Accidents and Incidents

This directory contains articles about particular Accidents and Incidents that are considered illustrative of the contemporary safety issues and recommended potential solutions. The information contained in the article summarising an individual accident or incident is derived from the published official investigation report, which may in each case be found on the SKYbrary bookshelf wherever possible in English as provided by the publishing Investigation Agency. A direct link to each official report is provided at the end of each summary article. The complete list of events is provided on this and the following pages in the order of the ICAO aircraft type designator in alphabetical order.

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Showing below 1340 results in range #1 to #100.


A109, vicinity London Heliport London UK, 2013 On 16 January 2013, an Augusta 109E helicopter positioning by day on an implied (due to adverse weather conditions) SVFR clearance collided with a crane attached to a tall building under construction. It and associated debris fell to street level and the pilot and a pedestrian were killed and several others on the ground injured. It was concluded that the pilot had not seen the crane or seen it too late to avoid whilst flying by visual reference in conditions which had become increasingly challenging. The Investigation recommended improvements in the regulatory context in which the accident had occurred.

A124, Zaragoza Spain, 2010 On 20 April 2010, the left wing of an Antonov Design Bureau An124-100 which was taxiing in to park after a night landing at Zaragoza under marshalling guidance was in collision with two successive lighting towers on the apron. Both towers and the left wingtip of the aircraft were damaged. The subsequent investigation attributed the collision to allocation of an unsuitable stand and lack of appropriate guidance markings.

A139 / A30B, Ottawa Canada, 2014 On 5 June 2014, an AW139 about to depart from its Ottawa home base on a positioning flight exceeded its clearance limit and began to hover taxi towards the main runway as an A300 was about to touch down on it. The TWR controller immediately instructed the helicopter to stop which it did, just clear of the runway. The A300 reached taxi speed just prior to the intersection. The Investigation attributed the error to a combination of distraction and expectancy and noted that the AW139 pilot had not checked actual or imminent runway occupancy prior to passing his clearance limit.

A139, vicinity Sky Shuttle Heliport Hong Kong China, 2010 On 3 July 2010, an AW139 helicopter was climbing through 350 feet over Victoria Harbour Hong Kong just after takeoff when the tail rotor detached. A transition to autorotation was accomplished and a controlled ditching followed. All occupants were rescued but some sustained minor injuries. The failure was attributed entirely to manufacturing defects but no corrective manufacturer or regulatory action was taken until two similar accidents had occurred in Qatar (non-fatal) and Brazil (fatal) the following year and two interim Safety Recommendations were issued from this Investigation after which a comprehensive review of the manufacturing process led to numerous changes.

A140, vicinity Tehran Mehrabad Iran, 2014 On 10 August 2014, one of the engines of an Antonov 140-100 departing Tehran Mehrabad ran down after V1 and prior to rotation. The takeoff was continued but the crew were unable to keep control and the aircraft stalled and crashed into terrain near the airport. The Investigation found that a faulty engine control unit had temporarily malfunctioned and that having taken off with an inappropriate flap setting, the crew had attempted an initial climb with a heavy aircraft without the failed engine propeller initially being feathered, with the gear remaining down and with the airspeed below V2.

A169, Leicester UK, 2018 On 27 October 2018, a single pilot Augusta Westland AW169 lifted off from within the Leicester City Football Club Stadium, but after a failure of the tail rotor control system, a loss of yaw control occurred a few hundred feet above ground. The helicopter began to descend with a high rotation rate and soon afterward impacted the ground and almost immediately caught fire, which prevented those onboard surviving. An Investigation is being conducted by the UK AAIB.

A20N / A320, Amsterdam Netherlands, 2019 On 3 February 2019, two aircraft which had just landed on adjacent parallel runways almost collided during their taxi in after one failed to give way to the other at an intersection as instructed, causing the other to perform an emergency stop which was achieved just in time to avoid a collision. Whilst not attributing direct cause to other than the crew of the aircraft which continued high speed taxiing as the intersection was approached, having noted that all taxiway lighting at Amsterdam is permanently lit at night, a range of factors were identified which had facilitated the error made.

A21N, Bristol UK, 2020 On 3 January 2020, an Airbus A321neo crew found that the boarded passengers were seated such that the flight could not operate within the allowable flight envelope. Necessary reseating followed with a safety report filed. An internal investigation with State Investigation Agency awareness found that a systemic company IT issue was enabling invalid outputs. When the same aircraft’s inbound flight from Bristol was checked, a similar but undetected error was found to have resulted in that flight having operated outside the allowable flight envelope. Pending a permanent fix for the computerised load control system, manual checking procedures were immediately implemented.

