Accident and Serious Incident Reports
Accident and Serious Incident Reports: AGC
Definition
Reports relating to accidents and serious incidents included Air-Ground Communication (AGC) as a causal factor.
Call Sign Confusion
B737 / B738, vicinity Amsterdam Netherlands, 2018
On 29 March 2018, a Boeing 737-700 commenced a late go-around from landing at Amsterdam on a runway with an extended centreline that passed over another runway from which a Boeing 737-800 had already been cleared for takeoff.
An attempt by the controller responsible for both aircraft to stop the departing aircraft failed because the wrong callsign was used, so low-level divergent turns were given to both airplanes and 0.5nm lateral and 300 feet vertical separation was achieved.
The Investigation concluded that the ATC procedure involved was potentially hazardous and made a safety recommendation that it should be withdrawn.
B738/B738, vicinity Oslo Norway, 2012
On 31 October 2012, a Boeing 737-800 on the go around after delaying the breaking off of a fast and high unstable ILS approach at Oslo lost separation in IMC against another aircraft of the same type and Operator which had just taken off from the same runway as the landing was intended to be made on.
The situation was aggravated by both aircraft responding to a de-confliction turn given to the aircraft on go around.
Minimum separation was 0.2nm horizontally when 500 feet apart vertically, both climbing. Standard missed approach and departure tracks were the same.
A333 / A319, en-route, east of Lashio Myanmar, 2017
On 3 May 2017, an Airbus A330 and an Airbus A319 lost prescribed separation whilst tracking in opposite directions on a radar-controlled ATS route in eastern Myanmar close to the Chinese border.
The Investigation found that the response of the A330 crew to a call for another aircraft went undetected and they descended to the same level as the A319 with the lost separation only being mitigated by intervention from the neighboring Chinese ACC which was able to give the A319 an avoiding action turn.
At the conflict, the A330 had disappeared from the controlling ACC’s radar.
B738/A319 en-route, southeast of Zurich Switzerland, 2013
On 12 April 2013, a Ryanair Boeing 737-800 took a climb clearance intended for another Ryanair aircraft on the same frequency.
The aircraft for which the clearance was intended did not respond and the controller did not notice that the clearance readback had come from a different aircraft. Once the wrong aircraft began to climb, from FL360 to FL380, a TCAS RA descent occurred due to traffic just transferred to a different frequency and at FL370.
That traffic received a TCAS RA to climb. STCA was activated at the ATS Unit controlling both Ryanair aircraft.
AT43/A346, Zurich Switzerland, 2010
On 18 June 2010, an ATR 42 began daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began to take off from intersecting runway 16 with an ATC clearance.
ATC was unaware of this until alerted to the situation by the crew of another aircraft that was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so before the runway intersection whilst the A340 continued departure on runway 16.
Loss of Communication
B788, en-route, central Romania, 2017
On 10 March 2017, a Boeing 787-8 lost contact with ATC over central Romania whilst the Captain was taking his second in-seat controlled rest and the flight continued through Romanian and then, in daylight and without clearance, into Hungarian airspace
. After well over an hour out of contact, military fighter interception prompted the re-establishment of normal communication.
It was found that whilst the Captain was asleep, both speakers had been off and the First Officer had not been wearing her headset although she claimed that normal ATC communications had occurred whilst admitting that they had not been written down as required.
B772 en-route suspected location southern Indian Ocean, 2014
On 8 March 2014, contact was lost with a Malaysian Airlines Boeing 777-200ER operating a scheduled night passenger flight from Kuala Lumpur to Beijing as MH370.
The available evidence indicates that it crashed somewhere in the South Indian Ocean but a carefully- targeted underwater search coordinated by the Australian Transport Safety Bureau has failed to locate the aircraft wreckage and the Investigation process is now effectively stalled.
A comprehensive Investigation Report has been published and Safety Recommendations informed by the work of the Investigation have been made but it has not been possible to establish what happened and why.
A332, en-route, North Atlantic, 2019
On 6 February 2019, an Airbus A330-200 Captain’s Audio Control Panel (ACP) malfunctioned and began to emit smoke and electrical fumes after coffee was spilled on it.
