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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

  • B737 / B738, vicinity Amsterdam Netherlands, 2018 (On 29 March 2018, a Boeing 737-700 commenced a late go-around from landing at Amsterdam on a runway with an extended centreline which passed over another runway from which a Boeing 737-800 had already been cleared for takeoff. An attempt by the controller responsible for both aircraft to stop the departing aircraft failed because the wrong callsign was used, so low level divergent turns were given to both aircraft and 0.5nm lateral and 300 feet vertical separation was achieved. The Investigation concluded that the ATC procedure involved was potentially hazardous and made a safety recommendation that it should be withdrawn.)
  • 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.)
  • 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.)
  • A333 / A319, en-route, east of Lashio Myanmar, 2017 (On 3 May 2017, an Airbus A330 and an Airbus A319 lost prescribed separation whilst tracking in opposite directions on a radar-controlled ATS route in eastern Myanmar close to the Chinese border. The Investigation found that the response of the A330 crew to a call for another aircraft went undetected and they descended to the same level as the A319 with the lost separation only being mitigated by intervention from the neighbouring Chinese ACC which was able to give the A319 an avoiding action turn. At the time of the conflict, the A330 had disappeared from the controlling ACCs radar.)
  • B738/B738, vicinity Oslo Norway, 2012 (On 31 October 2012, a 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.)

Loss of Communication

  • B772 en-route suspected location southern Indian Ocean, 2014 (On 8 March 2014, contact was lost with a Malaysian Airlines Boeing 777-200ER operating a scheduled night passenger flight from Kuala Lumpur to Beijing as MH370. The available evidence indicates that it crashed somewhere in the South Indian Ocean but a carefully- targeted underwater search coordinated by the Australian Transport Safety Bureau has failed to locate the aircraft wreckage and the Investigation process is now effectively stalled. A comprehensive Investigation Report has been published and Safety Recommendations informed by the work of the Investigation have been made but it has not been possible to establish what happened and why.)
  • 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.)
  • 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.)
  • 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.)

Incorrect Readback Missed

  • AT75 / B739, Medan Indonesia, 2017 (On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.)
  • A320, vicinity Birmingham UK, 2019 (On 26 August 2019, an Airbus A320 attempted two autopilot-engaged non-precision approaches at Birmingham in good weather before a third one was successful. Both were commenced late and continued when unstable prior to eventual go-arounds, for one of which the aircraft was mis-configured causing an ‘Alpha Floor’ protection activation. A third non-precision approach was then completed without further event. The Investigation noted an almost identical event involving the same operator four months later, observing that all three discontinued approaches appeared to have originated in confusion arising from a slight difference between the procedures of the aircraft operator and AIP plates.)
  • 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.)
  • 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.)
  • A320 / E145, vicinity Barcelona Spain, 2019 (On 27 September 2019, an Airbus A320 and an Embraer 145 both inbound to Barcelona and being positioned for the same Transition for runway 25R lost separation and received and followed coordinated TCAS RAs after which the closest point of approach was 0.8nm laterally when 200 feet vertically apart. The Investigation found that the experienced controller involved had initially created the conflict whilst seeking to resolve another potential conflict between one of the aircraft and a third aircraft inbound for the same Transition and having identified it had then implemented a faulty recovery plan and executed it improperly.)

Phraseology

  • 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.)
  • B744 / B773 / B773, en-route, Delhi India, 2018 (On 22 December 2018, a Boeing 747-400 crew began to climb from FL310 without clearance and prescribed separation was lost against both an opposite direction Boeing 777-300 at FL 320 and another same direction Boeing 777-300 cleared to fly at FL330. The Investigation found that the 747 crew had requested FL 390 and then misunderstood the controller’s response of “level available 350” as a clearance to climb and gave a non-standard response and began to climb when the controller responded instructing the flight to standby for higher. Controller attempts to resolve the resultant ‘current conflict warnings’ were only partially successful.)
  • Vehicle / PAY4, Perth Western Australia, 2012 (Whilst a light aircraft was lined up for departure, a vehicle made an incorrect assumption about the nature of an ambiguously-phrased ATC TWR instruction and proceeded to enter the same runway. There was no actual risk of conflict since, although LVP were still in force after earlier fog, the TWR controller was able to see the vehicle incursion and therefore withhold the imminent take off clearance. The subsequent Investigation noted that it was imperative that clearance read backs about which there is doubt are not made speculatively in the expectation that they will elicit confirmation or correction.)
  • B77W, en-route, northeast of Los Angeles USA, 2016 (On 16 December 2016, a Boeing 777-300 which had just departed from runway 07R at Los Angeles was radar vectored in Class ‘B’ airspace at up to 1600 feet below the applicable minimum radar vectoring altitude. The Investigation found that the area controller’s initial vectoring had been contrary to applicable procedures and their communication confusing and that they had failed to recover the situation before it became dangerous. As a result, as the crew were responding in night IMC to a resulting EGPWS ‘PULL UP’ Warning, the aircraft had passed within approximately 0.3 nm of obstructions at the same altitude.)
  • A319 / A320, Paris CDG France, 2014 (On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.)

