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.

Report: Incorrect take-off data causes A340-500 tailstrike and runway overrun at Melbourne

The incorrect entry of take-off weight data that resulted in the tailstrike and runway overrun of an Emirates Airbus A340 aircraft in 2009 was not a unique event. Similar events continue to occur throughout the world, according to the Australian Transport Safety Bureau (ATSB).

The ATSB published the final report of its investigation into a 20 March 2009 accident, when flight EK407, with 18 crew and 257 passengers, sustained a tailstrike and overran the runway end on departure from Melbourne Airport.  The aircraft became airborne in the grass clearway but struck a light and several antennae, which damaged and disabled the instrument landing system for the airport.
The flight crew climbed the aircraft to 7,000 ft and circled over Port Phillip Bay, Victoria, while jettisoning fuel to reduce the aircraft’s weight. The flight crew then returned the aircraft to Melbourne for an uneventful landing on runway 34.

The ATSB found that the accident resulted from the use by the crew of incorrect take-off performance parameters. The initial error was likely due to mistyping, when a weight of 262.9 tonnes, instead of the intended 362.9 tonnes, was entered into a laptop computer to calculate the aircraft’s take-off settings. The error passed through several subsequent checks without detection.

Although a number of contributing factors were identified, the ATSB determined that there were two primary factors in the development of the accident as follows:

• the flight crew did not detect the erroneous take-off weight that was used for the take-off performance calculations, and
• the flight crew did not detect the degraded take-off performance until very late in the take-off roll.

More information:

• ATSB Investigation Report
• ATSB Study: Take-off performance calculation and entry errors: A global perspective

ATSB animation of the occurrence.

Report: Inadvertent brake application leads to rejected takeoff at V2

Final position of D-CKDM, about 5 m from the end of the paved surface of Runway 25 (photo: AAIB)

The crew of a Gulfstream G150 corporate jet rejected the takoff from Northolt Airport, London just before V2 speed because the airplane failed to rotate. 

A report by the U.K. AAIB details the serious incident that happened on February 6, 2011. A takeoff was attempted from runway 25 at Northolt Airport, London. When the commander pulled the control column back to rotate at rotation speed, VR, and subsequently fully back, the aircraft only pitched up to 1º. The takeoff was rejected just before V2, full braking was applied and the aircraft came to a stop at the end of the paved surface. A fire broke out around the left main wheels which was suppressed quickly by the Rescue and Fire Fighting Service (RFFS).

The flight data showed that the aircraft’s acceleration during the takeoff roll was below normal but the investigation did not reveal any technical fault with the aircraft. The most likely explanation for the lack of acceleration and rotation was that the brakes were being applied during the takeoff, probably as a result of inadvertent braking application by the commander, which caused a reduction in acceleration and a nose-down pitching moment sufficient to prevent the aircraft from rotating. However, it could not be ruled out that another factor had caused partial brake operation.

A similar occurrence led to a fatal accident in Yaroslavl, Russia on September 7, 2011 when a Yak-42 passenger plane crashed on takeoff when the airplane stalled. Forty-four occupants died in the accident. Investigation revealed that one of the crew members probably activated the brakes during the takeoff roll.

In the case of the Gulfstream incident, the AAIB reiterated two safety recommendation issued to EASA in 2009 pertaining specifications for a takeoff performance monitoring system which provides a timely alert to flight crews when achieved takeoff performance is inadequate for given aircraft configurations and airfield conditions.

More information:

• AAIB Investigation Report (PDF)
• ASN Description of Yak-42 accident

Report: Unstabilized approach preceded Colombian ERJ-145 runway excursion

The Colombian aircraft accident investigation committee concluded that the an ERJ-145 runway excursion at Mitú, Colombia occurred because the flight crew continued to land following an unstabilzed approach.

On May 5, 2010. an Embraer ERJ145, registered HK-4536, sustained substantial damage in a runway excursion accident at Mitú-Fabio Alberto León Bentley Airport (MVP), Colombia. There were no fatalities and there was no fire.
SATENA flight NSE-9634 had departed Villavicencio-La Vanguardia Airport (VVC) on a domestic flight to Mitú. The airplane could not be stopped on the runway when it landed on runway 20. It overran into a down sloping field, causing the undercarriage to collapse. The airplane came to rest 167 metres past the runway threshold and 4 metres below runway elevation.