Subsequently, the right side ACP also failed, becoming hot enough to begin melting its plastic. Given the consequent significant communications difficulties, a turnback to Shannon was with both pilots taking turns to go on oxygen.
The Investigation found that flight deck drinks were routinely served in unlidded cups with the cup size in use incompatible with the available cup holders. Pending the provision of suitably-sized cups, the operator decided to begin providing cup lids.
A319, Mumbai India, 2013
On 12 April 2013, an Airbus A319 landed without clearance on a runway temporarily closed for routine inspection after failing to check in with TWR following acceptance of the corresponding frequency change.
Two vehicles on the runway saw the aircraft approaching on a short final and successfully vacated. The Investigation concluded that the communication failure was attributable entirely to the Check Captain who was in command of the flight involved and was acting as ‘Pilot Monitoring.
It was considered that the error was probably attributable to the effects of operating through the early hours during which human alertness is usually reduced.
AT43, vicinity Oksibil Papua Indonesia, 2015
On 26 August 2015, contact was lost with an ATR 42-300 making a descent to Oksibil supposedly using detailed Company-provided visual approach guidance over mountainous terrain. Its burnt-out wreckage was subsequently located 10 nm from the airport at 4,300 feet aal.
The Investigation found that the prescribed guidance had not been followed and that the Captain had been in the habit of disabling the EGPWS to prelude nuisance activations.
It was concluded that several safety issues identified collectively indicated that the organizational oversight of the aircraft operated by the regulator was ineffective.
Incorrect Readback Missed
B733, Singapore Changi Singapore, 2020
On 28 November 2020, a Boeing 737-300F taxiing for an early morning departure at Singapore Changi crossed an illuminated red stop bar in daylight and entered the active runway triggering an alert that enabled the controller to instruct the aircraft to immediately exit the runway and allow another aircraft already on approach to land.
The Investigation found that the flight was the final one of a sequence of six carried out largely overnight as an extended duty predicated on an augmented crew.
The context for the crew error was identified as a poorly managed operator subject to insufficient regulatory oversight.
A320 / E145, vicinity Barcelona Spain, 2019
On 27 September 2019, an Airbus A320 and an Embraer 145 both inbound to Barcelona and being positioned for the same Transition for runway 25R lost separation and received and followed coordinated TCAS RAs after which the closest point of approach was 0.8nm laterally when 200 feet vertically apart.
The Investigation found that the experienced controller involved had initially created the conflict whilst seeking to resolve another potential conflict between one of the aircraft and a third aircraft inbound for the same Transition and having identified it had then implemented a faulty recovery plan and executed it improperly.
A320, vicinity Birmingham UK, 2019
On 26 August 2019, an Airbus A320 attempted two autopilot-engaged non-precision approaches at Birmingham in good weather before a third one was successful.
Both were commenced late and continued when unstable before eventual go-arounds, for one of which the aircraft was misconfigured causing an ‘Alpha Floor’ protection activation. A third non-precision approach was then completed without further event.
The Investigation noted an almost identical event involving the same operator four months later, observing that all three discontinued approaches appeared to have originated in confusion arising from a slight difference between the procedures of the aircraft operator and AIP plates.
A320, vicinity Oslo Norway, 2008
On 19 December 2008, an Aeroflot Airbus A320 descended significantly below its cleared and acknowledged altitude after the crew lost situational awareness at night whilst attempting to establish on the ILS at Oslo from an extreme intercept track after a late runway change and an unchallenged incorrect readback.
The Investigation concluded that the response to the EGPWS warning which resulted had been “late and slow” but that the risk of CFIT was “present but not imminent”.
The context for the event was considered to have been poor communications between ATC and the aircraft in respect of changes in the landing runway.
SF34/AT72, Helsinki Finland, 2011
On 29 December 2011 a Golden Air ATR 72 making a daylight approach to runway 22R at Helsinki and cleared to land observed a Saab 340 entering the runway and initiated a low go-around shortly before ATC, who had observed the incursion, issued a go-around instruction.
The Investigation attributed the breach of clearance by the Latvian-operated Saab 340 primarily to poor CRM, a poor standard of R/T, and inadequate English Language proficiency despite valid certification of the latter.