Language Clarity

  • Vehicle / PAY4, Perth Western Australia, 2012 (Whilst a light aircraft was lined up for departure, a vehicle made an incorrect assumption about the nature of an ambiguously-phrased ATC TWR instruction and proceeded to enter the same runway. There was no actual risk of conflict since, although LVP were still in force after earlier fog, the TWR controller was able to see the vehicle incursion and therefore withhold the imminent take off clearance. The subsequent Investigation noted that it was imperative that clearance read backs about which there is doubt are not made speculatively in the expectation that they will elicit confirmation or correction.)
  • 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.)
  • AT75 / B739, Medan Indonesia, 2017 (On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.)
  • CRJ2, en-route, Jefferson City USA, 2004 (On October 14, 2004, a Bombardier CRJ-200 being operated by Pinnacle Airlines on a non revenue positioning flight crashed into a residential area in the vicinity of Jefferson City Memorial Airport, Missouri after the flight crew attempted to fly the aircraft beyond its performance limits and a high altitude stall, to which their response was inappropriate, then followed.)
  • 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

  • A319 / A320, Paris CDG France, 2014 (On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.)
  • 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.)
  • C25A / Vehicle, Reykjavik Iceland, 2018 (On 11 January 2018, a privately-operated Cessna 525A Citation with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within “less than a metre” of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated. The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking. It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.)
  • A343, Bogotá Colombia, 2017 (2) (On 19 August 2017, an Airbus A340-300 encountered significant unforecast windshear on rotation for a maximum weight rated-thrust night takeoff from Bogotá and was unable to begin its climb for a further 800 metres during which angle of attack flight envelope protection was briefly activated. The Investigation noted the absence of a windshear detection system and any data on the prevalence of windshear at the airport as well as the failure of ATC to relay in English reports of conditions from departing aircraft received in Spanish. The aircraft operator subsequently elected to restrict maximum permitted takeoff weights from the airport.)
  • B738, Alicante Spain, 2018 (On 7 June 2018, a Boeing 737-800 operated by a non-Spanish speaking crew was given takeoff clearance at Alicante after the same supervised student controller had previously cleared two vehicles to begin a full-length opposite-direction runway inspection in Spanish. The controller error was only recognised when the vehicles were able to transmit that they were still on the runway, the aircraft crew being unaware of the conflict until then was told to reject the takeoff. The maximum speed reached by the aircraft was 88 knots and minimum separation between the aircraft and the closest vehicle was never less than 1000 metres.)

CPDLC

None on SKYbrary

Flight Crew Oxygen Mask Use

  • E195, en-route, Irish Sea UK, 2008 (On 1 August 2008, an en-route Embraer 195 despatched with one air conditioning pack inoperative lost all air conditioning and pressurisation when the other pack’s Air Cycle Machine (ACM) failed, releasing smoke and fumes into the aircraft. A MAYDAY diversion was made to the Isle of Man without further event. The Investigation found that the ACM failed due to rotor seizure caused by turbine blade root fatigue, the same failure which had led the other air conditioning system to fail failure four days earlier. It was understood that a modified ACM turbine housing was being developed to address the problem.)
  • A332, en-route, North Atlantic, 2019 (On 6 February 2019, an Airbus A330-200 Captain’s Audio Control Panel (ACP) malfunctioned and began to emit smoke and electrical fumes after coffee was spilt on it. Subsequently, the right side ACP also failed, becoming hot enough to begin melting its plastic. Given the consequent significant communications difficulties, a turnback to Shannon was with both pilots taking turns to go on oxygen. The Investigation found that flight deck drinks were routinely served in unlidded cups with the cup size in use incompatible with the available cup holders. Pending provision of suitably-sized cups, the operator decided to begin providing cup lids.)
  • 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