The Board of Inquiry found that the probable cause of the accident was the execution of a landing on runway 20 at Mitu, following a destabilized approach especially with respect to deviations of height and speed when crossing the runway threshold, and the EGPWS alarm sound, which caused the aircraft to exceed the available runway. Additionally, the crew used  faulty techniques for landing on short and wet runways. Contributing to the accident was the lack of planning to carry out and complete the published instrument approach procedure for runway 20 and the deviation from standard operating procedures of the company.

More info:

• ASN Accident Description

Bird strikes increase after extension of runway at Tokyo-Narita, Japan

The number of cases of bird strikes near Tokyo’s Narita International Airport, Japan increased significantly since one of the runways was extended in late 2009, according to The Mainichi  Daily News.

Bird strikes avereaged 5.8 a year from 1991 to 2002. The airport just operated a single runway during that period. In 2002 a second parallel runway, 16L/34R, was opened. The runway, also known as “Runway B” was 2,180 m in length, compared to 4,000m long runway 16R/34L.

The number of bird strikes increased to an average of 26.3 cases per year from 2003 to 2008. Then, in October 2009, “Runway B” was extended to 2,500 m.  In the area of the extension,  noise protection embankments covered with trees were used to curb the noise.

To curb the noise, trees were planted in the area.  The number bird  strikes incidents rose to 46 in 2009 and 82 in 2010. The number of aircraft movements in 2010 was 191,459. For comparison, Los Angeles International Airport, CA, suffered 87 reported bird strike incidents in 2010 for a total of 433,452 aircraft movements.

The rise in bird hits seems attributable to the grow in airport traffic and the fact that the area near the runway extension has become more quiet and inhabitable for birds.

 

 

NTSB issues ASDE-X and airport lighting recommendations following Atlanta taxiway landing

On October 19, 2009, about 06:05 a Boeing 767, N185DN, operating as Delta Air Lines flight 60, landed on taxiway M at Atlanta-Hartsfield-Jackson International Airport (ATL), Georgia. No injuries to the 11 crew or 182 passengers were reported, and the airplane was not damaged. Night visual meteorological conditions prevailed.

During the descent and approach, the flight crew was assigned a number of runway changes; the last of which occurred near the final approach fix for runway 27L. While the flight was on final approach, the crew was offered and accepted a clearance to sidestep to runway 27R for landing. Although the flight crew had previously conducted an approach briefing for runways 27L and 26R, they had not briefed the approach for runway 27R and were not aware that the approach light system and the ILS were not available to aid in identifying that runway.

The captain maneuvered for the sidestep from runway 27L to 27R and lined up on “the next brightest set of lights” he saw. The first officer was preoccupied during the final approach with attempting to tune and identify the ILS frequency for runway 27R. Just prior to the airplane touching down, the captain realized they were landing on a taxiway. The airplane landed on taxiway M, 200 feet north of, and parallel to, runway 27R. The local controller did not notice the crew’s error until after the airplane had landed. The taxiway was unoccupied, and the flight crew was able to stop the aircraft safely and taxi to the gate.

The National Transportation Safety Board (NTSB) determined that the probable cause of this incident was the flight crew’s failure to identify the correct landing surface due to fatigue.
Contributing to the cause of the incident were:

1. the flight crew’s decision to accept a late runway change,
2. the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and
3. the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.

 

The National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

Perform a technical review of Airport Surface Detection Equipment-Model X to determine if the capability exists systemwide to detect improper operations such as landings on taxiways. (A-11-12)

At those installation sites where the technical review recommended in Safety Recommendation A-11-12 determines it is feasible, implement modifications to Airport Surface Detection Equipment-Model X to detect improper operations, such as landings on taxiways, and provide alerts to air traffic controllers that these potential collision risks exist. (A-11-13)

Amend Federal Aviation Administration (FAA) Order 7210.3, “Facility Operation and Administration,” to direct that, at airports with air traffic control towers equipped with airport lighting control panels that do not provide direct indication of airport lighting intensities, the air traffic manager annually reviews and compares, with the airport operator, the preset selection settings configured in the tower lighting control system to verify that they comply with FAA requirements. (A-11-14)