A306 / B744, vicinity London Heathrow UK, 1996 On 5 April 1996 a significant loss of separation occurred when a B744, taking off from runway 27R at London Heathrow came into conflict to the west of Heathrow Airport with an A306 which had carried out a missed approach from the parallel runway 27L. Both aircraft were following ATC instructions. Both aircraft received and correctly followed TCAS RAs, the B744 to descend and the A306 to adjust vertical speed, which were received at the same time as corrective ATC clearances.

A306, East Midlands UK, 2011 On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.

A306, Paris CDG France, 1997 On 30 July 1997, an Airbus A300-600 being operated by Emirates Airline was departing on a scheduled passenger flight from Paris Charles de Gaulle in daylight when, as the aircraft was accelerating at 40 kts during the take off roll, it pitched up and its tail touched the ground violently. The crew abandoned the takeoff and returned to the parking area. The tail of the aircraft was damaged due to the impact with the runway when the plane pitched up.

A306, Stockholm Sweden, 2010 On 16 January 2010, an Iran Air Airbus A300-600 veered off the left side of the runway after a left engine failure at low speed whilst taking off at Stockholm. The directional control difficulty was attributed partly to the lack of differential braking but also disclosed wider issues about directional control following sudden asymmetry at low speeds. The Investigation concluded that deficiencies in the type certification process had contributed to the loss of directional control. It was concluded that the engine malfunction was due to the initiation of an engine stall by damage caused by debris from a deficient repair.

A306, vicinity Birmingham AL USA, 2013 On 14 August 2013, a UPS Airbus A300-600 crashed short of the runway at Birmingham Alabama on a night IMC non-precision approach after the crew failed to go around at 1000ft aal when unstabilised and then continued descent below MDA until terrain impact. The Investigation attributed the accident to the individually poor performance of both pilots, to performance deficiencies previously-exhibited in recurrent training by the Captain and to the First Officer's failure to call in fatigued and unfit to fly after mis-managing her off duty time. A Video was produced by NTSB to further highlight human factors aspects.

A306, vicinity London Gatwick, 2011 On 12 January 2011, an Airbus A300-600 being operated by Monarch Airlines on a passenger flight from London Gatwick to Chania, Greece experienced activations of the stall protection system after an unintended configuration change shortly after take off but following recovery, the flight continued as intended without further event. There were no abrupt manoeuvres and no injuries to the 347 occupants.

A306, vicinity Nagoya Japan, 1994 On 26 April 1994, the crew of an Airbus A300-600 lost control of their aircraft on final approach to Nagoya and the aircraft crashed within the airport perimeter. The Investigation found that an inadvertent mode selection error had triggered control difficulties which had been ultimately founded on an apparent lack understanding by both pilots of the full nature of the interaction between the systems controlling thrust and pitch on the aircraft type which were not typical of most other contemporary types. It was also concluded that the Captain's delay in taking control from the First Officer had exacerbated the situation.

A306, vicinity New York JFK, 2001 On 12 November 2001, an Airbus A300-600 encountered mild wake turbulence as it climbed after departing New York JFK to which the First Officer responded with a series of unnecessary and excessive control inputs involving cyclic full-deflection rudder pedal inputs. Within less than 7 seconds, these caused detachment of the vertical stabiliser from the aircraft resulting in loss of control and ground impact with a post crash fire. The Investigation concluded that elements of the company pilot training process and the design of the A300-600 rudder system had contributed to this excessive use of the rudder and its consequences.

A306, Yerevan Armenia, 2015 On 17 May 2015, an Airbus A300-600 crew descended their aircraft below the correct vertical profile on a visual daytime approach at Yerevan and then landed on a closed section of the runway near the displaced runway threshold. The Investigation found that the crew had failed to review relevant AIS information prior to departing from Tehran and had not been expecting anything but a normal approach and landing. The performance of the Dispatcher in respect of briefing and the First Officer in respect of failure to adequately monitor the Captain's flawed conduct of the approach was highlighted.

A30B, Bratislava Slovakia, 2012 On 16 November 2012, an Air Contractors Airbus A300 departed the left the side of the landing runway at Bratislava after an abnormal response to directional control inputs. Investigation found that incorrect and undetected re-assembly of the nose gear torque links had led to the excursion and that absence of clear instructions in maintenance manuals, since rectified, had facilitated this. It was also considered that the absence of any regulation requiring equipment in the vicinity of the runway to be designed to minimise potential damage to aircraft departing the paved surface had contributed to the damage caused by the accident.

