Hong Kong CAD issues final report on A340 attempted taxiway takeoff

Chart of runway 07L and taxiway A at Hong Kong

The Hong Kong Civil Aviation Department released the final investigation report into the serious incident involving an Airbus A340 that attempted to take off from a taxiway.

The serious incident occurred on November 27, 2010. The incident flight involved a Finnair Airbus A340-313X which operated on flight AY070 from Hong Kong-Chek Lap Kok International Airport (HKG/VHHH) to Helsinki-Vantaa Airport (HEL/EFHK).

The incident occurred at night time and in good visibility conditions. One of the runways was closed for maintenance.  The north runway (07L/25R) remained operational with runway 07L in use for both arrivals and departures.

Flight 070 was cleared by ATC to taxi on taxiway B westbound for departure on runway 07L. When the aircraft was approaching the western end of taxiway B, ATC cleared the aircraft for take-off on runway 07L. The aircraft took the normal right turn at the end of taxiway B towards runway 07L but then took a premature right turn onto taxiway A, a taxiway parallel to and in between the runway-in-use and taxiway B. With the help of the Advanced Surface Movement Guidance and Control System (A-SMGCS) provided in the Control Tower, ATC observed that the aircraft commenced take-off roll on taxiway A. On detecting the anomaly, ATC immediately instructed the pilot to stop rolling and the aircraft was stopped abeam Taxiway A5, approximately 1400 metres from the beginning (western end) of taxiway A.

The following causal factors were identified:

1. A combination of sudden surge in cockpit workload and the difficulties experienced by both the Captain and the First Officer in stowing the EFB computers at a critical point of taxiing shortly before take-off had distracted their attention from the external environment that resulted in a momentary degradation of situation awareness.
2. The SOP did not provide a sufficiently robust process for the verification of the departure runway before commencement of the take-off roll.
3. The safety defence of having the First Officer and the Relief Pilot to support and monitor the Captain’s taxiing was not sufficiently effective as the Captain was the only person in the cockpit trained for ground taxi.

Hong Kong CAD issues preliminary report on A340 attempted taxiway takeoff

Chart of runway 07L and taxiway A at Hong Kong

The Hong Kong Civil Aviation Department released a preliminary investigation report into the serious incident involving an Airbus A340 that attempted to take off from a taxiway.

The serious incident occurred on November 27, 2010. The incident flight involved a Finnair Airbus A340-313X which operated on flight AY070 from Hong Kong-Chek Lap Kok International Airport (HKG/VHHH) to Helsinki-Vantaa Airport (HEL/EFHK).

The incident occurred at night time and in good visibility conditions. Flight 070 was cleared by ATC to taxi on taxiway B westbound for departure on runway 07L. When the aircraft was approaching the western end of taxiway B, ATC cleared the aircraft for take-off on runway 07L. The aircraft took the normal right turn at the end of taxiway B towards runway 07L but then took a premature right turn onto taxiway A, a taxiway parallel to and in between the runway-in-use and taxiway B. With the help of the Advanced Surface Movement Guidance and Control System (A-SMGCS) provided in the Control Tower, ATC observed that the aircraft commenced take-off roll on taxiway A. On detecting the anomaly, ATC immediately instructed the pilot to stop rolling and the aircraft was stopped abeam Taxiway A5, approximately 1400 metres from the beginning (western end) of taxiway A.

Whilst the investigation is still in progress, the Investigation Team considered it prudent to institute a temporary ATC procedure to minimize the possibility of recurrence. In this connection, Hong Kong ATC, as an extra precautionary safeguard, issued an Operational Instruction on 29 November 2010, which required that during runway 07L operations, the Air Movements Controller shall withhold the take-off clearance until ascertaining that the aircraft has completely crossed taxiway A.

 

Report: Premature thrust during rolling takeoff caused runway B737 excursion

According to a French investigation report, the runway excursion incident involving a Boeing 737 in August 2009 was caused by the premature application of thrust during a rolling takeoff.

On August 29, 2009 an Air Algérie Boeing 737-8D6 departed the right side of runway 36L at Lyon-Saint-Exupéry Airport (LYS/LFLL), France during takeoff. It rolled for about 250 meters on the grass verge alongside the runway. The aircraft joined the track after hitting a runway edge light and continued the takeoff.

