A321, Daegu South Korea, 2006
From SKYbrary Wiki
|On 21 February 2006, an Airbus A321-200 being operated by China Eastern on a scheduled passenger flight from Daegu to Shanghai Pudong failed to follow the marked taxiway centreline when taxiing for departure in normal daylight visibility and a wing tip impacted an adjacent building causing minor damage to both building and aircraft. None of the 166 occupants were injured.|
|Actual or Potential
|Ground Operations, Human Factors|
|Flight Conditions||On Ground - Normal Visibility|
|Operator||China Eastern Airlines|
|Type of Flight||Public Transport (Passenger)|
|Intended Destination||Shanghai Pudong International|
|Take off Commenced||No|
|Location - Airport|
|Tag(s)||Flight Crew Training,|
Civil use of military airport
Inappropriate ATC Communication
Aircraft / Object or Structure conflict,
|Damage or injury||Yes|
|Causal Factor Group(s)|
Air Traffic Management,
Air Traffic Management,
On 21 February 2006, an Airbus A321-200 being operated by China Eastern on a scheduled passenger flight from Daegu to Shanghai Pudong failed to follow the marked taxiway centreline when taxiing for departure in normal daylight visibility and a wing tip impacted an adjacent building causing minor damage to both building and aircraft. None of the 166 occupants were injured.
An Investigation was carried out by the Korean Aircraft and Railway Accident Investigation Board (ARAIB). It was noted that Daegu was a military airport which handles civilian traffic. It was also noted that the aircraft was being operated with the aircraft commander, an Instructor Pilot, in the co pilot seat and the First Officer in the left hand seat taxiing as PF.
It was established that the aircraft had been cleared to taxi “straight ahead” along the full length of the parallel taxiway, which, about half way along, had a brief deviation to the right for a short distance to increase separation past a building (for the re-located PAR) recently constructed quite close to the original straight line of the taxiway. Whilst this deviation was clearly marked by the yellow taxiway centreline, there was no other visible cue for the deviation and the deviation rejoined the straight line of the original taxiway a short distance further on. The accident aircraft failed to follow the deviation and its left wing hit the building.
The taxi route is shown on the diagram below taken from the Official Report:
The detail of the deviation at the PAR site is shown in a second diagram also taken from the official report:
It was noted that the change to the taxiway had not been advised by Notice To Airmen or Automatic Terminal Information Service (ATIS) and was not published in the State AIPs. No special caution had been provided by ATC to alert the crew to the deviation from the straight line depicted on their charts.
The Investigation determined Probable Cause as:
“While taxiing, the flight crew did not fully perform “Pilot’s obligation for caution” such as being negligent in watching for all directions and verifying ground markings.”
It found that a number of factors, quoted below verbatim from the official report, contributed to the errors made by the flight crew:
- The flight crew was taxiing without knowing the information on the curved taxiway and obstacles (PAR building)
- The control tower’s “Taxi straight ahead” instruction to Aircraft 5054 when the aircraft entered the parallel taxiway where the curved taxiway was located
- Non-installation of a taxiway edge marking which would enable the flight crew to recognize the pavement surface not to be used by aircraft.
Noting that Safety Action during the course of the investigation included the provision of edge markings for the curved taxiway and appropriate communication made through the State AIP, no safety recommendations on these matters were deemed necessary. However, 8 Safety Recommendations were made as follows and are re quoted verbatim from the official report.
To China Eastern Airlines The following items should be reflected in flight crew training and flight operation Procedure:
- Non-essential conversations should be avoided during critical phases of flight below 10,000 feet3,048 m
- Aircraft should not be operated in a negligent manner bringing on danger to human life or property, and flight crew should always stay vigilant for potential collisions while operating on the movement area of an aerodrome, regardless of the type of flight or the class of airspace;
- In order to ensure the safety of aircraft wing tips ideally during taxi, the aircraft should always keep the taxiway centerline, and as safety guidelines during taxi, when separation from obstacles is in doubt, hold the aircraft, and assign a wing-walker;
- The Captain is in direct charge of controlling an aircraft, having the final authority. If ATC issues a clearance that would cause flight crew to violate a rule or regulation, or it is deemed that the aircraft would be in danger by following the clearance, flight crew should request an amendment to the clearance from ATC, and requesting the amended clearance is the responsibility of flight crew. (AIR F0601-1)
To Busan Regional Aviation Administration (Civil Aviation Safety Authority)
- A review is urged on a method to establish a system preventing the omission of aeronautical information collection related to civil aviation, by designating the personnel to be in charge of aeronautical information notification for each aviation facility of the military aerodrome used by civil aircraft, and assigning the responsibility to each airport representative office for collecting aeronautical information on competent military aviation facility. (AIR F0601-2)
- A review is urged on a method for the civil controller to practically contribute to the safe operation of civil aircraft, by re-emphasizing the compliance with the principle and purpose of the agreement between the organizations concerned on the civil controller allocated in the control tower of the military aerodrome used by civil aircraft, or by re-examining the necessity of allocation of the civil controller to the control tower. (AIR F0601-3)
To the Korean Air Force
- A review is urged on a method to amend the installation standards of aviation facilities including taxiways of military aerodromes used by civil aircraft, in order to meet international civil aviation standards. (AIR F0601-4)
- A review is urged on a method to amend the items on the issuance of NOTAM in flight information service regulations by referring to civil aviation regulations pertaining to NOTAM, in order for the handling personnel to understand the items on the issuance of NOTAM accurately. (AIR F0601-5)
- A review is urged on a method to positively apply the air traffic control phraseologies and standards prescribed in air traffic control procedures commonly applied by civil and military, in the case of providing air traffic control services to civil aircraft. (AIR F0601-6)
To the Korea Airports Corporation
- A review is urged on a method to satisfy the purpose of the ATIS installation by improving the ATIS for controllers to be able to directly record and broadcast in voice at any time whenever new aeronautical information not stored in advance is brought about. (AIR F0601-7)
To Korean Airlines
- Ensure the thorough propagation of necessary aeronautical information by the flight operation personnel of each airport to the flight crew on the respective aircraft is to be accomplished by positively compiling and understanding the official or non-official aeronautical information of the competent airport, and conduct training to raise the flight crew perception of the importance on aeronautical information for the safe operation of aircraft. (AIR F0601-8)
The Final Report was published on 19 November 2007 and may be seen in full at SKYbrary bookshelf: ARAIB/Aircaft Incident Report F0601