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A320 / CRJ2, Sofia Bulgaria, 2007

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Summary
On 13 April 2007 in day VMC, an Air France A320 departing Sofia lined up contrary to an ATC Instruction to remain at the holding point and be ready immediate. The controller did not immediately notice and after subsequently giving a landing clearance for the same runway, was obliged to cancel it send the approaching aircraft around. An Investigation attributed the incursion to both the incorrect terminology used by TWR and the failure to challenge the incomplete clearance read back by the A320 crew.
Event Details
When April 2007
Actual or Potential
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/Charles de Gaulle Airport
Flight Phase Taxi
TXI
Flight Details
Aircraft BOMBARDIER Regional Jet CRJ-200
Operator Lufthansa
Domicile Germany
Type of Flight Public Transport (Passenger)
Origin Dusseldorf
Intended Destination Sofia
Flight Phase Descent
ENR / APR
Location - Airport
Airport Sofia
General
Tag(s) Flight Crew Training
Inadequate Aircraft Operator Procedures
Copilot less than 500 hours on Type
AGC
Tag(s) Incorrect Readback missed
Phraseology
HF
Tag(s) ATC clearance error
Ineffective Monitoring
Procedural non compliance
Violation
RI
Tag(s) Accepted ATC Clearance not followed
Incursion pre Take off
Phraseology
R/T Response to Conflict
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Air Traffic Management
Safety Recommendation(s)
Group(s) Aircraft Operation
Air Traffic Management
Investigation Type
Type Independent

Description

On 13 April 2007, an Airbus A320 (F-GJVA) being operated by Air France on a scheduled passenger flight from Sofia to Paris CDG under call sign AF268P entered the runway without clearance in normal day visibility having acknowledged that a Bombardier CRJ-200 (D-ACRM) being operated by Lufthansa on a scheduled passenger flight from Düsseldorf to Sofia under call sign DLH 5HW which would be landing on the same runway was in sight. ATC, having given a landing clearance to the CRJ-200 without noticing the incursion, were obliged to cancel it. The go around instruction was acknowledged at a range from touchdown of 5.5nm

Investigation

A Commission for Investigation of an Aviation Occurrence was appointed by order of the Minister of Transport.

It was found that the TWR controller had not issued the instruction to the A320 to hold clear of the runway whilst expecting an immediate take off using the correct terminology and also that the A320 crew had failed to read it back fully, but had not the been challenged to do so by TWR.

It was noted that the runway involved, runway 27, was a recently opened one, displaced to the east of the former runway which had "changed the operational conditions". A new Terminal had been constructed at the same time and was located "in such a way that it hides about 300 - 320m of the runway in the observation sector of the air traffic controller to the East". In the absence of compensatory arrangements, this had made the task of the TWR controller more difficult.

It was found that pilot line training had been taking place on the A320 with a Training Captain as aircraft commander accompanied by two First Officers. However, during the investigation Air France submitted documentation which it was considered that showed that neither First Officer had "possess(ed) type rating for A320 aircraft on the day of aviation occurrence" and noted that on the day the Official Report had been finalised "the Commission hadn’t receive any answer from Air France why the two first officers had no type rating for A320 aircraft in their licenses on the day of the aviation occurrence" and had "assumed the two First Officers were trainees" with "no safety pilot onboard".

The formally stated Conclusions of the Commission were as follows:

  • The air traffic controller at Sofia Tower was hampered in looking after aircraft movements in the manoeuvring area of Sofia Airport visually from their workstation.
  • The technical equipment at the workstation in Sofia Tower is of poor quality and this hampers the ATCO.
  • The workstation at Sofia Tower should be assessed from ergonomic point of view.
  • The ATCO at the workstation in Sofia Tower didn’t require full acknowledgement of a basic instruction , which is a violation of air traffic service procedures.
  • The crew of A320 aircraft didn’t maintain awareness of the traffic situation at Sofia Airport The commander of the A320 aircraft didn’t correctly recollect the circumstances which led to 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 on board. The Commission concluded that the Main Cause of the incident was "inattention by the TWR ATC controller and by the crew of A320 aircraft during movement on the manoeuvring area of the airfield". Accompanying Causes were identified as:

  • The tower of Sofia Airport doesn’t correspond to the new layout of RWY 27 and Terminal No 2.
  • The technical equipment at the workstation in Sofia Tower is not useful enough in assisting the ATCO in the execution of his duty for control of aircraft on the manoeuvring area of Sofia Airport.
  • The First Officer on board of Air France A320 aircraft was under training without a safety pilot.

Six Safety Recommendations were made as a result of the Investigation as follows:

  • that ATSA BULGARIA should 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 manoeuvring area.
  • that CAA and ATSA BULGARIA should ensure that the methods for the control of aircraft ground movements at Sofia Airport area are compatible with the new airfield infrastructure.
  • that ATSA BULGARIA to review the expedience of creating of new workstation “Ground Control”.
  • that ATSA BULGARIA should perform an ergonomic assessment of the workstation at Sofia Tower and create adequate working conditions.
  • that the DGAC of the Republic of France should inspect the training process for new First Officers in Air France.
  • that the Chief Pilot of Air France should discuss with the commander of Air France 268P the correctness of his recollection of the occurrence.

The [Final Report http://www.mtitc.government.bg/upload/docs/OK_DOKL_AirFrance_eng_web.pdf] of the Investigation was subsequently published in English. Note that the 'Enclosures' listed at the end of the Official Report were not attached to the Report as made available.

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