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Accident and Serious Incident Reports: AGC

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Category: Air Ground Communication Air Ground Communication
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Definition

Reports relating to accidents and serious incidents which included Air-Ground Communication (AGC) as a causal factor.

Call Sign Confusion

  • AT43/A346, Zurich Switzerland, 2010 (On 18 June 2010, an ATR 42 began a daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began take off from intersecting runway 16 with an ATC clearance. ATC were unaware of this until alerted to the situation by the crew of another aircraft which was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so prior to the runway intersection whilst the A340 continued departure on runway 16 .)
  • B738/A319 en-route, south east of Zurich Switzerland, 2013 (On 12 April 2013, a Ryanair Boeing 737-800 took a climb clearance intended for another Ryanair aircraft on the same frequency. The aircraft for which the clearance was intended did not respond and the controller did not notice that the clearance readback had come from a different aircraft. Once the wrong aircraft began to climb, from FL360 to FL380, a TCAS RA to descend occurred due to traffic just transferred to a different frequency and at FL370. That traffic received a TCAS RA to climb. STCA was activated at the ATS Unit controlling both Ryanair aircraft.)
  • B738/B738, vicinity Oslo Norway, 2012 (On 31 October 2012, a Norwegian Air Shuttle Boeing 737-800 on go around after delaying the breaking off of a fast and high unstable ILS approach at Oslo lost separation in IMC against another aircraft of the same type and Operator which had just taken off from the same runway as the landing was intended to be made on. The situation was aggravated by both aircraft responding to a de-confliction turn given to the aircraft on go around. Minimum separation was 0.2nm horizontally when 500 feet apart vertically, both climbing. Standard missed approach and departure tracks were the same.)
  • B190 / B190, Auckland NZ, 2007 (On 1 August 2007, the crew of a Beech 1900 aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Beech 1900 that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.)


Loss of Communication

  • A319, en-route, Nantes France, 2006 (On 15 September 2006, an Easyjet Airbus A319, despatched under MEL provision with one engine generator inoperative and the corresponding electrical power supplied by the Auxiliary Power Unit generator, suffered a further en route electrical failure which included power loss to all COM radio equipment which could not then be re-instated. The flight was completed as flight planned using the remaining flight instruments with the one remaining transponder selected to the standard emergency code. The incident began near Nantes, France.)
  • B738 / E135, en-route, Mato Grosso Brazil, 2006 (On 29 September 2006, a Boeing 737-800 level at FL370 collided with an opposite direction Embraer Legacy at the same level. Control of the 737 was lost and it crashed, killing all 154 occupants. The Legacy's crew kept control and successfully diverted to the nearest suitable airport. The Investigation found that ATC had not instructed the Legacy to descend to FL360 when the flight plan indicated this and soon afterwards, its crew had inadvertently switched off their transponder. After the consequent disappearance of altitude from all radar displays, ATC assumed but did not confirm the aircraft had descended.)
  • A332 / A333, en-route, North West Australia, 2012 (On 31 March 2012, after the implementation of contingency ATC procedures for a period of 5 hours due to controller shortage, two Garuda A330 aircraft which had been transiting an associated Temporary Restricted Area (TRA) prior to re-entering controlled airspace were separately involved in losses of separation assurance, one when unexpectedly entering adjacent airspace from the TRA, the other when the TRA ceased and controlled airspace was restored. The Investigation did not find that any actual loss of separation had occurred but identified four Safety Issues in relation to the inadequate handling of the TRA activation by ANSP Airservices Australia.)
  • A320, en-route, Denver CO USA, 2009 (On 21 October 2009, an Airbus 320-200 being operated by Northwest Airlines on a scheduled passenger flight from San Diego to Minneapolis-St Paul, with the Captain as PF, overflew its destination at cruise level in VMC at night by more than 100 nm, after the two pilots had become distracted in conversation and lost situational awareness. They failed to maintain radio communications with a series of successive ATC units for well over an hour. After a routine inquiry from the cabin crew as to the expected arrival time, the flight crew realised what had happened and re-established ATC contact after which the flight was completed without further incident.)
  • B733, en-route, northwest of Athens Greece, 2005 (On 14 August 2005, a Boeing 737-300 was released to service with the cabin pressurisation set to manual. This abnormal setting was not detected by the flight crew involved during standard checks. They took no corrective action after take-off when a cabin high altitude warning occurred. The crew lost consciousness as the aircraft climbed on autopilot and after eventual fuel exhaustion, the aircraft departed controlled flight and impacted terrain. The Investigation found that inadequate crew performance had occurred within a context of systemic organisational safety deficiencies at the Operator compounded by inadequate regulatory oversight.)