A30B, en-route, Bristol UK, 2000 On 27 June 2000 an Airbus A300-600 being operated by American Airlines on a scheduled passenger service from London Heathrow to New York JFK was being flown manually in the day VMC climb and approaching FL220 when a loud bang was heard and there was a simultaneous abrupt disturbance to the flight path. The event appeared to the flight crew to have been a disturbance in yaw with no obvious concurrent lateral motion. Although following the disturbance, the aircraft appeared to behave normally, the aircraft commander decided to return to London Heathrow rather than commence a transatlantic flight following what was suspected to have been an un-commanded flight control input. An uneventful return was made followed by an overweight landing 50 minutes after take off.

A310 / B736, en-route, Southern Norway, 2001 On 21 February 2001, a level bust 10 nm north of Oslo Airport by a climbing PIA A310 led to loss of separation with an SAS B736 in which response to a TCAS RA by the A310 not being in accordance with its likely activation (descend). The B736 received and correctly actioned a Climb RA.

A310 / C421, en-route, northeast of Montréal Canada, 2018 On 16 May 2018, an Airbus A310 and a Cessna 421 being positioned for ILS approaches to adjacent parallel runways at Montréal by different controllers lost separation. One controller incorrectly believed that he had transferred control of the Cessna to the other when the shift supervisor re-opened a sector which had been temporarily combined with his. The Investigation attributed the conflict to multiple deviations from standard procedures, memory lapses relating to controller information exchange of information and a loss of full situational awareness compounded by the shift supervisor also acting as an instructor whilst being distracted by his other duties.

A310, en-route, Florida Keys USA, 2005 On 6 March 2005, an Airbus A310-300 being operated by Canadian airline Air Transat on a passenger charter flight from Varadero Cuba to Quebec City was in the cruise in daylight VMC at FL350 seventeen minutes after departure and overhead the Florida Keys when the flight crew heard a loud bang and felt some vibration. The aircraft entered a Dutch roll which was eventually controlled in manual flight after a height excursion. During descent for a possible en route diversion, the intensity of the Dutch Roll lessened and then stopped and the crew decided to return to Varadero. It was found during landing there that rudder control inputs were not effective and after taxi in and shutdown at the designated parking position, it was discovered that the aircraft rudder was missing. One of the cabin crew sustained a minor back injury during the event but no others from the 271 occupants were injured.

A310, Irkutsk Russia, 2006 On 8 July 2006, S7 Airlines A310 overran the runway on landing at Irkutsk at high speed and was destroyed after the Captain mismanaged the thrust levers whilst attempting to apply reverse only on one engine because the flight was being conducted with one reverser inoperative. The Investigation noted that the aircraft had been despatched on the accident flight with the left engine thrust reverser de-activated as permitted under the MEL but also that the previous two flights had been carried out with a deactivated right engine thrust reverser.

A310, Khartoum Sudan, 2008 On 10 June 2008, a Sudan Airways Airbus A310 made a late night touchdown at Khartoum and the actions of the experienced crew were subsequently unable to stop the aircraft, which was in service with one thrust reverser inoperative and locked out, on the wet runway. The aircraft stopped essentially intact some 215 metres beyond the runway end after overrunning on smooth ground but a fuel-fed fire then took hold which impeded evacuation and eventually destroyed the aircraft.

A310, Ponta Delgada Azores Portugal, 2013 On 2 March 2013, the crew of an Airbus A310 mishandled a night tailwind touchdown at Ponta Delgada after a stabilised ILS approach had been flown and, after an initial bounce, the pitch was increased significantly and the main landing gear was fully compressed during the subsequent touchdown resulting in a tail strike and substantial related structural damage. The mishandling was attributed to deviation from the recommended 'light bounce' recovery technique. The absence of an instrument approach to the reciprocal (into wind) direction of the runway was noted and a recommendation that an RNAV procedure be made available was made.

A310, vicinity Abidjan Ivory Coast, 2000 On 30 January 2000, an Airbus 310 took off from Abidjan (Ivory Coast) at night bound for Lagos, Nigeria then Nairobi, Kenya. Thirty-three seconds after take-off, the airplane crashed into the Atlantic Ocean, 1.5 nautical miles south of the runway at Abidjan Airport. 169 persons died and 10 were injured in the accident.

A310, vicinity Birmingham UK, 2006 On 24 November 2006, an A310 descended significantly below cleared altitude during a radar vectored approach positioning, as a result of the flight crew's failure to set the QNH, which was unusually low.