Phraseology
B738 / E110, Brasilia Brazil, 2018
On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a small aircraft that had just landed on the same runway until it appeared in the landing lights with rotation imminent.
After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway.
The Investigation attributed the conflict primarily to the controller’s use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.
C56X, Aarhus Denmark, 2019
On 5 August 2019, a Cessa 560XLS touched down on runway undershot at Aarhus whilst making a night ILS approach there and damage sustained when it collided with parts of the ILS LOC antenna caused a fuel leak which after the injury-free evacuation of the occupants then ignited destroying most of the aircraft.
The Investigation attributed the accident to the Captain’s decision to intentionally fly below the ILS glideslope to touch down at the threshold and to the disabling of the EGWPS alerting function in the presence of a steep authority gradient, procedural non-compliance, and poor CRM.
CRJ2 / B773, Toronto Canada, 2019
On 9 August 2019, a Bombardier CRJ-200LR was about to depart Toronto which had read back and actioned a clearance to line up on the departure runway then began its takeoff without clearance and only commenced a high speed rejected takeoff when a Boeing 777-300 came into view crossing the runway ahead.
A high-speed rejected takeoff was completed from a maximum speed of around 100 knots.
The Investigation concluded that an increased crew workload, an expectation that a takeoff clearance would be received without delay, and misinterpretation of the lineup instructions led to the premature initiation of a takeoff.
CRJX / AT75, Tambolaka Indonesia, 2018
On 11 May 2018, a Bombardier CRJ1000 climbing on departure from Tambolaka and an ATR72-500 descending inbound there lost safe separation when during opposite turns in visual flight in uncontrolled airspace.
Prompt response to both coordinated TCAS RAs resolved the conflict. The Investigation found the departing flight Captain mixed up left and right downwind circuit joined by the ATR 72 and that his inexperienced First Officer had not picked this up.
It also noted that this Captain may not have been fit for duty and that all parties may have failed to fully recognize the limitations of ANSP’s‘ information’ service.
E170 / Vehicles, Toronto Canada, 2019
On 28 January 2019, a departing Embraer 170-200 narrowly avoided collision with part of a convoy of four snow clearance vehicles which failed to follow their clearance to enter a parallel taxiway and instead entered a Rapid Exit Taxiway and continued across the runway holding point before stopping just clear of the actual runway after multiple calls to do so.
A high-speed rejected takeoff led to the aircraft stopping just before the intersection where the incursion had occurred.
The Investigation noted the prevailing adverse weather without attributing any specific cause to the vehicle convoy’s failure to proceed as cleared.
Language Clarity
IL76 / B741, en-route, west of Delhi India, 1996
On 12 November 1996, an Ilyushin IL76TD and an opposite direction Boeing 747-100 collided head-on at the same level in controlled airspace destroying both aircraft and the loss of 349 lives.
The Investigation concluded that the IL76 had descended one thousand feet below its cleared level after its crew had interpreted ATC advice of opposite direction traffic one thousand feet below as the reason to remain at FL150 as re-clearance to descend to this lower level.
Fifteen Safety Recommendations relating to English language proficiency, crew resource management, collision avoidance systems, and ATC procedures were made.
B735, vicinity Madrid Barajas Spain, 2019
On 5 April 2019, a Boeing 737-500 crew declared an emergency shortly after departing Madrid Barajas after problems maintaining normal lateral, vertical, or airspeed control of their aircraft in IMC. After two failed attempts at ILS approaches in unexceptional weather conditions, the flight was successfully landed at a nearby military airbase.
The Investigation found that a malfunction that probably prevented the use of the Captain’s autopilot found before departure was not documented until after the flight but could not find a technical explanation for the inability to control the aircraft manually given that dispatch without either autopilot working is permitted.
Vehicle / PAY4, Perth Western Australia, 2012
Whilst a light aircraft was lined up for departure, a vehicle made an incorrect assumption about the nature of an ambiguously-phrased ATC TWR instruction and proceeded to enter the same runway.
There was no actual risk of conflict since, although LVP was still in force after earlier fog, the TWR controller was able to see the vehicle incursion and therefore withhold the imminent take-off clearance.
