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: Boeing 737-800 struck runway construction markers on takeoff at Paris-CDG

Take-off trajectory of AMV6104 (source: BEA)

The French Bureau d’Enquêtes et d’Analyses (BEA) released the final report of their investigation into a serious incident in which a Boeing 737-800 struck runway construction markers on takeoff from Paris-CDG, France.

On August 17, 2008 at 00:57 local time, AMC Airlines Flight AMV6104 struck some provisional lights at the end  runway 27L at Paris-Charles de Gaulle Airport. Then, during the rotation, it destroyed some markers on the safety-barrier positioned in front of the construction zone. It took off before a provisional blast fence and continued its flight to its destination.
Repair works on runway 09R/27L were in progress between 4 and 20 August 2008. During this period, the last 1,240 metres of runway  27L were closed for flight operations. The AMC Airlines Boeing 737 commenced takeoff from after lining up from taxiway Y11, leaving 2360 metres for takeoff. This was reported to the crew by ground controller.

The crew had calculated takeoff parameters using a computer program, but the takeoff distance calculated by the program was not known to the crew.

BEA Concluded that:
The event was caused by the crew’s failure to take into account the length of the runway available for takeoff.
The following factors may have contributed to the event:

• ˆ the inadequacy of the OPT utilisation procedures set up by the operator AMC to prevent such an error;
• ˆ the impaired level of crew performance, specifically related to the pilots’ fatigue.

More information:

• BEA report su-z080816 (PDF)

Report: Canadair RJ uncommanded roll on takeoff in icing conditions

The CRJ shortly before Stick pusher activates (graphic from AIBN animation)

AIBN Norway published the final report of their investigation into an serious incident involving a Cimber Air Denmark Canadair CRJ200LR Regional Jet, January 2008. During take-off, immediately after lift-off, the aircraft suddenly lost lift on the right wing. The wing dropped, sending the aircraft into an uncontrolled 40-degree bank. The stall protection system activated, and the crew regained control 

On 31 January 2008, at 17:21 hours, a serious aircraft incident took place during take-off from runway 19L at Oslo Airport Gardermoen (ENGM). A Canadair CRJ200LR aircraft with two pilots and two cabin crew members on board suddenly lost lift on the right wing, causing the wing to drop and sending the aircraft into an uncontrolled 40-degree bank immediately after lift-off. The stall protection system activated, and the crew regained control and continued as scheduled to Copenhagen.
The investigation has shown that prescribed de-icing took place 15 minutes prior to departure, and that the wings were not cold-soaked in advance. Weather conditions were temperature at freezing, 15 kt wind and continuous precipitation in the form of aggregated, wet snowflakes. The runway was covered by slush and wet snow which had fallen after the runway had been cleared of snow and sanded 30 minutes earlier. Unintentionally, due to distraction, the system for heating the leading edge of the wing was not switched on prior to take-off. The nose wheel was lifted from the ground at the correct speed, but at a higher than recommended rotation rate.
This incident is one in a number of similar cases. From 2002 to 2008, six CL-600 series aircraft were involved in accidents during winter conditions. The wing of the aircraft type has proven to be especially sensitive to contamination on the leading edge. After the accidents, a number of measures have been implemented to ensure that the wing is clean during take-off, and to ensure that the pilots use the correct take-off technique.

The AIBN believes that the safety measures that have been introduced have not resulted in a definitive solution to the problem. When the de-icing fluid runs off during take-off, it is essential that the leading edge of the wing is heated. On take-off from contaminated runways, spray from the nose wheel will envelop the aircraft’s wing root. This source of contamination hits an aerodynamically critical area on the wing, and comes in addition to the precipitation which can adhere to the wing and disturb the airflow. The AIBN believes that it is not sufficient to depend solely on ”soft” safety barriers such as check lists and memory when the position of one switch (Wing Anti-Ice ON) can be critical to prevent a catastrophic accident during take-off. Technical or physical safety barriers in the form of design changes, automatic systems or automatic warning systems are, in the opinion of the Accident Investigation Board, necessary to obtain adequate reduction in accident risk. Alternatively, more severe restrictions for winter operations with the affected aircraft models must be introduced.

The Accident Investigation Board issues four safety recommendations.

