraft movement in the apron

(d) Nadim Tower and Batam AMC reach a decision if the diversion can be
accepted.

(e) Nadim Tower updates TPAC if the diversion can be accepted.

(f) TPAC informs SAC if aircraft can be accepted.

1.10.1.2 When TPAC first informed Nadim Tower for the possible diversion of the
occurrence aircraft at 0834 hrs, both air traffic control units were in the midst of
coordinating the movement of two other aircraft scheduled to depart Batam
Airport. By 0844 hrs when TPAC asked for updates on the diversion for the
occurrence flight, they were informed that Batam AMC was still processing this
request. At around the same time when the flight crew informed SAC that they
have decided to divert to Batam, SAC provided TPAC with information on the
aircraft’s flight plan to which TPAC replied to wait for their update.

1.10.1.3 At 0847 hrs, SAC informed TPAC that the flight had already decided to divert to
Batam Airport and again checked if the diversion for the flight had been
accepted. TPAC replied that Nadim Tower had received the earlier information
but not provided any updates. TPAC further informed that should the flight
declare an emergency, SAC can proceed to route the aircraft directly to Batam
Airport.

1.10.1.4 By 0848 hrs, SAC informed TPAC that it would continue to vector the aircraft

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 closer to Batam Airport, while waiting for updates on the diversion request.

1.10.1.5 SAC contacted TPAC at 0850 hrs again but there were still no updates on the
diversion request. SAC proceeded to inform and passed on information to TPAC
to coordinate the diversion of another two aircraft to Batam Airport and
highlighted that it would like to hand over movement control of the occurrence
aircraft once Nadim Tower accepts the earlier diversion request.

1.10.1.6 The investigation team understood that when the Batam AMC initially received
the diversion request, it noted that the aircraft type (B777) does not usually
operate into the airport. Nadim Tower was unable to provide updates on the
outcome of the diversion request when queried by SAC, as Batam AMC was in
the midst of verifying if it could facilitate the non-emergency diversion request.

1.10.1.7 At 0854 hrs, immediately after the flight crew declared “Mayday Fuel”, SAC
informed TPAC of the situation. TPAC immediately accepted aircraft’s diversion
and informed SAC that the flight was given priority to land ahead of all other
arrivals.

1.10.2 Minimum fuel information

1.10.2.1 When the flight crew informed SAC that they were at minimum fuel, it was in line
with the operator’s fuel policy which is meant to inform air traffic control that all
planned airport options have been reduced to a specific airport of intended
landing and any change to existing clearance my result in landing with less than
the FRF. A minimum fuel declaration is not an emergency situation but an
indication that an emergency situation is possible should any additional delay
occur.

1.10.2.2 Based on the standard operating procedures of SAC, when being informed of
an aircraft in a minimum fuel situation, the air traffic controllers will avoid
extending the track miles of the aircraft with the aim of not aggravating the
aircraft’s fuel situation. However, as a minimum fuel situation is not an
emergency situation vis-à-vis a “Mayday Fuel” declaration, the routing provided
to the aircraft will be based on the prevailing traffic condition. Direct routing will
only be provided in the event when an aircraft declares emergency.

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2 ANALYSIS

The investigation looked into the following:

(a) Flight crew’s decision making

(b) Information on autoland for Runway 04 of Batam Airport

(c) Understanding of minimum fuel

2.1 Flight crew’s decision making

2.1.1 The operator has indicated that there is no set policy or procedure for initiating
a diversion and provides its flight crew with the discretion to initiate a diversion
as required, as they are in the best position to evaluate the dynamic factors of
each individual flight.

2.1.2 The operator’s fuel policy is clear in the guidance to its flight crew that if the
maximum delay or an EAT is known, the flight may continue to hold, as long as
landing at destination is assured and the fuel remaining at touchdown is not less
than the FRF. However, the situation faced by the flight crew on the day of
occurrence where information on the maximum delay or EAT was not available
does not necessarily mean that a diversion should be initiated immediately.