The subsequent Investigation noted that clearance needed to read backs about which there is doubt are not made speculatively in the expectation that they will elicit confirmation or correction.
AT75 / B739, Medan Indonesia, 2017
On 3 August 2017, a Boeing 737-900ER landing at Medan was in a wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear.
The Investigation concluded that the ATR 72 had entered the runway in an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC.
Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.
GLEX/F2TH, vicinity Ibiza Spain, 2012
On 21 September 2012, two aircraft came into conflict in Class ‘A’ airspace whilst under radar control at night, and the loss of separation was resolved by TCAS RA responses by both aircraft.
The investigation found that one of the aircraft had passed a procedurally-documented clearance limit without ATC clearance or intervention and that situational awareness of its crew had been diminished by communications with the conflicting aircraft being conducted in Spanish rather than English.
A Safety Recommendation on resolving the persistent problem of such language issues was made, noting that a similar recommendation had been made 11 years earlier.
Multiple Language use on Frequency
B712 / CRJ7, vicinity Strasbourg France, 2019
On 12 April 2019, a Boeing 717-200 commenced a go-around at Strasbourg because the runway ahead was occupied by a departing Bombardier CRJ700 which subsequently, despite co-ordinated TCAS RAs, then came to within 50 feet vertically when only 740 meters apart laterally as the CRJ, whose crew did not see the 717, passed right to left in front of it.
The Investigation attributed the conflict primarily to a series of flawed judgments by the TWR controller involved whilst also noting one absent and one inappropriate ATC procedure which respectively may have provided a context for the resultant risk.
CPDLC
none on SKYbrary
Flight Crew Oxygen Mask Use
A332, en-route, North Atlantic, 2019
On 6 February 2019, an Airbus A330-200 Captain’s Audio Control Panel (ACP) malfunctioned and began to emit smoke and electrical fumes after coffee was spilled on it.
Subsequently, the right side ACP also failed, becoming hot enough to begin melting its plastic. Given the consequent significant communications difficulties, a turnback to Shannon was with both pilots taking turns to go on oxygen.
The Investigation found that flight deck drinks were routinely served in unlidded cups with the cup size in use incompatible with the available cup holders. Pending the provision of suitably-sized cups, the operator decided to begin providing cup lids.
A320, en-route, north of Marseilles France, 2013
On 12 September 2013, pressurization control failed in an A320 after a bleed air fault occurred following dispatch with one of the two pneumatic systems deactivated under MEL provisions.
The Investigation found that the cause of the in-flight failure was addressed by an optional SB not yet incorporated.
Also, relevant crew response SOPs lacking clarity and a delay in the provision of a revised MEL procedure meant that the use of the single system had not been optimal and after a necessary progressive descent to FL100 was delayed by inadequate ATC response, and ATC failed to respond to a PAN call required it to be upgraded to MAYDAY.
E195, en-route, Irish Sea UK, 2008
On 1 August 2008, an en-route Embraer 195 despatched with one air conditioning pack inoperative lost all air conditioning and pressurization when the other pack’s Air Cycle Machine (ACM) failed, releasing smoke and fumes into the aircraft.
A MAYDAY diversion was made to the Isle of Man without further event.
The Investigation found that the ACM failed due to rotor seizure caused by turbine blade root fatigue, the same failure which had led the other air conditioning system to fail failure four days earlier.
It was understood that a modified ACM turbine housing was being developed to address the problem.
Take off without clearance
A359, Barcelona Spain, 2020
On 24 October 2020, an Airbus A350-900 took off in daylight from runway 07R at Barcelona without clearance to do so when an Airbus A320 was on approach to land on runway 02 which involves an approach path that crosses over runway 07R and lateral separation was reduced to 2.8nm.
The Investigation attributed the inadvertent failure to await clearance to “some form of reduced alertness” on the part of the crew.
CRJ2 / B773, Toronto Canada, 2019
On 9 August 2019, a Bombardier CRJ-200LR was about to depart Toronto which had read back and actioned a clearance to line up on the departure runway then began its takeoff without clearance and only commenced a high speed rejected takeoff when a Boeing 777-300 came into view crossing the runway ahead.