More information:

• AIBN report SL 2011/09

Video: Russian Alrosa TU-154 takeoff from abandoned airstrip – repaired after crash-landing

On September 7, 2010 and Alrosa Tupolev 154M operated on a flight from Polyarnyj Airport (PYJ), Russia to Moskva-Domodedovo Airport (DME). At an altitude of 10,600m in the region of town of Usinsk the Tu-154 lost all of its electrical systems including radio and navigation systems, flaps and fuel pumps. After emergency decent below cloud level the crew were able to spot an abandoned air strip near the town of Izhma. The abandoned air strip is 1325m, whereas Tu-154 requires a minimum of 2200m. The aircraft came to rest 160m past the end of the runway coming to rest amidst trees.
The airplane was repaired on site and departed in March 2011.

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: Fatigue stress caused Ilyushin 76 wheel failure

On October 19th 2009, the pilot of an Ayk Avia IL-76TD, registered EK-76754, requested to return to the departure stand 56 at Sharjah International Airport after an aborted takeoff at runway 12 due to heavy vibration during the aircraft roll.

The United Arab Emirates’ General Civil Aviation Authority investigated the incident and reported that heavy vibration occurred during takeoff with the pilot-in-command (PIC) aborting at a speed of approximately 155 km/hr.

He retarded the throttles and advanced the thrust reversers when the aircraft started to decelerate normally. The aircraft vacated the runway via Taxiway D, and the PIC requested an ATC clearance to return to his departure stand 56 due to technical problem. Upon arrival, the crew disembarked the aircraft normally and the ground engineer, who was onboard the aircraft, requested the Airport Fire Services to cool down the axle of the left aft inboard main landing gear by dry air where a wheel had separated leaving part of its hub attached to the axle. During the runway inspection, the disintegrated wheel tyre was found at about 100 m from the aircraft stop point at the runway.

PROBABLE CAUSE:  The Investigation Department determined that the probable cause of the Ayk Avia Airline “aborted takeoff incident” was the fracture and disintegration of left hand inboard aft wheel due to progressive undetected fatigue stress. The cause of why the fatigue was undetected is not determined.

More information:

• GCAA Report 09/2009

 

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

Report: airline, airport and controller were factors in A320 taxiway takeoff at Oslo-Gardermoen

Oslo-Gardermoen. The orange line indicates where the aircraft took off northbound on taxiway M, instead of on runway 01L, west of taxiway M. (photo: AIBN)

An investigation report by the Accident Investigation Board Norway (AIBN) concluded that the airline, airport and controller were all factors in a serious incident at Oslo-Gardermoen Airport when an Aeroflot Airbus A320 took off from a taxiway.

The serious incident occurred on 25 February 2010. Aeroflot flight number AFL212, an Airbus A320 aircraft, made a taxiing mistake and took off from taxiway M instead of runway 01L. There were three pilots, four cabin crew members and sixty passengers onboard. After the incident, the flight continued as planned to Moscow.

The flight crew was not aware that they had taken off from the taxiway until informed of this by the air traffic controller after take-off. Under the prevailing conditions, taxiway M was by chance long enough for the aircraft to take off. The taxiway was at the time of the incident also free of other traffic and obstacles. This prevented a more serious outcome of the incident.

The investigation has uncovered several causes for AFL212’s taxiing mistake and take-off from the taxiway. The factors which contributed to the events can be found with the parties involved, i.e. the airline, the control tower and the airport.

The Accident Investigation Board is of the opinion that deficient procedures and insufficient alertness in the cockpit, in combination with insufficient monitoring from the control tower and insufficient signposting in the manoeuvring area, resulted in AFL212 making a taxiing mistake and taking off from taxiway M.

On the basis of the investigation, the Accident Investigation Board has issued a safety recommendation to the airline involved, Aeroflot Russian Airlines. As the airport has already implemented measures to prevent similar incidents, and the Civil Aviation Authority has reopened an earlier safety recommendation from AIBN to Avinor, no further safety recommendations were issued.

 

Serious incident: Finnair A340 attempts takeoff from Hong Kong taxiway

The  Accident Investigation Division of the Hong Kong Civil Aviation Department, HKCAD has launched an investigation into a serious incident in which an A340 attempted to takeoff from a taxiway.

The incident happened on November 26, 2010  as Finnair Flight 70 was cleared to takeoff at Hong Kong-Chek Lap Kok International Airport.  The tower controller noted that the flight was starting the takeoff roll from the parallel taxiway and instructed the crew to abort the takeoff.

There were no injuries or damage. The airplane involved in the incident was Airbus A340-313X registered OH-LQD.

The occurrence was classified as a serious incident as is under investigation by the  Accident Investigation Division of the Hong Kong Civil Aviation Department, HKCAD.