  • 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.)
  • 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.)
  • CRJ2 / B773, Toronto Canada, 2019 (On 9 August 2019, a Bombardier CRJ-200LR about to depart Toronto which had read back and actioned a clearance to line up on the departure runway then began its takeoff without clearance and only commenced a high speed rejected takeoff when a Boeing 777-300 came into view crossing the runway ahead. A high speed rejected takeoff was completed from a maximum speed of around 100 knots. The Investigation concluded that an increased crew workload, an expectation that a takeoff clearance would be received without delay and misinterpretation of the line up instructions led to the premature initiation of a takeoff.)
  • 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.)
  • 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.)
  • B744 / MD90, New 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.)
  • 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.)
  • C25A / Vehicle, Reykjavik Iceland, 2018 (On 11 January 2018, a privately-operated Cessna 525A Citation with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within “less than a metre” of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated. The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking. It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.)
  • 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.)
  • 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.)

Landing without clearance

  • B733, Wamena Papua Indonesia, 2016 (On 13 September 2016, a Boeing 737-300 made an unstabilised approach to Wamena and shortly after an EGPWS ‘PULL UP’ warning due to the high rate of descent, a very hard landing resulted in collapse of the main landing gear, loss of directional control and a lateral runway excursion. The Investigation found that the approach had been carried out with both the cloudbase and visibility below the operator-specified minima and noted that the Captain had ignored a delayed go around suggestion from the First Officer because he was confident he could land safely as the two aircraft ahead had done.)
  • 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.)
  • A319, Mumbai India, 2013 (On 12 April 2013, an Airbus A319 landed without clearance on a runway temporarily closed for routine inspection after failing to check in with TWR following acceptance of the corresponding frequency change. Two vehicles on the runway saw the aircraft approaching on short final and successfully vacated. The Investigation concluded that the communication failure was attributable entirely to the Check Captain who was in command of the flight involved and was acting as 'Pilot Monitoring'. It was considered that the error was probably attributable to the effects of operating through the early hours during which human alertness is usually reduced.)
  • 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.)
  • MD83, Port Harcourt Nigeria, 2018 (On 20 February 2018, a Boeing MD-83 attempting a night landing at Port Harcourt during a thunderstorm and heavy rain touched down well beyond the touchdown zone and departed the side of the runway near its end before continuing 300 metres beyond it. The Investigation found that a soft touchdown had occurred with 80% of the runway behind the aircraft and a communications failure on short final meant a wind velocity change just before landing leading to a tailwind component of almost 20 knots was unknown to the crew who had not recognised the need for a go around.)

Military Formation Clearance

  • 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.)
  • 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).)

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

None on SKYbrary

ATC Clearance Cancelled

  • B738, Alicante Spain, 2018 (On 7 June 2018, a Boeing 737-800 operated by a non-Spanish speaking crew was given takeoff clearance at Alicante after the same supervised student controller had previously cleared two vehicles to begin a full-length opposite-direction runway inspection in Spanish. The controller error was only recognised when the vehicles were able to transmit that they were still on the runway, the aircraft crew being unaware of the conflict until then was told to reject the takeoff. The maximum speed reached by the aircraft was 88 knots and minimum separation between the aircraft and the closest vehicle was never less than 1000 metres.)
  • 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.)
  • B38M, Helsinki Finland, 2019 (On 18 January 2019, two aircraft taxiing for departure at Helsinki were cleared to cross the landing runway between two landing aircraft. Landing clearance for the second was given once the crossing traffic had cleared as it passed 400 feet in expectation that the previous landing aircraft would also shortly be clear. However, the first landing aircraft was slower than expected clearing the runway and so the second was instructed to go-around but did not then do so because this instruction was lost in the radar height countdown below 50 feet and the runway was seen clear before touchdown.)

Blocked Transmission

  • 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 .)
  • SF34 / B190, Auckland NZ, 2007 (On 29 May 2007, a Saab 340 aircraft that was holding on an angled taxiway at Auckland International Airport was inadvertently cleared to line up in front of a landing Raytheon 1900D. The aerodrome controller transmitted an amended clearance, but the transmission crossed with that of the Saab crew reading back the line-up clearance. The pilots of both aircraft took action to avoid a collision and stopped on the runway without any damage or injury.)
  • B738/B738, vicinity Oslo Norway, 2012 (On 31 October 2012, a 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.)

Misunderstanding

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