A310, vicinity Moroni Comoros, 2009 On 29 June 2009, an Airbus A310-300 making a dark-night visual circling approach to Moroni crashed into the sea and was destroyed. The Investigation found that the final impact had occurred with the aircraft stalled and in the absence of appropriate prior recovery actions and that this had been immediately preceded by two separate GWPS 'PULL UP' events. It was concluded that the attempted circling procedure had been highly unstable with the crew's inappropriate actions and inactions probably attributable to their becoming progressively overwhelmed by successive warnings and alerts caused by their poor management of the aircraft's flight path.

A310, vicinity Paris Orly France, 1994 On 24 September 1994, lack of understanding of automatic flight control modes, by the crew of an Airbus A-310, led to a full stall. The aircraft was recovered and subsequently landed without further event at Paris Orly.

A310, vicinity Quebec Canada, 2008 On 5 March 2008, an Air Transat A310-300 was unintentionally mishandled by the flight crew during and shortly after departure from Quebec and effective control of the aircraft was temporarily lost. Whilst it was concluded that the origin of the initial difficulties in control were a result of confusion which began on the take off roll and led to a take off at excessive speed followed by subsequent mismanagement and overload, the inappropriate steep descent that followed was attributed to the effect of somatogravic illusion in respect of aircraft attitude control in conjunction with a singular focus on airspeed.

A310, Vienna Austria, 2000 On 12 July 2000, a Hapag Lloyd Airbus A310 was unable to retract the landing gear normally after take off from Chania for Hannover. The flight was continued towards the intended destination but the selection of an en route diversion due to higher fuel burn was misjudged and useable fuel was completely exhausted just prior to an intended landing at Vienna. The aeroplane sustained significant damage as it touched down unpowered inside the aerodrome perimeter but there were no injuries to the occupants and only minor injuries to a small number of them during the subsequent emergency evacuation.

A318 / B738, en-route, Trasadingen Switzerland, 2009 On 8 June 2009, an Airbus A318-100 being operated by Air France on a scheduled passenger flight from Belgrade, Serbia to Paris CDG in day VMC came into conflict with a Boeing 737-800 being operated by Ryanair on a scheduled passenger flight from Nottingham East Midlands UK to Bergamo Italy. The conflict was resolved mainly by TCAS RA response and there were no injuries to any occupants during the avoidance manoeuvres carried out by both aircraft.

A318, vicinity Toulon-Hyères France, 2019 On 20 December 2019, an Airbus A318 making a tailwind ILS approach to Toulon-Hyères with the autopilot engaged and expecting to intercept the glideslope from above had not done so when reaching the pre-selected altitude and after levelling off, it then rapidly entered a steep climb as it captured the glideslope false upper lobe and the automated stall protection system was activated. Not fully following  the recovery procedure caused a second stall protection activation before a sustained recovery was achieved. The Investigation noted Captain's  relative inexperience in that rank and a First Officer's inexperience on type.

A318/B738, Nantes France, 2010 On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.

A318/B739, vicinity Amsterdam Netherlands, 2007 On 6 December 2007 an Airbus A318 being operated by Air France on a scheduled passenger flight from Lyon to Amsterdam carried out missed approach from runway 18C at destination and lost separation in night VMC against a Boeing 737-900 being operated by KLM on a scheduled passenger flight from Amsterdam to London Heathrow which had just departed from runway 24. The conflict was resolved by correct responses to the respective coordinated TCAS RAs after which the A318 passed close behind the 737. There were no abrupt manoeuvres and none of the 104 and 195 occupants respectively on board were injured.

A319 / A320, Naha Okinawa Japan, 2012 On 5 July 2012, an Airbus A319 entered its departure runway at Naha without clearance ahead of an A320 already cleared to land on the same runway. The A320 was sent around. The Investigation concluded that the A319 crew - three pilots including one with sole responsibility for radio communications and a commander supervising a trainee Captain occupying the left seat - had misunderstood their clearance and their incorrect readback had not been detected by the TWR controller. It was concluded that the controller's non-use of a headset had contributed to failure to detect the incorrect readback.

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.

A319 / A321, en-route, west north west of Geneva, Switzerland 2011 On 6 August 2011 an Easyjet Airbus A319 on which First Officer Line Training was in progress exceeded its cleared level during the climb after a different level to that correctly read back was set on the FMS. As a result, it came into conflict with an Alitalia A321 and this was resolved by responses to coordinated TCAS RAs. STCA alerts did not enable ATC resolution of the conflict and it was concluded that a lack of ATC capability to receive Mode S EHS DAPs - since rectified - was a contributory factor to the outcome.