Incorrect Readback Missed

  • A320, vicinity Oslo Norway, 2008 (On 19 December 2008, an Aeroflot Airbus A320 descended significantly below its cleared and acknowledged altitude after the crew lost situational awareness at night whilst attempting to establish on the ILS at Oslo from an extreme intercept track after a late runway change and an unchallenged incorrect readback. The Investigation concluded that the response to the EGPWS warning which resulted had been “late and slow” but that the risk of CFIT was “present but not imminent”. The context for the event was considered to have been poor communications between ATC and the aircraft in respect of changes of landing runway.)
  • E145, en-route, north east of Madrid Spain, 2011 (On 4 August 2011, a Luxair Embraer 145 flying a STAR into Madrid incorrectly read back a descent clearance to altitude 10,000 feet as being to 5,000 feet and the error was not detected by the controller. The aircraft was transferred to the next sector where the controller failed to notice that the incorrect clearance had been repeated. Shortly afterwards, the aircraft received a Hard EGPWS ‘Pull Up’ Warning and responded to it with no injury to the 47 occupants during the manoeuvre. The Investigation noted that an MSAW system was installed in the ACC concerned but was not active.)
  • B738/A319 en-route, south east of Zurich Switzerland, 2013 (On 12 April 2013, a Ryanair Boeing 737-800 took a climb clearance intended for another Ryanair aircraft on the same frequency. The aircraft for which the clearance was intended did not respond and the controller did not notice that the clearance readback had come from a different aircraft. Once the wrong aircraft began to climb, from FL360 to FL380, a TCAS RA to descend occurred due to traffic just transferred to a different frequency and at FL370. That traffic received a TCAS RA to climb. STCA was activated at the ATS Unit controlling both Ryanair aircraft.)
  • C525 / B773, vicinity London City UK, 2009 (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 ft QNH SID Stop altitude and at 4000 ft QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300ER. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • A320 / B738, en-route, near Córdoba Spain, 2014 (On 30 October 2014, a descending Airbus A320 came close to a Boeing 737-800 at around FL 220 after the A320 crew significantly exceeded a previously-instructed 2,000 fpm maximum rate of descent assuming it no longer applied when not reiterated during re-clearance to a lower altitude. Their response to a TCAS RA requiring descent at not above 1,000 fpm was to further increase it from 3,200 fpm. Lack of notification delayed the start of an independent Investigation but it eventually found that although the A320 TCAS equipment had been serviceable, its crew denied failing to correctly follow their initial RA.)


Phraseology

  • A343, Changi Singapore, 2007 (On 30 May 2007, at about 0555 hours local time, the crew of an Airbus A340-300 had to apply (Take-off Go Around) power and rotate abruptly at a high rate to become airborne while taking off from Runway 20C at Singapore Changi Airport, when they noticed the centreline lights were indicating the impending end of the available runway. The crew had calculated the take-off performance based on the full TORA (Take-off Run Available) of 4,000 m because they were unaware of the temporary shortening of Runway 20C to 2,500 m due to resurfacing works.)
  • A333, en-route, near Bournemouth UK, 2012 (On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.)
  • A320, en-route, Denver CO USA, 2009 (On 21 October 2009, an Airbus 320-200 being operated by Northwest Airlines on a scheduled passenger flight from San Diego to Minneapolis-St Paul, with the Captain as PF, overflew its destination at cruise level in VMC at night by more than 100 nm, after the two pilots had become distracted in conversation and lost situational awareness. They failed to maintain radio communications with a series of successive ATC units for well over an hour. After a routine inquiry from the cabin crew as to the expected arrival time, the flight crew realised what had happened and re-established ATC contact after which the flight was completed without further incident.)
  • SH33 / MD83, Paris CDG France, 2000 (On the 25th of May, 2000 a UK-operated Shorts SD330 waiting for take-off at Paris CDG in normal visibility at night on a taxiway angled in the take-off direction due to its primary function as an exit for opposite direction landings was given a conditional line up clearance by a controller who had erroneously assumed without checking that it was at the runway threshold. After an aircraft which had just landed had passed, the SD330 began to line up unaware that an MD83 had just been cleared in French to take off from the full length and a collision occurred.)
  • B773, vicinity Houston TX USA, 2014 (On 3 July 2014, a Boeing 777-300 departing Houston came within 200 feet vertically and 0.61nm laterally of another aircraft after climbing significantly above the Standard Instrument Departure Procedure (SID) stop altitude of 4,000 feet believing clearance was to FL310. The crew responded to ATC avoiding action to descend and then disregarded TCAS 'CLIMB' and subsequently LEVEL OFF RAs which followed. The Investigation found that an inadequate departure brief, inadequate monitoring by the augmented crew and poor communication with ATC had preceded the SID non-compliance and that the crew should have followed the TCAS RAs issued.)