2.1.3 The decision to initiate a diversion when an aerodrome is unable to accept

arrivals is not always straightforward. The flight crew would have to balance the
possibility of potentially holding a while longer and possibly landing with more
than the FRF requirement at the scheduled arrival airport against the possibility
of diverting earlier but landing below the FRF requirement at the diversion
airport.

2.1.4 In this occurrence, the flight crew appeared to have preferred to land at the
scheduled arrival airport, Changi Airport, and held off deciding to divert based
on the following decisions that were made:

(a) They offered to perform another hold over SAMKO at 0839 hrs even
though Arrival Control was unable to offer any update when queried by
the PM earlier at 0836 hrs and they had previously indicated that they
could only perform a single hold.

(b) They indicated that they could perform an orbit at 0842 hrs, as they were
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 about to complete the second hold, when informed by Arrival Control
that Changi Airport was not accepting any arrivals and was in the midst
of coordinating a diversion for the aircraft to Batam Airport.

(c) They queried if Changi Airport was accepting arrivals at 0845 hrs despite
declaring that they would divert a minute earlier and had accepted
Arrival Control’s instruction to be vectored towards Batam Airport.

2.1.5 With the decision taken to stay in hold as much as possible in hope that the
scheduled arrival airport starts to accept arrivals again, the trade-off for any flight
crew is the reduced safety margins available to them when the decision to divert
is eventually made and should they need to perform more than one landing
attempt due to unforeseen events such encountering windshear during short
finals that requires a go-around to be performed.

2.1.6 The operator opines that the decision taken by the flight crew to stay in hold as
much as possible in the hope that the scheduled arrival airport starts to accept
arrivals again does not compromise safety margins. It further opines that had
the pertinent information been given to the crew, a more informed decision could
have been made to extend the hold or to initiate a diversion. Such pertinent
information should be in the form of SAC explicitly stating it was holding off
arrival.

2.1.7 The investigation team is of the opinion that the repeated information on Changi
Airport being unable to accept arrivals should be interpreted that a landing at
the airport was not assured and the flight crew could have made a decision
based on this information. Between 0820 - 0844 hrs, three other aircraft were
presented with similar information by SAC and were able to make a decision to
divert earlier.

2.1.8 In this occurrence, the flight crew had identified Batam Airport as a viable
alternate destination with fair weather when Changi Airport, Paya Lebar Air
Base and Senai International Airport were all affected by heavy precipitation.
Unfortunately, when the flight crew persisted with their decision to hold as long
as possible, the weather system affecting Changi Airport started to move in the
South Easterly direction towards Batam Airport. Had the flight crew initiated a
diversion after the first hold based on their original intention as communicated
to Arrival Control, when they were first instructed to hold over SAMKO, it is
reasonable to believe that they would have arrived at Batam Airport earlier and
would be able to attempt a successful landing on Runway 22 in a better weather
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 condition.

2.1.9 Recent studies identified that one of the effects of climate change is more
intense and more frequent storms in many regions exacerbated by extreme
rainfall and flooding. This may likely result in pilots operating into areas where
the weather conditions exceed the limits to conduct a safe landing or results in
loss of capacity of an airport that may impact the regional airspace system.

2.1.10 The effects of climate change are also expected to make the operating
environment for pilots more unpredictable. The events in this occurrence
suggest that it may be prudent for pilots to interpret operating procedures in a
more conservative manner to conclude that landing at a scheduled destination
is not assured if the air traffic controllers are not able to provide definitive
updates. This will allow pilots to make an earlier decision to divert, with higher
safety margins, especially when weather conditions are favourable, to increase
the chances of conducting a safe landing at the diversion aerodrome.

2.2 Information on autoland for Runway 04 of Batam Airport

2.2.1 According to the operator’s FCOM, an autoland should not be attempted when
information contained within the published charts indicates that the localiser
signal is not aligned to the runway heading. Hence, an autoland should not have
been attempted on Runway 04 of Batam Airport as the heading for the final
approach course of the localiser signal is 41°, which is a 1° offset from the
runway heading of 42°.