A high-speed rejected takeoff was completed from a maximum speed of around 100 knots. The Investigation concluded that an increased crew workload, an expectation that a takeoff clearance would be received without delay, and misinterpretation of the lineup instructions led to the premature initiation of a takeoff.
B738, Eindhoven Netherlands, 2012
On 11 October 2012, the crew of a Ryanair Boeing 737-800 did not change frequency to TWR when instructed to do so by GND whilst already backtracking the departure runway and then made a 180° turn and took off without clearance still on GND frequency.
Whilst no actual loss of ground or airborne safety resulted, the Investigation found that when the Captain had queried the receipt of a take-off clearance with the First Officer, he had received and accepted a hesitant confirmation.
Crew non-compliance with related AIP ground maneuvering restrictions replicated in their airport briefing was also noted.
C25A / Vehicle, Reykjavik Iceland, 2018
On 11 January 2018, a privately-operated Cessna 525A Citation with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within less than a meter of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated.
The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking.
It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.
DH8B, Kangerlussuaq Greenland, 2017
On 2 March 2017, a DHC8-200 took off from Kangerlussuaq in normal day visibility without clearance and almost immediately overflew three snow clearance vehicles on the runway.
The investigation identified several likely contributory factors including a one-hour departure delay which the crew was keen to reduce to remain within their maximum allowable duty period and their inability to initially see the vehicles because of the runway downslope.
No evidence of crew fatigue was found; it was noted that the vehicles involved had been in contact with TWR on a separate frequency using the local language.
Landing without clearance
B733, Wamena Papua Indonesia, 2016
On 13 September 2016, a Boeing 737-300 made an unstabilized approach to Wamena, and shortly after an EGPWS ‘PULL UP’ warning due to the high rate of descent, a very hard landing resulted in the collapse of the main landing gear, loss of directional control and a lateral runway excursion.
The Investigation found that the approach had been carried out with both the cloud base and visibility below the operator-specified minima and noted that the Captain had ignored a delayed go-around suggestion from the First Officer because he was confident he could land safely as the two aircraft ahead had done.
MD83, Port Harcourt Nigeria, 2018
On 20 February 2018, a Boeing MD-83 attempting a night landing at Port Harcourt during a thunderstorm and heavy rain touched down well beyond the touchdown zone and departed the side of the runway near its end before continuing 300 meters beyond it.
The Investigation found that a soft touchdown had occurred with 80% of the runway behind the aircraft and a communications failure on a short final meant a wind velocity change just before landing leading to a tailwind component of almost 20 knots was unknown to the crew who had not recognized the need for a go-around.
A319, Mumbai India, 2013
On 12 April 2013, an Airbus A319 landed without clearance on a runway temporarily closed for routine inspection after failing to check in with TWR following acceptance of the corresponding frequency change.
Two vehicles on the runway saw the aircraft approaching on a short final and successfully vacated. The Investigation concluded that the communication failure was attributable entirely to the Check Captain who was in command of the flight involved and was acting as ‘Pilot Monitoring.
It was considered that the error was probably attributable to the effects of operating through the early hours during which human alertness is usually reduced.
A319, vicinity Zurich Switzerland, 2014
On 17 October 2014, two recently type-qualified Airbus A319 pilots responded in a disorganized way after a sudden malfunction soon after take-off from Zurich required one engine to be shut down.
The return to land was flown manually and visually at an excessive airspeed and rate of descent with idle thrust on the remaining engine to a touchdown which occurred without a landing clearance.
The Investigation concluded that the poor performance of the pilots had been founded on a lack of prior analysis of the situation, poor CRM, and non-compliance with system management and operational requirements.
TBM8, Birmingham UK, 2011
On 12 January 2011, a privately operated Socata TBM850 light aircraft on a flight from Antwerp to Birmingham lost radio contact with ATC whilst in IMC on a non-precision approach to runway 15 before the issue of a landing clearance and before checking in on the ATC TWR frequency.
It continued the approach to obtain the required visual reference before landing over the top of a DHC8-400 aircraft which had lined up ready for take-off by ATC instructions. No damage or personal injury resulted from the proximity.