Language Clarity

  • SH33 / MD83, Paris CDG France, 2000 (On the 25th of May, 2000 a UK-operated Shorts SD330 waiting for take-off at Paris CDG in normal visibility at night on a taxiway angled in the take-off direction due to its primary function as an exit for opposite direction landings was given a conditional line up clearance by a controller who had erroneously assumed without checking that it was at the runway threshold. After an aircraft which had just landed had passed, the SD330 began to line up unaware that an MD83 had just been cleared in French to take off from the full length and a collision occurred.)
  • B742 / B741, Tenerife Canary Islands Spain, 1977 (On 27 March 1977, a KLM Boeing 747-200 began its low visibility take-off at Tenerife without requesting or receiving take-off clearance and a collision with a Boeing 747-100 backtracking the same runway subsequently occurred. Both aircraft were destroyed by the impact and consequential fire and 583 people died. The Investigation attributed the crash primarily to the actions and inactions of the KLM Captain, who was the Operator's Chief Flying Instructor. Safety Recommendations made emphasised the importance of standard phraseology in all normal radio communications and avoidance of the phrase "take-off" in ATC Departure Clearances.)
  • B763, en-route, Northern France, 1998 (On 9 January 1998, a Boeing 767-300 operated by United Airlines experienced an electrical systems malfunction subsequently attributed to arcing in a faulty electrical loom. The crew elected to divert to London Heathrow where emergency evacuation was carried out on a taxiway upon landing.)
  • GLEX/F2TH, vicinity Ibiza Spain, 2012 (On 21 September 2012, two aircraft came into conflict in Class 'A' airspace whilst under radar control at night and loss of separation was resolved by TCAS RA responses by both aircraft. Investigation found that one of the aircraft had passed a procedurally-documented clearance limit without ATC clearance or intervention and that situational awareness of its crew had been diminished by communications with the conflicting aircraft being conducted in Spanish rather than English. A Safety Recommendation on resolving the "persistent problem" of such language issues was made, noting that a similar recommendation had been made 11 years earlier.)
  • B735, vicinity London Heathrow UK, 2007 (On 7 June 2007, a Boeing 737-500 operated by LOT Polish Airlines, after daylight takeoff from London Heathrow Airport lost most of the information displayed on Electronic Flight Instrument System (EFIS). The information in both Electronic Attitude Director Indicator (EADI) and Electronic Horizontal Situation Indicators (EHSI) disappeared because the flight crew inadvertently mismanaged the Flight Management System (FMS). Subsequently the crew had difficulties both in maintaining the aircraft control manually using the mechanical standby instruments and communicating adequately with ATC due to insufficient language proficiency. Although an emergency situation was not declared, the ATC realized the seriousness of the circumstances and provided discrete frequency and a safe return after 27 minutes of flight was achieved.)


Multiple Language use on Frequency

  • SH33 / MD83, Paris CDG France, 2000 (On the 25th of May, 2000 a UK-operated Shorts SD330 waiting for take-off at Paris CDG in normal visibility at night on a taxiway angled in the take-off direction due to its primary function as an exit for opposite direction landings was given a conditional line up clearance by a controller who had erroneously assumed without checking that it was at the runway threshold. After an aircraft which had just landed had passed, the SD330 began to line up unaware that an MD83 had just been cleared in French to take off from the full length and a collision occurred.)
  • GLEX/F2TH, vicinity Ibiza Spain, 2012 (On 21 September 2012, two aircraft came into conflict in Class 'A' airspace whilst under radar control at night and loss of separation was resolved by TCAS RA responses by both aircraft. Investigation found that one of the aircraft had passed a procedurally-documented clearance limit without ATC clearance or intervention and that situational awareness of its crew had been diminished by communications with the conflicting aircraft being conducted in Spanish rather than English. A Safety Recommendation on resolving the "persistent problem" of such language issues was made, noting that a similar recommendation had been made 11 years earlier.)
  • A320 / B738, en-route, near Córdoba Spain, 2014 (On 30 October 2014, a descending Airbus A320 came close to a Boeing 737-800 at around FL 220 after the A320 crew significantly exceeded a previously-instructed 2,000 fpm maximum rate of descent assuming it no longer applied when not reiterated during re-clearance to a lower altitude. Their response to a TCAS RA requiring descent at not above 1,000 fpm was to further increase it from 3,200 fpm. Lack of notification delayed the start of an independent Investigation but it eventually found that although the A320 TCAS equipment had been serviceable, its crew denied failing to correctly follow their initial RA.)


