Edit Accident: B763, Atlanta GA, USA 2009 (HF RE)

Accident Form

When:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Event Type:	AGC AI AW BS CFIT CS FIRE GND HF LB LOC LOS RE RI WAKE WX
Day/Night:	None Not Recorded Day Night
Flight Conditions:	None Not Recorded VMC IMC On Ground - Low Visibility On Ground - Normal Visibility
One sentence description:	On 19 October 2009, a Boeing 767-300 being operated by Delta Airlines on a scheduled passenger flight from Rio de Janeiro to Atlanta inadvertently made a landing at destination in night VMC on parallel taxiway ‘M’ instead of the intended and ATC-cleared landing runway 27R. None of the 194 occupants were injured and there was no damage to the aircraft or conflict with other traffic or vehicles. The third rostered crew member had become incapacitated en route with the consequence that neither of the other pilots had been able to take any in flight rest.
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Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

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Origin: Destination:

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Airport: In Vicinity of airport:

Airport: In Vicinity of airport:

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Coordinates: Location: ICAO Region: AFIAPACCARSAMEURMIDNAMNAT ICAO Territory: AGANAYBGBIBKCCTDADBDFDGDIDNDRDTDXEBEDEEEFEGEHEIEKELENEPESEVEYFAFBFCFDFEFGFHFIFJFKFLFMFNFOFPFQFSFTFVFWFXFYFZGAGBGCGEGFGGGLGMGOGQGSGUGVHAHBHCHDHEHFHHHKHLHRHSHTHUKLALBLCLDLELFLGLHLILJLKLLLMLOLPLQLRLSLTLULWLXLYLZMBMDMGMHMKMMMNMPMRMSMTMUMWMYMZNCNFNGNINLNSNTNVNWNZOAOBOEOIOJOKOLOMOOOPOROSOTOYPAPGPHPJPKPLPMPOPPPTPWRCRJRKRORPSASBSCSESFSGSKSLSMSOSPSUSVSYTATBTDTFTGTITJTKTLTNTQTRTTTUTVTXUAUBUDUEUGUHUIUKULUMUNURUSUTUUUWVAVBVCVDVEVGVHVIVLVMVNVOVQVRVTVVVYWAWBWIWMWPWRWSYYPZZKZM

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Tags: ATC Training Flight Crew Training Military use of civil airport Civil use of military airport Approach not stabilised Aircraft-aircraft collision Aircraft-aircraft near miss Extra flight crew (no training) Safety pilot present Non Precision Approach Circling Approach Event reporting non compliant Inadequate Airworthiness Procedures Inadequate Aircraft Operator Procedures Inadequate ATC Procedures Airspace Design Airport Layout Ineffective Regulatory Oversight Root Cause Not Determined Military Fast Jet Formation Foreign Military Aircraft Approach to Wrong Airport Inadequate Airport Procedures

Tags: ATC Training Flight Crew Training Military use of civil airport Civil use of military airport Approach not stabilised Aircraft-aircraft collision Aircraft-aircraft near miss Extra flight crew (no training) Safety pilot present Non Precision Approach Circling Approach Event reporting non compliant Inadequate Airworthiness Procedures Inadequate Aircraft Operator Procedures Inadequate ATC Procedures Airspace Design Airport Layout Ineffective Regulatory Oversight Root Cause Not Determined Military Fast Jet Formation Foreign Military Aircraft Approach to Wrong Airport Inadequate Airport Procedures

Add AGC Tags

Tags: Call Sign Confusion Loss of Comms Incorrect Readback missed Phraseology Language Clarity Low Fuel Status CPDLC Flight Crew Oxygen Mask Use Take off without clearance Landing without clearance Military Formation Clearance Military/Civil Coordination Provision of Aircraft Performance Data ATC Clearance Cancelled

Add AI Tags

Tags: CA Incursion DA Incursion PA Incursion TSA Incursion GPS VFR Navigation ATC Complicit Aircraft not in contact with Airspace ATC

Add BS Tags

Tags: Large Birds Flocking Birds Significant Airframe Damage Flight Crew Injury Engine damage Coastal Location Migration Engine Ingestion Prior verbal warning

