Hong Kong CAD issues final report on A340 attempted taxiway takeoff

January 14, 2012

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

August 30, 2011

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:

Report: Canadair RJ uncommanded roll on takeoff in icing conditions

April 15, 2011

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:


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

March 24, 2011

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)

February 28, 2011

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:


Report: Fatigue stress caused Ilyushin 76 wheel failure

February 16, 2011

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:

 


Hong Kong CAD issues preliminary report on A340 attempted taxiway takeoff

December 23, 2010

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.

 


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