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A320 / CRJ2, Sofia Bulgaria, 2007 (AGC RI HF)

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Summary
On 13 April 2007 an Airbus A320, operated by Air France, in VMC with line training in progress, entered an active runway for take-off without ATC clearance at Sofia Airport. Consequently a CRJ-200 on short final with a valid ATC clearance was instructed to go around.
Event Details
When April 2007
Event Type AGC, HF, RI
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft AIRBUS A-320
Operator Air France
Domicile France
Type of Flight Public Transport (Passenger)
Origin Sofia
Intended Destination Paris/Roissy/Charles de Gaulle
Flight Phase Take Off
TOF
Flight Details
Aircraft CANADAIR Regional Jet CRJ-200
Operator Lufthansa
Domicile Germany
Type of Flight Public Transport (Passenger)
Origin Dusseldorf
Intended Destination Sofia
Flight Phase Landing
LDG
Location - Airport
Airport Sofia
General
Tag(s) Flight Crew Training
AGC
Tag(s) Phraseology
HF
Tag(s) Ineffective Monitoring
Procedural non compliance
RI
Tag(s) Accepted ATC Clearance not followed
Incursion pre Take off
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation
Air Traffic Management
Investigation Type
Type Independent

Contents

Description

On 13 April 2007 an Airbus A320, operated by Air France, in VMC with line training in progress, entered an active runway for take-off without ATC clearance at Sofia Airport. Consequently a CRJ-200 on short final with a valid ATC clearance was instructed to go around.

Synopsis

The following is an extract (verbatim) from the final Report prepared by the AAAIU Bulgaria on the Serious Incident:

"At 11:43:15 Sofia Tower gave RWY 27 taxi clearance and announced departure conditions.

At 11:52:30 Sofia Tower asked the crew whether it was ready for an immediate take-off from RWY27: "AF 268P are you ready for immediate departure RWY 27". The pilot answered indistinctly and ATC asked an answer again: "Sorry, say again".

The pilot answered the second time clearly: "We are ready for immediate AF 268P".

ATCo [tower air traffic controller] said "Roger" and after that informed the crew about the location of the approaching for landing on the same runway aircraft and gave instruction to stay at holding point "AF 268P landing traffic RW 27 five miles from touch down, кeep holding point."

Pilots of Air France reported a visual on the landing aircraft: "OK. Traffic in sight AF 268P", but didn’t repeat the Sofia-Tower instruction: "Кeep holding point".

The air traffic controller skipped the lack of reply (confirmation of understanding). He didn’t asked for a reiteration of his instruction “Кeep holding point”.

At 11:53:27 the landing traffic (for which Air France reported in sight), a CRJ 200 aircraft, registration DA-CRM of Lufthansa, performing scheduled flight from Düsseldorf to Sofia, flight number DLH 5HW, reported: "Sofia Tower, hallo, Lufthansa 5HW aaа…. Left hand base visual 27".

Sofia Tower controller gave actual weather information and a landing clearance to the aircraft: "Good afternoon Lufthansa 5HW tower, wind 270°/8kt, clear to land RW 27. Lufthansa confirmed the landing clearance for RWY27: "Clear to land RW 27 Lufthansa 5HW".

This radio exchange was at the frequency of Sofia Tower, which the pilots of A320 of Air France were still listening.

At 11:53:46 h there is a record from Sofia Tower: „Air France”….

At 11:53:53 [tower air traffic controller] informed Lufthansa that the runway is occupied and gave instruction for a go around: "Lufthansa 5….Sorry, Lufthansa 5HW runway is occupied. Go around now, go around". Lufthansa executed and answered: "Going around, Lufthansa 5HW".

At 11:54:08 the air controller gave instruction to Air France: "AF 268P keep position, stop at this position".

Air France answered: "Keep position AF 268P".

At 11:54:55 the А320 crew asked: "Air France.., for information,…268Р…, аre will us clear for line up confirm?" The air controller answered: "Negаtive AF 268P, I told you to keep your holding position due to landing traffic who was five miles from touch down".

Followed by: "Sorry, we understood continue in taxi for position, sorry".

At 11:55:29 Sofia Tower asked Lufthansa: "Lufthansa 5HW, would you like to make visual approach, RW 27 right hand circuit?"

Lufthansa pilot answered: "OK…Will be nice 5НW".

At 11:56:15 the air controller cleared Air France for take-off.


The Investigation

The Report presents the following summary of conclusions:

  • "The air traffic controller at Sofia Tower was hampered to look visually after the AC [aircraft] movements in the manoeuvring area of Sofia Airport from its workstation.
  • The technical equipment at the workstation in Sofia Tower is of lowered qualitative indexes and it hampers also the ATCo.
  • The workstation at Sofia Tower should be assessed from ergonomic point of view.
  • ATCo at workstation in Sofia Tower didn’t require repetition of basic instruction (acknowledgement), which is a violation of the technology of the air traffic service.
  • The crew of A320 aircraft didn’t follow attentively the situation at Sofia Airport
  • The commander of the A320 aircraft didn’t assess properly the conflict situation created by the crew.
  • During the flight planning the requirements of JAR-OPS 1.940, Para (a), p.1 & 3 were not met:
    • The two pilots had no type rating for A320 aircraft;
    • There was no safety pilot onboard.


Causal and Contributory Factors

The Report identifies the following causal (Cause) and contributory (Accompanying causes) factors.

"Causal factor (Cause):

  • Understated attention by ATC - workstation in Sofia Tower and by the crew of A320 aircraft during movement in maneuvering area of the airfield

Contributory factors (Accompanying causes):

  • The tower of Sofia Airport doesn’t correspondent to the new layout of RWY 27 and Terminal No 2.
  • Technical equipment of workstation in Sofia Tower is not useful enough and in full the ATCo in execution of his duty for control of AC in Airport Sofia maneuvering area.
  • Fist officer training was performed onboard of Air France A320 aircraft without safety pilot.


Safety Recommendations

The Report produces the following six Safety Recommendations:

  • "ATSA BULGARIA to reappraise the working technology at ATC workstation in Sofia Tower in the specific created situation, related with a raised risk during the control of AC in Airport Sofia maneuvering area.
  • CAA and ATSA BULGARIA to ensure that the conditions for execution of control technology of the AC in Airport Sofia maneuvering area are according to the new airfield infrastructure.
  • ATSA BULGARIA to analyze the expedience of creating of new workstation “Ground Contol”.
  • ATSA BULGARIA to perform ergonomic assessment of workstation Sofia Tower and to create adequate working conditions.
  • DGAC of Republic of France to inspect the training process of new first officers in Air France airline.
  • Chief pilot of Air France airline to give a talk with the commander of „Air France 268P” flight about the correctness of the described by him aviation occurrence.


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Further Reading

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