A319 / AS32, vicinity Marseille France, 2016 On 27 June 2016, an Airbus A319 narrowly avoided a mid-air collision with an AS532 Cougar helicopter whose single transponder had failed earlier whilst conducting a local pre-delivery test flight whilst both were positioning visually as cleared to land at Marseille and after the helicopter had also temporarily disappeared from primary radar. Neither aircraft crew had detected the other prior to their tracks crossing at a similar altitude. The Investigation attributed the conflict to an inappropriate ATC response to the temporary loss of radar contact with the helicopter aggravated by inaccurate position reports and non-compliance with the aerodrome circuit altitude by the helicopter crew.

A319 / B735, vicinity Prague Czech Republic, 2012 On 7 September 2012, the crew of an Air France Airbus A319 failed to follow their arrival clearance at destination and turned directly towards the ILS FAF and thereby into conflict with a Boeing 737-500 on an ILS approach. When instructed to turn left (and clear of the ILS) by the controller, the crew replied that they were following standard arrival which was not the case. As the separation between the two aircraft reduced, the controller repeated the instruction to the A319 to turn left and this was acknowledged. Minimum lateral separation was 1.7nm, sufficient to activate STCA.

A319 / B737, Zurich Switzerland, 2002 On 23 November 2002, an A319, landing on Rwy16 at Zurich Switzerland, narrowly missed collision with a B737-600 cleared for take off on an intersecting runway.

A319 / B738 / B738, en-route, near Lausanne Switzerland, 2013 On 26 May 2013, an A319 in Swiss Class 'C' airspace received a TCAS 'Level Off' RA against a 737 above after being inadvertently given an incorrect climb clearance by ATC. The opposing higher-altitude 737 began a coordinated RA climb from level flight and this triggered a second conflict with another 737 also in the cruise 1000 feet above which resulted in coordinated TCAS RAs for both these aircraft. Correct response to all RAs resulted in resolution of both conflicts after prescribed minimum separations had been breached to as low as 1.5nm when 675 feet apart vertically.

A319 / B744, en-route near Oroville WA USA, 2008 On 10 January 2008, an Air Canada Airbus A319 en route over the north western USA encountered unexpected sudden wake vortex turbulence from an in trail Boeing 747-400 nearly 11nm ahead to which the pilots who then responded with potentially hazardous flight control inputs which led to reversion to Alternate Control Law and aggravated the external /disturbance to the aircraft trajectory with roll up to 55° and an unintended descent of 1400 feet which with cabin service in progress and sea belt signs off led to cabin service carts hitting the cabin ceiling and several passenger injuries, some serious.

A319 / PRM1, en-route, near Fribourg Switzerland, 2011 On 10 June 2011 an ATC error put a German Wings A319 and a Hahn Air Raytheon 390 on conflicting tracks over Switzerland and a co-ordinated TCAS RA followed. The aircraft subsequently passed in very close proximity without either sighting the other after the Hahn Air crew, contrary to Company procedures, followed an ATC descent clearance issued during their TCAS ‘Climb’ RA rather than continuing to fly the RA. The Investigation could find no explanation for this action by the experienced crew - both Hahn Air management pilots. The recorded CPA was 0.6 nm horizontally at 50 feet vertically.

A319 / UNKN, Stockholm Arlanda Sweden, 2011 On 5 February 2011, an Airbus A319-100 being operated by Air Berlin on a passenger flight departing Stockholm inadvertently proceeded beyond the given clearance limit for runway 19R and although it subsequently stopped before runway entry had occurred, it was by then closer to high speed departing traffic than it should have been. There was no abrupt stop and none of the 103 occupants were injured.

A319 / WT9, vicinity Stuttgart Germany, 2017 On 26 June 2017, an Airbus A319 which had just taken off from Stuttgart came into conflict in Class ‘D’ airspace with a VFR light aircraft crossing its track and when, at 1,200 feet agl, the TCAS RA to descend which resulted was followed, an EGPWS Mode 3 Alert was generated. Clear of Conflict was annunciated after 10 seconds and climb resumed. The Investigation concluded that the light aircraft pilot had failed to follow the clearance which had been accepted and had caused the flight path conflict which was resolved by the response of the A319 to the TCAS RA.

A319, Belfast Aldergrove UK, 2011 On 6 January 2011 an Easyjet Airbus A319 experienced the sudden onset of thick smoke in the cabin as the aircraft cleared the runway after landing. The aircraft was stopped and an evacuation was carried out during which one of the 52 occupants received a minor injury. The subsequent investigation attributed the occurrence to the continued use of reverse idle thrust after clearing the runway onto a little used taxiway where the quantity of de-ice fluid residue was much greater than on the runway.