Add CFIT Tags

Tags: Into water Into terrain Into obstruction No Visual Reference Lateral Navigation Error Vertical navigation error Pressure altimeter setting error VFR flight plan IFR flight plan

Add FIRE Tags

Tags: Post Crash Fire Non-Fire Fumes Dangerous Goods Fire-Cabin Baggage origin Fire-Cargo origin Fire-Electrical origin Fire-Fuel origin Fire-Power Plant origin Fire-Underfloor origin Fire-Galley Fire-Wing De-Ice fluid contamination Electrical fumes - No fire Landing Gear Overheat

Add HF Tags

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Add GND Tags

Tags: Taxiway collision On gate collision Aircraft / Aircraft conflict Aircraft / Person conflict Aircraft / Vehicle conflict Aircraft / Object or Structure conflict ATC clearance error Ground de/anti icing Jet Blast / Prop wash Surface Friction Towed aircraft involved Aircraft Push Back Incorrect Parking Position Airbridge Positioning Both objects moving Wingtip clearance Centreline obscured Accepted ATC clearance not followed Surface Lighting control Hold Loading Passenger Loading Cargo Loading Fuel Loading Dangerous Goods Engine Ground Running Engine Powered Systems Test No Flight Crew on Board

Add LB Tags

Tags: Accepted ATC Clearance not followed SID bust Clearance readback error undetected TCAS RA response Manual flight Pressure altimeter setting error

Add LOC Tags

Tags: Airframe Structural Failure Significant Systems or Systems Control Failure Degraded flight instrument display Uncommanded AP disconnect AP Status Awareness Non-normal FBW flight control status Loss of Engine Power Crew Incapacitation Flight Management Error Flight Control Error Environmental Factors Bird or Animal Strike Aircraft Loading Malicious Interference Temporary Control Loss Extreme Bank Extreme Pitch Last Minute Collision Avoidance Hard landing Take off Trim Setting Incorrect Thrust Computed Unintended transitory terrain contact Collision Damage Incorrect Aircraft Configuration Aerodynamic Stall

Add LOS Tags

Tags: TCAS RA Mis Flown Accepted ATC Clearance not followed See and Avoid Ineffective Required Separation not maintained Released to Own Separation Level Bust Lateral Navigation Error ATC Error Near Miss Lateral Offset in use Mid-Air Collision Uncommanded AP disconnect Military Aircraft involved Apparent de-selection of transponder Transponder non selection

Add RI Tags

Tags: ATC error Accepted ATC Clearance not followed Incursion pre Take off Incursion after Landing Runway Crossing Intersecting Runways Intersecting extended centrelines Towed aircraft involved Near Miss Ground Collision Phraseology Intentional Premature Rotation Vehicle Incursion

Add RE Tags

Tags: Overrun on Take Off Overrun on Landing Directional Control Undershoot on Landing Wrong Runway Excessive Airspeed RTO decision after V1 High Speed RTO (V above 80 but not above V1) Unable to rotate at VR Frozen Deposits Collision Avoidance Action Parallel Approach Operations Excess Water Depth Late Touchdown Significant Tailwind Component Significant Crosswind Component Thrust Reversers not fitted Landing Performance Assessment Off side of Runway Misalignment on runway Taxiway Take Off/Landing Runway Length Temporarily Reduced Intentional Premature Rotation Incorrect Aircraft Configuration Reduced Thrust Take Off

Tags: Overrun on Take Off Overrun on Landing Directional Control Undershoot on Landing Wrong Runway Excessive Airspeed RTO decision after V1 High Speed RTO (V above 80 but not above V1) Unable to rotate at VR Frozen Deposits Collision Avoidance Action Parallel Approach Operations Excess Water Depth Late Touchdown Significant Tailwind Component Significant Crosswind Component Thrust Reversers not fitted Landing Performance Assessment Off side of Runway Misalignment on runway Taxiway Take Off/Landing Runway Length Temporarily Reduced Intentional Premature Rotation Incorrect Aircraft Configuration Reduced Thrust Take Off