On arrival in Sétif-Ain Arat Airport (QSF/DAAS), Algeria, minor damage was found on the right engine, the airframe and nose gear. There were 39 passengers and seven crew members on board.

The BEA report states: “The overrun is due to a non-compliance with the procedure of “rolling takeoff” by premature application of  takeoff thrust as the aircraft, light and with a rear centre of gravity, had not yet entered the runway. A possible tendency of the Pilot Flying to add thrust before the complete alignment of the aircraft on the centreline of the runway contributed to the occurrence of this serious incident.
The decision to continue the takeoff after having  returned to the track with a speed of less than V1, led the crew to continue the flight with a plane of which they did not know the extent of damage.”

Takeoff path on runway 36L

AAIB: Flight director mode confusion cited in serious DHC-8 incident

FDR parameters of the approach of G-JECI (AAIB)

An investigation into a serious incident involving a DHC-8-400 on approach to Edinburgh Airport, UK revealed that Flight Director mode confusion led to a descent to within 800 ft of local terrain approximately 5 nm from the runway threshold.

On December 23, 2008 a de Havilland Canada DHC-8-402Q Dash 8, registered G-JECI, was being operated on a scheduled passenger service from Southampton to Edinburgh as BEE247S. As it commenced its final approach to runway 24 at Edinburgh the approach controller (APC) instructed the aircraft to turn onto a heading of 280° to intercept the ILS localiser, descend from 3,000 ft to 2,100 ft and maintain a speed of at least 160 kt until 4 nm from touchdown. During the descent the aircraft accelerated to approximately 200 kt with flap and landing gear up.

The aircraft did not level off as intended at 2,100 ft but continued to descend at a constant vertical speed such that it remained at all times below the ILS glideslope. At an altitude of approximately 1,800 ft, apparently without having noticed that the aircraft had descended below the cleared altitude before intercepting the ILS, the APC instructed the pilots to contact the aerodrome controller (ADC). At about this time Flap 5 was selected and the aircraft decelerated to approximately 180 kt.
The ground movement controller (GMC), who sat beside the ADC in the visual control room (VCR), saw the aircraft when it was approximately 5 nm from touchdown and noticed that it looked “substantially below the glidepath”. He mentioned this to the ADC. When shortly afterwards the co-pilot called, “tower jersey two four seven sierra is five and a half miles two four”, the ADC responded “jersey two four seven sierra roger and we’ve got you five miles out showing nine hundred feet is everything ok”.

The co-pilot replied “err affirm jersey two four seven sierra”. Not content with the response the ADC replied “jersey two four seven sierra how low are you planning on descending at the moment”. The co-pilot responded “err we’re gonna level now actually our glideslope capture obviously failed jersey two four seven sierra”. The controllers in the VCR saw the aircraft climb slightly and continue an apparently normal approach.

Attempting to regain the correct flight path manually, the commander initially experienced some difficulty disconnecting the autopilot and found that the aircraft tended to adopt a pitch attitude 8° below the horizon. When able to resume full control, at approximately 700 ft agl, he called for Flap 15 and landing gear down. The landing was completed without further incident.

A similar incident occurred on 8 May 2009 involving a DHC-8-400 on approach to Glasgow Airport.

Both incidents appear to have been initiated by Flight Guidance Control Panel (FGCP) selections which resulted in Flight Director modes other than those intended by the pilots. In the case of G-JECI, recorded data indicates that the altitude select mode was not armed after selection of a lower altitude. This problem would be alleviated if the altitude select mode was automatic upon selection of a new altitude and vertical mode, as is the case on several other aircraft types and as envisaged by the aircraft manufacturer in its discussions with operators.

The AAIB issued two safety recommendations:

Safety Recommendation 2009-005
It is recommended that Bombardier Aerospace enable automatic arming of the altitude select mode of the flight director fitted to Dash-8-400 series aircraft upon selection of a new altitude and vertical mode.