A319, Casablanca Morocco, 2011 On 8 August 2011 an Air France Airbus A319 crew failed to correctly identify the runway on which they were cleared to land off a visual approach at Casablanca and instead landed on the parallel runway. ATC, who had already cleared another aircraft to cross the same runway, did not notice until this other aircraft crew, who had noticed the apparently abnormal position of the approaching aircraft and remained clear of the runway as a precaution, advised what had happened. Investigation was hindered by the stated perception of the Air France PIC that the occurrence was not a Serious Incident.

A319, Copenhagen Denmark, 2012 On 21 September 2012, an SAS A319 which had just landed normally under the control of an experienced pilot left the paved surface when attempting to make a turn off the RET at a taxi speed greater than appropriate. The pilot was familiar with the airport layout and the misjudgement was attributed in part to the fact that the pilot involved had recently converted to their first Airbus type after a long period operating the DC9/MD80/90 series which had a different pilot eye height and was fitted with steel rather than the more modern carbon brakes.

A319, en-route, east of Dublin Ireland, 2008 On 27 May 2008 an Airbus A319-100 being operated by Germanwings on a scheduled passenger flight from Dublin to Cologne was 30nm east of Dublin and passing FL100 in the climb in unrecorded daylight flight conditions when the Purser advised the flight crew by intercom that “something was wrong”, that almost all the passengers had fallen asleep, and that at least one of the cabin crew seated nearby was “unresponsive”. Following a review of this information and a check of the ECAM pressurisation page which showed no warnings or failures, a decision was taken to don oxygen masks and the aircraft returned uneventfully to Dublin without any further adverse effects on the 125 occupants. A MAYDAY was declared during the diversion.

A319, en-route, Free State Province South Africa, 2008 On 7 September 2008 a South African Airways Airbus A319 en route from Cape Town to Johannesburg at FL370 received an ECAM warning of the failure of the No 1 engine bleed system. The crew then closed the No. 1 engine bleed with the applicable press button on the overhead panel. The cabin altitude started to increase dramatically and the cockpit crew advised ATC of the pressurisation problem and requested an emergency descent to a lower level. During the emergency descent to 11000 ft amsl, the cabin altitude warning sounded at 33000ft and the flight crew activated the cabin oxygen masks. The APU was started and pressurisation was re-established at 15000ft amsl. The crew completed the flight to the planned destination without any further event. The crew and passengers sustained no injuries and no damage was caused to the aircraft.

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.

A319, Helsinki Finland, 2018 On 3 August 2018, smoke appeared and began to intensify in the passenger cabin but not the flight deck of an Airbus A319 taxiing for departure at Helsinki. Cabin crew notified the Captain who stopped the aircraft and sanctioned an emergency evacuation. This then commenced whilst the engines were still running and inadequate instructions to passengers resulted in a completely disorderly evacuation. The Investigation attributed this to inadequate crew procedures which only envisaged an evacuation ordered by the Captain for reasons they were directly aware of and not a situation where the evacuation need was only obvious in the cabin.

A319, Ibiza Spain, 2016 On 19 June 2016, an Airbus A320 failed to follow the clearly-specified and ground-marked self-positioning exit from a regularly used gate at Ibiza and its right wing tip collided with the airbridge, damaging both it and the aircraft. The Investigation found that the crew had attempted the necessary left turn using the Operator’s ‘One Engine Taxi Departure’ procedure using the left engine but then failed to follow the marked taxi guideline by a significant margin. It was noted that there had been no other such difficulties with the same departure in the previous four years it had been in use.

A319, Las Vegas NV USA, 2006 On 30 January 2006 the Captain of an Airbus A319 inadvertently lined up and commenced a night rolling take off from Las Vegas on the runway shoulder instead of the runway centreline despite the existence of an illuminated lead on line to the centre of the runway from the taxiway access used. The aircraft was realigned at speed and the take off was completed. ATC were not advised and broken edge light debris presented a potential hazard to other aircraft until eventually found. The Investigation found that other similar events on the same runway had not been reported at all.

A319, London Heathrow UK, 2007 On 12 February 2007, an Airbus A319-100 being operated by British Airways on a scheduled passenger flight into London Heathrow made unintended contact in normal daylight visibility with the stationary airbridge at the arrival gate. This followed an emergency stop made after seeing hand signals from ground staff whilst following SEGS indications which appeared to suggest that there was a further 5 metres to run to the correct parking position. There was no damage to the aircraft, only minimal damage to the airbridge and there were no injuries to the aircraft occupants or any other person

A319, London Heathrow UK, 2009 On 15 March 2009, an Airbus A319-100 being operated by British Airways on a scheduled passenger flight from London Heathrow to Edinburgh experienced an electrical malfunction which blanked the EFIS displays following engine start with some electrical fumes but no smoke. The engines were shut down, a PAN was declared to ATC and the aircraft was towed back onto the gate where passengers disembarked normally via the airbridge.