Add WAKE Tags

Tags: ICAO Standard Wake Separation prevailed ICAO Standard Wake Separation not met Accepted ATC clearance not followed Own separation In trail event Cross track event Pilot over compensation Intersection take off Intersecting extended centrelines Intersecting runways

Add WX Tags

Tags: In Flight Airframe Icing In Flight Icing - Piston Engine In Flight Icing - Turbine Engine CAT encounter En route In-cloud air turbulence Hail damage Volcanic Ash Effects Sand/Dust limited IFV Fog In Cloud on Visual Clearance Precipitation-limited IFV Strong Surface Winds Mountain Waves Lightning Damage Low Level Windshear

Add EPR Tags

Tags: Emergency Descent Emergency Evacuation Airport Emergency Medical Response MAYDAY declaration PAN declaration “Emergency” declaration Slide Malfunction RFFS Procedures Evacuation difficulties in Water Delay in Declaration of Emergency

Add CS Tags

Tags: Disruptive Pax Turbulence Injury - Cabin Crew Turbulence Injury - Pax with Seat Belts on Turbulence Injury - Pax with Seat Belts off Cabin Stowage - Pax Items Toilet compartment fire Cabin furnishings fire Evacuation slides deployed Pax oxygen mask drop Unauthorised PED use IFE fire Flight deck comms difficulty Cabin air contamination Malicious interference Hand held extinguisher used Evacuation on Cabin Crew initiative Flight Crew Evacuation Command Cabin Crew Incapacitation Cabin Crew Medical Fitness Passenger Illness Faulty or misused PED

Add AW Tags

System(s): Airframe Air Conditioning and Pressurisation Autoflight Communications Electrical Power Equipment / Furnishings Fire Protection Flight Controls Fuel Hydraulic Power Ice and Rain Protection Indicating / Recording Systems Landing Gear Landing Lights Navigation Oxygen Airborne Auxiliary Power (APU) Propellers Rotors Engine - General Engine Fuel and Control Bleed Air Other Emergency Evacuation Contributor(s): Maintenance Error (valid guidance available) Maintenance Error (invalid guidance available) Inadequate Maintenance Schedule Inadequate Maintenance Inspection Inadequate QRH Drills OEM Design fault Damage Tolerance Contributing ADD Component Fault in service Component Fault after installation Pilot verbal-only defect communication Corrosion/Disbonding/Fatigue Cross Connection Engine Compressor Washing

Add Safety Net Mitigation

Malfunction of Relevant Safety Net: None Yes No GPWS: None Effective Partially effective Available but ineffective TAWS: None Effective Partially effective Available but ineffective TAWS with RAAS: None Effective Partially effective Available but ineffective TCAS: None Effective Partially effective Available but ineffective STCA: None Effective Partially effective Available but ineffective MSAW: None Effective Partially effective Available but ineffective APM: None Effective Partially effective Available but ineffective APW: None Effective Partially effective Available but ineffective Mode 'S' EHS: None Effective Partially effective Available but ineffective Wind Shear Escape Guidance: None Effective Partially effective Available but ineffective Stall Protection: None Effective Partially effective Available but ineffective A-SMGCS: None Effective Partially effective Available but ineffective EMAS: None Effective Partially effective Available but ineffective TOCWS: None Effective Partially effective Available but ineffective

Add Causal Factor Group(s)

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Add Safety Recommendations

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Accident Report text:

==Description== On 19 October 2009, a [[Boeing 767-300]] being operated by Delta Airlines on a scheduled passenger flight from Rio de Janeiro to Atlanta inadvertently made a landing at destination in night [[VMC]] on parallel taxiway ‘M’ instead of the intended and ATC-cleared landing runway 27R. None of the 194 occupants were injured and there was no damage to the aircraft or conflict with other traffic or vehicles. The third rostered crew member had become incapacitated en route with the consequence that neither of the other pilots had been able to take any in flight rest. ==Investigation== An investigation was carried out by the [[NTSB]]. [[FDR]] and 2 hour [[CVR]] data were available to the Investigation. It was established that three flight crew had been on board with the third being a Check Captain overseeing the operating Captain for the purposes of his obtaining a special airport qualification. It is not clear from the report whether a third pilot was automatically required or customarily rostered to fulfil crew duty requirements but it is clear that this was the intention on this flight. Normal practice is reported to have been to divide the estimated time in the cruise into three equal parts and rest accordingly. The flight was expected to take around 10 hours and in the event landed around 10 hours and 10 minutes after the off gate time. Departure from Rio had been made with the Operating Captain in the left hand seat, the Check Captain in the right hand seat and the First Officer in the Observers seat. At top of climb, the Check Captain took the first of the three 2 hour 50 minute rest periods but was determined to be ill at the end of it an remained off the flight deck for the remainder of the flight. The other two pilots, with the Captain who had been in the left hand seat for departure as the designated aircraft commander and [[PF]] for the arrival, conducted the entire flight without the benefit of their usual in flight rest periods. Throughout the flight both made comments indicating that they were fatigued and identified fatigue as their highest threat for the approach, but did not discuss strategies to mitigate the consequences of that fatigue. During the descent and approach, the flight was given a number of runway changes, the last of which was in the vicinity of the FAF for runway 27L when an ATC offer of a visual sidestep to runway 27R was accepted. Although the earlier approach brief had covered two possible runways, these did not include 27R and they were not aware that the approach lighting and ILS were inoperative. The 27R PAPI was identified and the aircraft was lined up on what the PF said had been “the brightest set of lights he could see”. As the aircraft proceeded on finals, the First Officer became preoccupied with an attempt to tune and identify the 27R ILS. Four seconds prior to touchdown, the CVR tape includes the PF expressing his realisation that they were about to land on a taxiway. That taxiway was taxiway ‘M’ which was parallel to runway 27R and 61 metres north of it. [[File:KATL Diagram.jpg|600px|thumb|none|KATL Airport Diagram - to be used for description purposes only.]] All five runways at Atlanta were oriented approximately east-west and 27R was 3625 metres long and 45 metres wide. Taxiway ‘M’ was only 50% the width of the runway and was equipped with standard blue edge lights and standard green centreline lights. It was noted that the installed [[ASDE-X]] was not programmed to activate alerts for an aircraft landing or departing from a taxiway and, therefore, when the local controller scanned the ASDE-X display, system safety logic bars indicated that the approaching aircraft was correctly aligned with runway 27R. It was also noted that the installed airport lighting system did not provide ATC personnel with the capability to individually control each of the lighting circuits in accordance with guidance contained in the specifically applicable FAA AC 150/5345-56. Flight evaluations of the airport lighting system carried out as part of the Investigation indicated that there were a number of visual cues that could have been misleading. These included a plethora of taxiways signs along both sides of taxiway M which appeared to be white when seen from the air at night and could thus be mistaken for runway edge lights. In addition, the blue LED lights used on the ‘touchdown’ end of taxiway ‘M’ could appear brighter than the adjacent incandescent lights on the aerodrome and the alternating green and yellow lights in the ILS critical area were considered capable of giving the appearance of a runway centreline. However, the same flight evaluations also indicated that when either the approach lights or ILS for runway 27R were available and used, it was quite obvious when the aircraft was not aligned with the required runway. It was also found that “the color of the blue taxiway edge lights became distinguishable at about 500 feet above ground level while on approach”. The full NTSB '''Final Report''' of the Investigation: [http://www.skybrary.aero/bookshelf/books/1692.pdf OPS10IA001] includes the following '''Probable Cause''', determined by NTSB on 15 November 2010 as: ''“The flight crew’s failure to identify the correct landing surface due to fatigue”.'' It was also concluded that '''Contributory Factors''' were: * the flight crew’s decision to accept a late runway change * the unavailability of the approach light system and the instrument landing system for the runway of intended landing * the combination of numerous taxiway signs and intermixing of light technologies on the taxiway. No Safety Recommendations were made as a result of the event. ==Further Reading== *[[Wrong Runway Use]] *[[Runway Identification]] *[[Runway Visual Perspective]] *[[Fatigue]] *[[Runway Lighting]] *[[Taxiway Lighting]] *[[ASDE-X]]

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