2.2.2 The flight crew had intended to perform an autoland in their first attempt to land
on Runway 04 of Batam Airport. They appeared not to have determined that an
autoland should not be attempted, in accordance with the operator’s FCOM, as:

(a) It appears that while looking through the approach charts for Batam
Airport in preparation for the approach for Runway 04, they did not
recognise the 1° offset between the final approach course and the
heading of Runway 04 to realise that an autoland should not be
attempted; and

(b) The operator’s airport briefing document for Batam Airport did not
indicate autoland is not permitted even though such information may be
reflected for some other airports where the localiser signal is not aligned

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 to the runway heading.

2.2.3 The unexpected appearance of the “NO AUTOLAND” message on the PFD
appeared to have affected the flight crew’s operating capacity in the following
manner:

(a) The PIC (who was the PF for landing at Batam Airport) indicated to the
investigation team that he was startled by the appearance of the “NO
AUTOLAND” message and took a while to recover before eventually
deciding to perform a go-around. Based on the recorded FDR data
reviewed by the aircraft manufacturer, when the PF engaged autopilot
at 668 feet AGL, the AFDS was providing pitch and roll inputs to the
flight control systems to guide the aircraft towards the centre of the
glideslope and localiser signal. Had the flight crew been aware that an
autoland should not have been attempted, instead of disconnecting the
autopilot when the “NO AUTOLAND” message appeared, it was
possible for them to maximise the use of automation to allow the
autopilot to guide the aircraft to descend to the decision altitude (which
was 200 feet AGL) before disengaging the autopilot and manually land
the aircraft, if the runway could be sighted.

(b) It distracted the flight crew as they did not realise that they did not make
radio contact with Nadim Tower although instructed to do so by TPAC
at around the same period when the “NO AUTOLAND” message
appeared. Subsequently, they also did not realise that they had not
received landing clearance for their first attempt to land on Runway 04.

2.2.4 In this occurrence, the only means for the pilots to determine if autoland can be
performed, would be for them to look at specific areas of two different
documents, recognise the offset of the localiser signal and heading of Runway
04 and arrive at the conclusion that an autoland should not be attempted, as
prescribed by the operator’s procedures. There is no information in any of the
approach charts that explicitly indicates that an autoland should not be
attempted. Pilots have to be mindful and systematically make such a
determination if they intend to perform an autoland. It is all the more important
that pilots be periodically reminded of the operator’s requirement as it is easy to
overlook this process, more so in a high stress situation such as running short
of fuel.

2.2.5 As part of its initiative to improve their pilot’s awareness of the airports they are
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 operating into, the operator provides airport briefing document that highlights
useful operational information which is over and above the regulator’s
requirements. However, there was a lack of consistency in the level of details
when comparing one airport briefing document to another.

2.2.6 In the case of Runway 27 of Phuket Airport where the localiser signal is not
aligned to the runway heading, the critical section of this airport briefing
document clearly indicated that autoland is not permitted. However, this
information was not present in the Batam Airport briefing document even though
the information within the approach charts indicates that the localiser signal was
similarly offset to the runway heading. Undoubtedly, it is important for
information contained within documents which are provided to the pilots, to
make operational decisions, to be consistent in the level of detail.

2.2.7 Had this information been included in the Batam Airport briefing document, the
flight crew would have been aware that an autoland is not permitted by the
operator’s procedures when the FO (who was the PM for the landing at Batam
Airport) referred to it while preparing for the approach. As the aircraft descended
past 1,195 feet AGL, the flight crew indicated that they could sight the runway
when queried by TPAC for the first approach on Runway 04. It is reasonable to
believe that the PIC would be able to continue the approach manually if he had
been aware that autoland was not permitted instead of being startled by the “NO
AUTOLAND” message and eventually performing a go-around.