Safety Recommendation 2009-006
It is recommended that Flybe consider amending its standard operating procedures to require an altitude check whilst on final approach even when the pilots are in visual contact with the runway.

AIB Norway: report released on A321 runway skid

The Accident Investigation Board of Norway published its final report of their investigation into a serious incident involving an Airbus A321 at Sandefjord Airport Torp (ENTO), Norway.

An Airbus A321, registration OY-VKA and flight number VKG866, flew from Tenerife Airport (GCTS) to Sandefjord Airport Torp (ENTO) on 26th of March 2006. The flight was operated by My Travel Airways Scandinavia.
The first officer was Pilot Flying (PF) and the commander was Pilot Not Flying (PNF). The crew reviewed updated weather and runway status before commencing the approach to ENTO. Air Traffic Information Services (ATIS) indicated dry runway and Braking Action (BA) GOOD.
When checking in on Tower frequency, the crew was informed that the runway was contaminated by 8 mm wet snow with a measured (Friction Coefficient, FC) of 32-33-31. These numbers indicated a MEDIUM BA.
The crew requested wind information in order to check for any crosswind or tailwind limitations. They made a mental consideration regarding the landing conditions and decided that it was acceptable to perform the landing. The airplane got high on the glide slope after passing 250 ft Radio Height. This resulted in a touch down approximately 780 metres from the threshold. After landing the crew experienced POOR braking action and suspected auto brake failure. The first officer performed maximum manual braking without noticing any BA. After landing the crew experienced POOR BA and suspected a brake failure. The commander took control, pulled the Park Brake (PB) and steered the aircraft with Nose Wheel Steering (NWS) towards the left side of the runway with guidance from the first officer.
The effect of the PB and NWS was that the aircraft skidded sideways towards the end of the runway 18. This resulted in increased deceleration and the aircraft stopped at the very end of the hard surfaced runway, with the nose wheel against a concrete antennae base.
The crew advised the TWR about the anticipated runway excursion while the aircraft skidded towards the end. This allowed the TWR to alert the fire and rescue crew even before the aircraft had stopped. The fire and rescue service functioned as expected.
No persons were injured and the aircraft got some skin and nose wheel damage. The commander shut down the engines and evacuated the passengers through the forward left cabin door. The passengers were transported to the terminal building by buses while the crew remained in the aircraft being towed to the terminal.

AIBN issued three safety recommendations to MyTravel Scandinavia (now Thomas Cook Airlines Scandinavia) and two recommendations to Sandefjord Airport Torp, related to operations on contaminated runways.

ATSB releases report on mishandled go-around at Melbourne

The Australian Transport Safety Bureau (ATSB) released the final report AO-2007-044 of their investigation into a serious incident during a go around involving an Airbus A320 at Melbourne, Australia.

On July 21, 2007 an Airbus A320-232 aircraft was being operated on a scheduled international passenger service for Jetstar between Christchurch, New Zealand and Melbourne, Australia. At the decision height on the instrument approach into Melbourne, the crew conducted a missed approach as they did not have the required visual reference because of fog. The pilot in command did not perform the go-around procedure correctly and, in the process, the crew were unaware of the aircraft’s current flight mode. The aircraft descended to within 38 ft of the ground before climbing.
The aircraft operator had changed the standard operating procedure for a go-around and, as a result, the crew were not prompted to confirm the aircraft’s flight mode status until a number of other procedure items had been completed. As a result of the aircraft not initially climbing, and the crew being distracted by an increased workload and unexpected alerts and warnings, those items were not completed. The operator had not conducted a risk analysis of the change to the procedure and did not satisfy the incident reporting requirements of its safety management system (SMS) or of the Transport Safety Investigation Act 2003.

As a result of this occurrence, the aircraft operator changed its go-around procedure to reflect that of the aircraft manufacturer, and its SMS to require a formal risk management process in support of any proposal to change an aircraft operating procedure. In addition, the operator is reviewing its flight training requirements, has invoked a number of changes to its document control procedures, and has revised the incident reporting requirements of its SMS.
In addition to the safety action taken by the aircraft operator the aircraft manufacturer has, as a result of the occurrence, enhanced its published go-around procedures to emphasise the critical nature of the flight crew actions during a go-around.

