What happened
An Air France Boeing 747-400, registration F-GITC, landed at Montréal/Pierre Elliott Trudeau International Airport following a scheduled flight from Paris. The landing on Runway 24R was initially stable, with the aircraft maintaining the centerline and utilizing standard braking and thrust reverser settings.
However, during the landing rollout at approximately 65 knots, the pilot flying placed a hand on the nose wheel tiller. This movement caused an unintentional rightward deflection of the nose wheels. While the crew initially corrected the heading with rudder input, the nose wheels began to skid. As the aircraft slowed to 45 knots and the autobrake disengaged, the aircraft veered sharply to the right. In an attempt to correct the deviation, the pilot applied further tiller input that inadvertently increased the right turn. The aircraft eventually came to a stop with the nose gear 26 feet beyond the right edge of the runway. There were no injuries among the 491 passengers and 18 crew members, and the aircraft sustained no damage.
The investigation
The investigation examined the aircraft systems, weather, and crew actions. Meteorological conditions were clear with good visibility, and the runway surface was dry and free of irregularities. The investigation focused on the sequence of manual inputs during the rollout.
Investigators noted that the pilot flying had recently transitioned back to the B747-400 from the A320. The analysis suggested that the initial tiller movement may have been an accidental result of the pilot mistaking the tiller for the control column, or an instinctive movement based on previous A320 operating experience. Furthermore, the investigation identified that the cockpit voice recorder (CVR) was not deactivated following the event, leading to the loss of critical audio evidence as the recordings were overwritten.
Findings
- The placement of the pilot's hand on the tiller at high speed led to an unintentional deflection, causing the nose wheels to skid when rudder corrections were attempted.
- The pilot inadvertently pushed the tiller further forward and down during the turn correction, which increased the rightward deflection and caused the aircraft to depart the runway.
- The failure to deactivate the CVR resulted in the loss of vital cockpit conversations.
- Inconsistencies in procedures regarding the preservation of evidence and the protection of the occurrence site by airport personnel were identified.