2.3 Understanding of minimum fuel

2.3.1 The flight crew had informed SAC and Arrival Control about the progressively
deteriorating state of their fuel situation by mentioning that:

(a) They would be down to emergency fuel after one hold at 0831 hrs

(b) They were at minimum fuel at 0850 hrs

2.3.2 During the interviews with the investigation team, the flight crew indicated that
they had expected the air traffic controllers to have accorded priority for their
flight after they had indicated their fuel situation and provided a direct route when
they made the decision to divert.

2.3.3 According to Singapore ATS procedures and operator’s fuel policy, a minimum
fuel condition is not an emergency situation. As such, SAC provided the flight
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 crew with a routing based on the prevailing traffic condition.

2.3.4 The instruction by SAC for the flight to fly heading 180°, increased the distance
between the aircraft and Batam Airport. It is reasonable to believe that had the
flight crew been more assertive to inform SAC that they were unable to comply
with the given vector and reiterated their minimum fuel situation, SAC would
have facilitated by making adjustments to the overall traffic condition to provide
a more direct route to position the flight for an approach for Runway 22 at Batam
Airport.

2.3.5 Pilots should keep in mind that they have the prerogative to request air traffic
controllers to provide a more direct routing if they assess that safe operation of
their flight is compromised.

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3 CONCLUSIONS

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 flight crew appeared to have given preference to land at Changi Airport over
diverting to Batam Airport where the weather was good.

3.2 The flight crew offered to perform an additional hold and an orbit despite
informing SAC that they could only perform a single hold and would be down to
minimum fuel.

3.3 The weather over Batam Airport started to deteriorate shortly after the flight crew
decided to divert.

3.4 The flight crew did not realise that an autoland should not be performed on
Runway 04 of Batam Airport in accordance with the operator’s procedures as
information contained in the approach charts indicated that the heading for the
final approach course of the localiser signal is 41°, a 1° offset from the runway
heading.

3.5 The operator’s Batam Airport briefing document did not indicate that an autoland
should not be performed on Runway 04 as the approach charts indicate that the
localiser final course is offset from the runway heading even though such
information is included in its airport briefing document of other airports.

3.6 The appearance of the “NO AUTOLAND” message on the PFD startled the PF
who eventually decided to perform a go-around even though the flight crew were
able to sight the Runway 04 as they were descending past 1,195 feet AGL.

3.7 The appearance of the “NO AUTOLAND” message, coupled with a low fuel
situation, likely intensified the flight crew’s workload as they did not establish
communication with Nadim Tower and did not realise that no landing clearance
was given for their first attempt to land on Runway 04.

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4 SAFETY ACTIONS

Safety actions taken by organisation(s) concerned arising from discussions with

the investigation team.

4.1 The operator reviewed the event and conducted sharing sessions with all its
pilots covering the following:

• The appropriate application of the operator’s threat and error model in

respect to this occurrence. The threats from the operating environment,
weather and automation were reinforced.

• How the pilots can employ active communication to inform other parties
of information in a timely manner and ensuring the message is
understood by the receiver.

• Reiterating that compliance with the operator’s procedures is essential

to maintain operational safety.

• How to recognise high workload situations and the associated human

factors such as attentional tunnelling which could result in errors in
decision making.

4.2 The operator has incorporated lessons learnt from this occurrence as a micro-
learning module in its evident based training program focusing on inflight fuel
management, diversions to alternate airports and declaration of low fuel state.

4.3 The operator has incorporated this occurrence as a scenario in its line-oriented
flight training module in the simulator to ensure that its pilots are able to review
their understanding and appropriately apply the operator’s fuel policy.

4.4 The operator has initiated an exercise to review the contents of all the airport
briefing documents to ensure consistency in the level of details contained within
each document. The operator has decided to remove information indicating if
an autoland is permitted and reminded pilots to make this assessment by using
the published charts to determine if the localiser signal is aligned with the
runway heading.

4.5 The operator and air traffic services provider have initiated efforts to explore
possibilities to expedite the coordination process with nearby alternate airport

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 and consider setting up a team for real time operations management during
inclement weather.

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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.

In view of the safety actions already undertaken by the operator and the air
traffic services provider, the TSIB investigation team does not have safety
recommendations to propose.

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