Military Formation Clearance
EUFI / A321, en-route, near Clacton UK, 2008
On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east northeast of London without clearance while trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.
F15 / B752, en-route, South East of Birmingham UK, 2000
On 22 November 2000, near Birmingham UK, a dangerous loss of vertical and lateral separation occurred between a Boeing B757-200 being operated by Britannia Airways on a passenger flight and a formation flight of two F-15Es being operated by the United States Air Force (USAF).
F15 / E145, en-route, Bedford UK, 2005
On 27 January 2005, two USAF-operated McDonnell Douglas F15E fighter aircraft, continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.
Military/Civil Coordination
EUFI / A321, en-route, near Clacton UK, 2008
On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east northeast of London without clearance while trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.
F15 / E145, en-route, Bedford UK, 2005
On 27 January 2005, two USAF-operated McDonnell Douglas F15E fighter aircraft, continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.
Provision of Aircraft Performance Data
B78X, vicinity Abu Dhabi UAE, 2020
On 6 June 2020, a Boeing 787-10 on approach at Abu Dhabi began a low go around from an RNAV(RNP) approach when it became obvious to the crew that the aircraft was far lower than it should have been but were unaware of why this occurred until an ATC query led them to recognize that the wrong QNH had been set with recognition of the excessively low altitude delayed by haze limiting the PAPI range.
The Investigation found that advice on MSAW activations that would have enabled the flight crew to recognize their error was not advised to them.
ATC Clearance Cancelled
A320 / B738 Barcelona Spain, 2012
On 27 May 2012, an Airbus A320 departing Barcelona was cleared by GND to taxi across an active runway on which a Boeing 737-800 was about to land.
Whilst still moving but before entering the runway, the A320 crew, aware of the aircraft on approach, queried their crossing clearance but the instruction to stop was given too late to stop before crossing the unlit stop bar.
The 737 was instructed to go around and there was no actual risk of collision. The Investigation attributed the controller error to a lack of familiarisation with the routine runway configuration change in progress.
B738/B738, vicinity Queenstown New Zealand, 2010
On 20 June 2010, a Boeing 737-800 being operated by New Zealand company Pacific Blue AL on a scheduled passenger flight from Auckland to Queenstown lost IFR separation assurance against a Boeing 737-800 being operated by Qantas on a scheduled passenger flight from Sydney to Queenstown whilst both aircraft were flying a go-around following successive but different instrument approaches at their shared intended destination.
There were no abrupt maneuvers and none of the respectively 88 and 162 occupants of the two aircraft were injured.
B38M, Helsinki Finland, 2019
On 18 January 2019, two aircraft taxiing for departure at Helsinki were cleared to cross the landing runway between two landing aircraft.
Landing clearance for the second was given once the crossing traffic had cleared as it passed 400 feet in the expectation that the previous landing aircraft would also shortly be clear.
However, the first landing aircraft was slower than expected clearing the runway and so the second was instructed to go around but did not then do so because this instruction was lost in the radar height countdown below 50 feet and the runway was seen clear before touchdown.
B738, Alicante Spain, 2018
On 7 June 2018, a Boeing 737-800 operated by a non-Spanish speaking crew was given takeoff clearance at Alicante after the same supervised student controller had previously cleared two vehicles to begin a full-length opposite-direction runway inspection in Spanish.
The controller error was only recognized when the vehicles were able to transmit that they were still on the runway, the aircraft crew being unaware of the conflict until then told to reject the takeoff.
The maximum speed reached by the aircraft was 88 knots and the minimum separation between the aircraft and the closest vehicle was never less than 1000 meters.
Vehicles / B722, Hamilton ON Canada, 2013
On 19 March 2013, a Boeing 727 freighter was cleared to take off on a runway occupied by two snow clearance vehicles. The subsequent cancellation of the take-off clearance was not received but a successful high-speed rejected take-off was accomplished on the sight of the vehicles before their position was reached.
The Investigation attributed the occurrence to the controller’s failure to ‘notice’ the runway blocked indicator on his display and to his non-standard use of R/T communications. The late sighting of the vehicles by the aircraft crew was due to the elevated runway mid-section.