Revise Advisory Circular 150/5345-56A, “Specification for L- 890 Airport Lighting Control and Monitoring System (ALCMS)” to state that airport operators should inform air traffic managers of variances for, or modifications to, airfield lighting preset standards prescribed in Federal Aviation Administration requirements. (A-11-15)

More information:

• NTSB Safety Recommendations A-11-12 through -15
• Atlanta Airport diagram (FAA)
• NTSB incident investigtion public docket

 

Report: Poor CRM factor in cargo plane takeoff incident (India)

Indian investigators concluded that inadequate CRM and a lack of assertion on the part of the first officer were factors in a takeoff incident at Mumbai Airport in June 2010. A Boeing 757 was lined up right of the centreline and k knocked down 15 runway edge lights during the takeoff before the captain was able to steer to the runway centreline.

Blue Dart Aviation Flight No BD-201, a Boeing 757-200F, operated on a cargo flight from Kolkata to Delhi, Mumbai and Bangalore. The flight departed on schedule from Kolkata at 22:25 hrs and was uneventful till Mumbai.

At Mumbai, the aircraft taxied out from Bay No G-4 via Papa, Echo, and was cleared to proceed to holding point N1 for runway 27. The flight was cleared to line up after an arrival of Kuwait Airways Boeing 777 aircraft.

The Captain was PF and the FO was Pilot Monitoring for the departure. While lining up, the Captain lined up on the right of centerline of the runway. The FO promptly drew the attention of the Captain by stating that the centerline was on the left. This was acknowledged by the Captain. On being cleared for take off the thrust levers were opened by the Captain and the aircraft commenced its roll. The FO at this stage called out to the Captain that he was on the right, twice in quick succession. The Captain carried out a correction to the left to return to the centerline. The take off was continued with and the aircraft took off at 05:15 hours at the correct speed and carried out a standard departure. The flight to Bangalore i.e climb, cruise, decent and approach were normal. The aircraft carried out an uneventful landing with FO as PF. The aircraft taxied to the bay at 06:45 hours.

On arrival at the bay, the Engineer observed that there were damages to the right hand wheels. No. 3 main wheel tyre was deflated. There were deep incisions on No.3, 4 & 8 main wheel tyres and reverted rubber on No. 7 tyre. No. 3 brake assembly had signs of FOD and grease nipple was deformed.

At 08:30 hours information was received from Mumbai that a runway inspection was carried out and runway edge lights were damaged. A subsequent report indicated that a total of 15 runway edge lights of runway 27/09 were damaged, nine towards the north side between N1 and N4 and six on the southern side between taxiway E1 and intersection.

The investigators concluded:

The cause for the incident is incorrect lineup by the Captain on the right side of the RW instead of the Center even after being informed by the FO.

Contributory factors: An error in judgement / assessment in determining the extent of displacement to the right of centerline while lining up. Inadequate CRM practices both by the Captain and FO. Lack of assertion on the part of the FO in emphasizing the displacement of the aircraft to the Captain. Inadequate attention on the part of the Captain towards inputs from the FO.

More information:

• Final Investigation Report of Incident to M/s Blue Dart Aviation Ltd. B757-200 aircraft VT-BDM at Mumbai on 09 June 2010
• Mumbai (VABB) aerodrome chart

Report: ATR-72 runway excursion accident following unstabilized approach (India)

Investigators from the Indian DGCA concluded that an ATR-72 runway excursion at Mumbai was caused by the failure of the crew to execute a go around during an unstabilized approach.

An ATR-72 passenger plane, operated by Kingfisher Airlines, was substantially damaged when it aquaplaned off the runway on landing at Mumbai-Chhatrapati Shivaji International Airport (BOM), India on November 10, 2009.

Flight IT4124 operated on a scheduled domestic flight from Bhavnagar Airport (BHU) to Mumbai. There were 36 passengers, 2 Infants and four crew members on board the aircraft.