A319, London Heathrow UK, 2013 On 24 May 2013 the fan cowl doors on both engines of an Airbus A319 detached as it took off from London Heathrow. Their un-latched status after a routine maintenance input had gone undetected. Extensive structural and system damage resulted and a fire which could not be extinguished until the aircraft was back on the ground began in one engine. Many previously-recorded cases of fan cowl door loss were noted but none involving such significant collateral damage. Safety Recommendations were made on aircraft type certification in general, A320-family aircraft modification, maintenance fatigue risk management and aircrew procedures and training.

A319, Luton UK, 2012 On 14 February 2011, an Easyjet Airbus A319 being flown by a trainee Captain under supervision initiated a go around from below 50 feet agl after a previously stabilised approach at Luton and a very hard three point landing followed before the go around climb could be established. The investigation found that the Training Captain involved, although experienced, had only limited aircraft type experience and that, had he taken control before making a corrective sidestick input opposite to that of the trainee, it would have had the full instead of a summed effect and may have prevented hard runway contact.

A319, Montego Bay Jamaica, 2014 On 10 May 2014 the crew of an Airbus A319 failed to manage their daylight non-precision approach at destination effectively and it culminated in a very hard touchdown which exceeded landing gear design criteria. The Investigation concluded that the comprehensively poor performance of both pilots during the preparation for and execution of the approach could be attributed to both their repeated failure to follow SOPs and retain adequate situational awareness and to a failure of the aircraft operator to fully deliver effective training even though both this training and its SMS met relevant regulatory requirements and guidance.

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.

A319, Munich Germany, 2017 On 3 July 2017, an Airbus A319 sustained significant landing gear damage during the First Officer’s manual landing at Munich which recorded a vertical acceleration exceeding the threshold for a mandatory airworthiness inspection. That inspection found damage to nose and one main landing gear legs and, following Airbus advice, all three were replaced before release to service. The Investigation was unable to explain why neither pilot detected the incorrect pitch attitude and excessive rate of descent in time to take corrective action and noted that a reversion to manual flight during intermediate approach had been due to a technical malfunction.

A319, Nice France, 2019 On 29 August 2019, an Airbus A319 crew used more runway than expected during a reduced thrust takeoff from Nice, although not enough to justify increasing thrust. It was subsequently found that an identical error made by both pilots when independently calculating takeoff performance data for the most limiting runway intersection had resulted in use of data for a less limiting intersection than the one eventually used. The Investigation concluded that the only guaranteed way to avoid such an error would be an automatic cross check, a system upgrade which was not possible on the particular aircraft involved.

A319, Rio de Janeiro Galeão Brazil, 2017 On 19 July 2017, an Airbus A319 crew ignored the prescribed non-precision approach procedure for which they were cleared at Rio de Janeiro Galeão in favour of an unstabilised “dive and drive” technique in which descent was then continued for almost 200 feet below the applicable MDA and led to an EGPWS terrain proximity warning as a go around was finally commenced in IMC with a minimum recorded terrain clearance of 162 feet. The Investigation noted the comprehensive fight crew non-compliance with a series of applicable SOPs and an operational context which was conducive to this although not explicitly causal.

A319, Santiago de Compostela Spain, 2016 On 10 October 2016, an Airbus 319 was cleared to divert to its first alternate after failing to land off its Cat II ILS approach at Porto and obliged to land at its second alternate with less than final reserve fuel after the first alternate declined acceptance due to lack of parking capacity. The Investigation concluded that adjacent ATC Unit coordination in respect of multiple diversions was inadequate and also found that the crew had failed to adequately appraise ATC of their fuel status. It also noted that the unsuccessful approach at the intended destination had violated approach ban visibility conditions.

A319, south of London UK, 2005 On 22 October 2005, a British Airways Airbus A319 climbing en route to destination over south east England at night in VMC experienced a major but temporary electrical failure. Most services were re-instated within a short time and the flight was continued. However, during the subsequent Investigation, which took over two years, a series of significant deficiencies were identified in the design of the A320 series electrical system and the manufacturer-recommended responses to failures in it and in response, Airbus developed solutions to most of them.