BFU: Final report on A320 crosswind landing mishap

The German Federal Bureau of Aircraft Accident Investigation (BFU) released the final report 5X003-0/08 of their investigation into a serious incident involving an Airbus A320 at Hamburg Airport in March 2008.  The left wing of the A320 had made contact with the ground during an attempted cross-wind landing.

Lufthansa Airbus A320-211 file photo - ASN

Because of the weather associated with hurricane Emma, on 1 March 2008  Lufthansa Airbus A320 registered D-AIQP left Munich Airport (MUC) on a scheduled flight to Hamburg (HAM) at 12:31 about two hours behind schedule, with a crew of five and 13

2 passengers. Given the ATIS weather report including wind of 280°/23 kt with gusts of up to 37 kt, during the cruise phase of the flight the crew decided on an approach to Runway 23, the runway then also in use by other traffic. During the approach to land, the aerodrome controller gave several updates on the wind. Immediately prior to touchdown, the wind was reported as 300°/33 kt, gusting up to 47 kt. At the time of the decrab-procedure there was no significant gust.
The initial descent was flown by autopilot and the co-pilot assumed manual control from 940 ft above ground.
After the aircraft left main landing gear had touched down, the aircraft lifted off again and immediately adopted a left wing down attitude, whereupon the left wingtip touched the ground. The crew initiated a go-around procedure. The aircraft continued to climb under radar guidance to the downwind leg of runway 33, where it landed at 1352 hrs. No aircraft occupants were injured. The aircraft left wingtip suffered damage from contact with the runway.

This serious landing incident took place in the presence of a significant crosswind and immediate causes are as follows:

• The sudden left wing down attitude was not expected by the crew during the landing and resulted in contact between the wingtip and the ground.
• During the final approach to land the tower reported the wind as gusting up to 47 knots, and the aircraft continued the approach. In view of the maximum crosswind demonstrated for landing, a go-around would have been reasonable.

The following systematic causes led to this serious incident:

• The terminology maximum crosswind demonstrated for landing was not defined in the Operating Manual (OM/A) and in the Flight Crew Operating Manual (FCOM), Vol. 3, and the description given was misleading.
• The recommended crosswind landing technique was not clearly described in the aircraft standard documentation.
• The limited effect of lateral control was unknown.

Dublin Airport: serious runway incursion by grass mower

The Irish Air Accident Investigation Unit (AAIU) released the final report regarding the investigation into a serious runway incursion incident at Dublin Airport (DUB/EIDW) in May 2009.

On May 29, 2009, at 02:53 local time, a Boeing 757-200 landed on runway 10 following a passenger charter flight from Sharm-el-Sheikh, Egypt. On roll-out, it passed a ride-on grass mower which was travelling eastwards along the runway approximately 18.5 metres to the right of the centre-line. The driver of the mower was unaware that an aircraft was arriving until he heard it on the runway behind him. Prior to the incident, ATC was informed that all grass-cutting equipment had vacated the field.

Probable Cause:
The failure of the driver of the ride-on mower T3 to vacate the runway after he had been instructed to do so.
Contributory Causes:
1. The assumption by the supervisor in Maintenance 12 that the driver of T3 had vacated the runway, even though he had received no confirmatory transmission from T3 nor had he visually confirmed that the runway was clear.
2. The absence of a communication from the supervisor to the driver of T3 that an aircraft was approaching.
3. The use of grass-cutting vehicles that were not equipped in accordance with the requirements of Airport Direction 20.
4. The lack of a capability to listen out on the Tower frequency, which reduced the situational awareness of the driver of the ride-on mower.
5. The lack of specific procedures related to routine grass-cutting in the Airport Manual.
6. The poor visibility combined with the limited performance of the SMR restricted the AMC’s capability of intervening in the developing situation.

One safety recommendation was issued to the Dublin Airport Authority (DAA) to “review their training programmes, including the frequency of refresher training, for all operatives who are required to drive on the manoeuvring area. Reference to ICAO Doc 9870 AN/463 “Manual on the Prevention of Runway Incursions” should be included in all such training programmes.”