CPDLC

Flight Crew Oxygen Mask Use

  • A320, en route, north of Marseilles France, 2013 (On 12 September 2013, pressurisation control failed in an A320 after a bleed air fault occurred following dispatch with one of the two pneumatic systems deactivated under MEL provisions. The Investigation found that the cause of the in-flight failure was addressed by an optional SB not yet incorporated. Also, relevant crew response SOPs lacking clarity and a delay in provision of a revised MEL procedure meant that use of the single system had not been optimal and after a necessary progressive descent to FL100 was delayed by inadequate ATC response, and ATC failure to respond to a PAN call required it to be upgraded to MAYDAY.)


Take off without clearance

  • B738, Eindhoven Netherlands, 2012 (On 11 October 2012, the crew of a Ryanair Boeing 737-800 did not change frequency to TWR when instructed to do so by GND whilst already backtracking the departure runway and then made a 180° turn and took off without clearance still on GND frequency. Whilst no actual loss of ground or airborne safety resulted, the Investigation found that when the Captain had queried the receipt of a take off clearance with the First Officer, he had received and accepted a hesitant confirmation. Crew non-compliance with related AIP ground manoeuvring restrictions replicated in their airport briefing was also noted.)
  • E195 / A320, Brussels Belgium, 2016 (On 5 October 2016, an Embraer 195 took off at night without clearance as an Airbus A320 was about to touch down on an intersecting runway. The A320 responded promptly to the ATC go-around instruction and passed over the intersection after the E195 had accelerated through it during its take-off roll. The Investigation found that the E195 crew had correctly acknowledged a 'line up and wait' instruction but then commenced their take-off without stopping. Inadequate crew cross-checking procedures at the E195 operator and ATC use of intermediate runway access for intersecting runway take-offs were identified as contributory factors.)
  • AS32 / B734, Aberdeen UK, 2000 (For reasons that were not established, a Super Puma helicopter being air tested and in the hover at about 30 feet agl near the active runway at Aberdeen assumed that the departure clearance given by GND was a take off clearance and moved into the hover over the opposite end of the runway at the same time as a Boeing 737 was taking off. The 737 saw the helicopter ahead and made a high speed rejected take off, stopping approximately 100 metres before reaching the position of the helicopter which had by then moved off the runway still hovering.)
  • B463 / PA38 Birmingham UK, 1999 (On 28 April 1999, a BAe 146-300 departing Birmingham began its daylight take off from Runway 33 without ATC clearance just prior to the touchdown of a PA38 on the intersecting runway 06. Collision was very narrowly avoided after the Controller intervened and the BAe 146 rejected its take off, just missing the PA38 which had stopped just off the runway 33 centreline. The Investigation noted the 146 pilots belief that a take off clearance had been issued but also that no attempt appeared to have been made to read it back or confirm it with the First Officer.)
  • B190 / B190, Auckland NZ, 2007 (On 1 August 2007, the crew of a Beech 1900 aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Beech 1900 that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.)
  • B744 / MD90, Chitose Japan, 2008 (On 16 February 2008, during daylight and in poor visibility, a Boeing 747-400, operated by Japan Airlines, was holding on a taxiway next to runway 01R of New Chitose Airport, Japan. A Douglas MD-90-30 operated by the same airline landed on the same runway and was still on the runway when the B747 was cleared to line up and wait. Shortly after lineup the B747 began its takeoff roll without receiving such clearance and subsequently was instructed to abort the takeoff. The crew of the B747 successfully rejected the takeoff.)
  • B742 / B741, Tenerife Canary Islands Spain, 1977 (On 27 March 1977, a KLM Boeing 747-200 began its low visibility take-off at Tenerife without requesting or receiving take-off clearance and a collision with a Boeing 747-100 backtracking the same runway subsequently occurred. Both aircraft were destroyed by the impact and consequential fire and 583 people died. The Investigation attributed the crash primarily to the actions and inactions of the KLM Captain, who was the Operator's Chief Flying Instructor. Safety Recommendations made emphasised the importance of standard phraseology in all normal radio communications and avoidance of the phrase "take-off" in ATC Departure Clearances.)
  • DH8B, Kangerlussuaq Greenland, 2017 (On 2 March 2017, a DHC8-200 took off from Kangerlussuaq in normal day visibility without clearance and almost immediately overflew three snow clearance vehicles on the runway. The Investigation identified a number of likely contributory factors including a one hour departure delay which the crew were keen to reduce in order to remain within their maximum allowable duty period and their inability to initially see the vehicles because of the runway down slope. No evidence of crew fatigue was found; it was noted that the vehicles involved had been in contact with TWR on a separate frequency using the local language.)