Maintenance on runway runway 14/32 and runway 27 at Mumbai effected operations at the airport between certain times. There were several NOTAM’s in effect relating to runway 27:

GP RWY27 NOT AVBL DUE SHORTENED RWY27. BTN 0730-1130 ON EVERY TUE, 03 NOV 07:30 2009 UNTIL 23 MAR 11:30 2010
RWY27 CL LGT NOT AVBL. 27 OCT 12:30 2009 UNTIL 31 MAR 23:59 2010.
RWY27 TDZ LGT NOT AVBL. 27 OCT 12:30 2009 UNTIL 31 MAR 23:59 2010.
RWY27 SHALL BE USED FOR LDG AND TKOF FM A POINT 1262M FM THR OF RWY27
1.THE SHORTENED RWY SHALL BE DESIGNATED AS RWY 27A. RADAR VECTORED VISUAL APP WILL BE PROVIDED SUBJ TO VIS 2800M OR MORE.DECLARED DIST OF RWY27A-
RWY TORA TODA LDA ASDA
27A 1703M 1703M 1703M 1703M
2.THR MARKING PROVIDED ON BOTH SIDES OF RWY27A ON RWY SHOULDER AREA AT A DIST OF 180M
3.PAPI RWY27A PROVIDED
4.AIMING POINT MARKING PROVIDED ON SHOULDER OF RWY27A OPPOSITE PAPI
5.DIST INDICATION SIGN PROVIDED EV 300M FM RWY27A END.
6.TORA SIGN PROVIDED AT TWY Q HLDG POINT.
7.TEMP WING BAR LGT PROVIDED FOR THR.
8.RWY EDGE LGT,RWY CL AND RWY END LGT PROVIDED FOR RWY27A. BTN 0730-1130 UTC ON EV TUE ON [...],10,17,24 NOV 2009 [...]

Runway 27 thus was available only after runway intersection as runway 27A. To carry out operations on this reduced runway 27 a NOTAM was issued and designated runway 27A for visual approach only. The weather conditions prevailing at the time of accident was winds 070/07 knots visibility 2800 m with feeble rain. Prior to Kingfisher aircraft, Air India flight IC-164, an Airbus 319 had landed and reported to ATC that it had aquaplaned and broken two runway edge lights. The ATC acknowledged it and sent runway inspection vehicle to inspect the runway.

The ATC person was not familiar with the terminology of ‘aquaplaning’ and not realizing the seriousness of it, cleared the Kingfisher flight for landing. At the time of accident there were water patches on the runway. ATC also did not transmit to the Kingfisher aircraft the information regarding aquaplaning reported by the previous aircraft.

The ATR-72 approached high and fast. The aircraft landed late on the runway and the runway length available was around 1000 m from the touchdown point. In the prevailing weather conditions this runway length was just sufficient to stop the aircraft on the runway. During landing the aircraft aquaplaned and did not decelerate even though reversers and full manual braking was applied by both the cockpit crew. The aircraft started skidding toward the left of center line. On nearing the runway end, the pilot initiated a 45° right turn, after crossing Taxiway N10, the aircraft rolled into an unpaved wet area. It rolled over drainage pipes and finally came to a stop near open drain. There was no fire.

PROBABLE CAUSE OF THE ACCIDENT:

The accident occurred due to unstabilized approach and decision of crew not to carry out a ‘Go-around’.

Contributory Factors:

1. Water patches on the R/w 27A
2. Inability of the ATCO to communicate the aircraft about aquaplaning of the previous aircraft
3. Lack of input from the co-pilot.

More information:

VT-KAC final report

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.

 

Study: Factors influencing misaligned take-off occurrences at night

ATSB pilot information card to help flight crew identify factors that could increase the risk of a misaligned take-off or landing.

The Australian Transport Safety Bureau (ATSB) published a study into factors influencing misaligned take-off occurrences at night. This report examines both Australian as well as relevant international occurrences
where pilots have misperceived their lateral position on runway due to darkness and a combination of individual influences, runway, weather and task conditions.

The study was iniated following several occurrences that involved aircraft commencing takeoff on the runway edge lighting. All five recent Australian misaligned take-off and landing occurrences involved aircraft with weights greater than 5,700kg and three of the six occurrences involved scheduled regular passenger transport operations. The remaining two occurrences involved charter operations.

After reviewing the Australian and international occurrences, eight common factors were identified that increased the risk of a misaligned take-off or landing occurrence. The factors included:

• distraction or divided attention of the flight crew;
• confusing runway layout; displaced threshold or intersection departure;
• poor visibility or weather; air traffic control clearance/s issued during runway entry;
• no runway centreline lighting;
• flight crew fatigue; and
• recessed runway edge lighting

To foster safety awareness, knowledge and action, the ATSB developed a pilot information card to help flight crew identify factors that could increase the risk of a misaligned take-off or landing.