A319 / WT9, vicinity Stuttgart Germany, 2017
On 26 June 2017, an Airbus A319 which had just taken off from Stuttgart came into conflict in Class ‘D’ airspace with a VFR light aircraft crossing its track, and when, at 1,200 feet AGL, the TCAS RA descended which resulted was followed, an EGPWS Mode 3 Alert was generated.
Clear of Conflict was annunciated after 10 seconds and the climb resumed.
The Investigation concluded that the light aircraft pilot had failed to follow the clearance which had been accepted and had caused the flight path conflict which was resolved by the response of the A319 to the TCAS RA.
A343, Bogotá Colombia, 2017 (2)
On 19 August 2017, an Airbus A340-300 encountered significant unforecast wind shear on rotation for a maximum weight rated-thrust night takeoff from Bogotá and was unable to begin its climb for a further 800 meters during which angle of attack flight envelope protection was briefly activated.
The Investigation noted the absence of a wind shear detection system and any data on the prevalence of wind shear at the airport as well as the failure of ATC to relay in English reports of conditions from departing aircraft received in Spanish. The aircraft operator subsequently elected to restrict the maximum permitted takeoff weights from the airport.
CRJ7 / A319, Lyon Saint-Exupéry France, 2017
On 17 March 2017, a Bombardier CRJ 700 which had just landed on runway 35R at Lyon Saint-Exupéry was about to cross runway 35L as cleared when its crew saw the departing Airbus A319 on runway 35L accelerating towards their intended crossing position and braked to a stop before entering the runway.
The Investigation found that both aircraft had complied with all instructions issued by the TWR controller and concluded that safety management processes at the airport were not commensurate with the incursion risk involved and had been unchanged since an almost identical incident a year previously.
A319 / A320, Paris CDG France, 2014
On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff.
The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that the use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit.
It was also noted that an automated conflict alert had been activated too late to intervene.
Blocked Transmission
B738/B738, vicinity Oslo Norway, 2012
On 31 October 2012, a Boeing 737-800 on the go around after delaying the breaking off of a fast and high unstable ILS approach at Oslo lost separation in IMC against another aircraft of the same type and Operator which had just taken off from the same runway as the landing was intended to be made on.
The situation was aggravated by both aircraft responding to a de-confliction turn given to the aircraft on go around.
Minimum separation was 0.2nm horizontally when 500 feet apart vertically, both climbing. Standard missed approach and departure tracks were the same.
AT43/A346, Zurich Switzerland, 2010
On 18 June 2010, an ATR 42 began daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began to take off from intersecting runway 16 with an ATC clearance.
ATC was unaware of this until alerted to the situation by the crew of another aircraft that was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so before the runway intersection whilst the A340 continued departure on runway 16.
SF34 / B190, Auckland NZ, 2007
On 29 May 2007, a Saab 340 aircraft that was holding on an angled taxiway at Auckland International Airport was inadvertently cleared to line up in front of a landing Raytheon 1900D.
The aerodrome controller transmitted an amended clearance, but the transmission crossed with that of the Saab crew reading back the line-up clearance.
The pilots of both aircraft took action to avoid a collision and stopped on the runway without any damage or injury.
Misunderstanding
- A310 / B736, en-route, Southern Norway, 2001: On 21 February 2001, a level bust involving a PIA A310 led to the loss of separation with a SAS B737 with apparently uncoordinated Airborne Collision Avoidance System (ACAS) RA near Oslo.
- AS32 / B734, Aberdeen UK, 2000: On 27 July 2000, at Aberdeen UK, a British Airways B737 was forced to make a high speed rejected takeoff when a hovering AS332 helicopter moved without ATC clearance to a position 30 feet above the upwind end of the takeoff runway during the B737’s takeoff roll.
see more:
Aviation Handbooks & Manuals | Handbooks & Manuals | Federal Aviation Administration
Aircraft Safety Management System Course Syllabus, Course Structure [ Subject Code: 8276]
Aircraft Maintenance Practices Course Syllabus, Course Structure [ Subject Code: 8275]
Production Planning & Quality System Course Syllabus, Course Structure [ Subject Code: 8274]