Landing without clearance

  • TBM8, Birmingham UK, 2011 (On 12 January 2011, a privately operated Socata TBM850 light aircraft on a flight from Antwerp to Birmingham lost radio contact with ATC whilst in IMC on a non precision approach to runway 15 prior to the issue of a landing clearance and prior to checking in on the ATC TWR frequency. It continued the approach to obtain the required visual reference before landing over the top of a DHC8-400 aircraft which had lined up ready for take off in accordance with ATC instructions. No damage or personal injury resulted from the close proximity.)
  • A319, vicinity Zurich Switzerland, 2014 (On 17 October 2014, two recently type-qualified Airbus A319 pilots responded in a disorganised way after a sudden malfunction soon after take-off from Zurich required one engine to be shutdown. The return to land was flown manually and visually at an excessive airspeed and rate of descent with idle thrust on the remaining engine all the way to a touchdown which occurred without a landing clearance. The Investigation concluded that the poor performance of the pilots had been founded on a lack of prior analysis of the situation, poor CRM and non-compliance with system management and operational requirements.)


Military Formation Clearance

  • F15 / B752, en-route, South East of Birmingham UK, 2000 (On 22 November 2000, near Birmingham UK, a dangerous loss of vertical and lateral separation occurred between a Boeing B757-200 being operated by Britannia Airways on a passenger flight and a formation flight of two F-15Es being operated by the United States Air Force (USAF).)
  • F15 / E145, en-route, Bedford UK, 2005 (On 27 January 2005, two USAF-operated McDonnell Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)


Military/Civil Coordination

  • EUFI / A321, en-route, near Clacton UK, 2008 (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)
  • F15 / E145, en-route, Bedford UK, 2005 (On 27 January 2005, two USAF-operated McDonnell Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)


Provision of Aircraft Performance Data

ATC Clearance Cancelled

  • Vehicles / B722, Hamilton ON Canada, 2013 (On 19 March 2013 a Boeing 727 freighter was cleared to take off on a runway occupied by two snow clearance vehicles. The subsequent cancellation of the take off clearance was not received but a successful high speed rejected take off was accomplished on sight of the vehicles before their position was reached. The Investigation attributed the occurrence to the controller's failure to 'notice' the runway blocked indicator on his display and to his non-standard use of R/T communications. The late sighting of the vehicles by the aircraft crew was due to the elevated runway mid section.)
  • A320 / B738 Barcelona Spain, 2012 (On 27 May 2012, an Airbus A320 departing Barcelona was cleared by GND to taxi across an active runway on which a Boeing 737-800 was about to land. Whilst still moving but before entering the runway, the A320 crew, aware of the aircraft on approach, queried their crossing clearance but the instruction to stop was given too late to stop before crossing the unlit stop bar. The 737 was instructed to go around and there was no actual risk of collision. The Investigation attributed the controller error to lack of familiarisation with the routine runway configuration change in progress.)
  • B738/B738, vicinity Queenstown New Zealand, 2010 (On 20 June 2010, a Boeing 737-800 being operated by New Zealand company Pacific Blue AL on a scheduled passenger flight from Auckland to Queenstown lost IFR separation assurance against a Boeing 737-800 being operated by Qantas on a scheduled passenger flight from Sydney to Queenstown whilst both aircraft were flying a go around following successive but different instrument approaches at their shared intended destination. There were no abrupt manoeuvres and none of the respectively 88 and 162 occupants of the two aircraft were injured.)


Blocked Transmission

Misunderstanding

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