A319, vicinity Glasgow UK, 2018 On 30 September 2018, an Airbus A319 Captain had to complete a flight into Glasgow on his own when the First Officer left the flight deck after suffering a flying-related anxiety attack. After declaring a ‘PAN’ to ATC advising that the aircraft was being operated by only one pilot, the flight was completed without further event. The Investigation found that the First Officer had been “frightened” after the same Captain had been obliged to take control during his attempted landing the previous day and had “felt increasingly nervous” during his first ‘Pilot Flying’ task since the event the previous day.

A319, vicinity Paris CDG, France 2014 On 12 March 2014, an Airbus A319 left engine stopped without any apparent cause on approach to Paris CDG. The crew then started the APU which also stopped. The Investigation found that the cause was engine and APU fuel starvation caused by non-identification of a recurring intermittent malfunction in the fuel quantity indicating system because of a combination of factors including crew failure to record fuel status in line with clear instructions and an inadequate maintenance troubleshooting manual. An inadequately-written abnormal crew drill and the crew’s inadequate fuel system knowledge then resulted in the fuel crossfeed valve not being opened.

A319, vicinity Tunis Tunisia, 2012 On 24 March 2012, an Air France Airbus A319 Captain continued descent towards destination Tunis at high speed with the landing runway in sight well beyond the point where a stabilised approach was possible. With 5nm to go, airspeed was over 100 KIAS above the applicable VApp and the aircraft was descending at over 4000fpm with flaps zero. EGPWS activations for Sink Rate, PULL UP and Too Low Terrain apparently went unnoticed but at 400 feet agl, ATC granted a crew request for a 360° turn. The subsequent approach/landing was without further event. Investigation attributed the event to “sloppy CRM”.

A319, vicinity Wuxi China, 2010 On 14 September 2010, the crew of a Sichuan Airlines Airbus A319 continued an ILS approach into Wuxi despite awareness of adverse convective weather conditions at the airport. Their inattention to automation management then led to a low energy warning and the inappropriate response to this led to the activation of flight envelope protection quickly followed by a stall warning. Inappropriate response to this was followed by loss of control and a full stall and high rate of descent from which recovery was finally achieved less than 900 feet agl.

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/A319, en-route, South west of Basle-Mulhouse France, 2010 On 29 June 2010, an Easyjet Switzerland Airbus A319 inbound to Basle-Mulhouse and an Air France Airbus A319 outbound from Basle-Mulhouse lost separation after an error made by a trainee APP controller under OJTI supervision during procedural service. The outcome was made worse by the excessive rate of climb of the Air France aircraft approaching its cleared level and both an inappropriate response to an initial preventive TCAS RA and a change of track during the ensuing short sequence of RAs by the Training Captain in command of and flying the Easyjet aircraft attributed by him to his situational ‘anxiety’.

A319/A332, vicinity Barcelona Spain, 2012 On 8 February 2012, a TCAS RA occurred between an Airbus A330 and an Airbus A319 both under ATC control for landing on runway 25R at Barcelona as a result of an inappropriate plan to change the sequence. The opposite direction aircraft both followed their respective RAs and minimum separation was 1.4 nm horizontally and 400 feet vertically. The Investigation noted that the use of Spanish to communicate with one aircraft and English to communicate with the other had compromised situational awareness of the crew of the latter who had also not had visual contact with the other aircraft.

A319/B733, en-route, near Moutiers France, 2010 On 8 July 2010 an Easyjet Airbus A319 on which line training was being conducted mis-set a descent level despite correctly reading it back and, after subsequently failing to notice an ATC re-iteration of the same cleared level, continued descent to 1000 feet below it in day VMC and into conflict with crossing traffic at that level, a Boeing 737. The 737 received and actioned a TCAS RA ‘CLIMB’ and the A319, which received only a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.

A320 (2) / CRJX (2) / B738 (3) / A332, vicinity Madrid Barajas Spain, 2018 On 27 May 2018, four losses of separation on final approach during use of dependent parallel landing runways occurred within 30 minutes at Madrid following a non-scheduled weather-induced runway configuration change. This continuing situation was then resolved by reverting to a single landing runway. The Investigation attributed these events to “the complex operational situation” which had prevailed following a delayed decision to change runway configuration after seven consecutive go-arounds in 10 minutes using the previous standard runway configuration. The absence of sufficient present weather information for the wider Madrid area to adequately inform ATC tactical strategy was assessed as contributory.

A320 / A139 vicinity Zurich Switzerland, 2012 On 29 May 2012, a British Airways Airbus A320 departing Zürich and in accordance with its SID in a climbing turn received and promptly and correctly actioned a TCAS RA 'CLIMB'. The conflict which caused this was with an AW 139 also departing Zürich IFR in accordance with a SID but, as this aircraft was only equipped with a TAS to TCAS 1 standard, the crew independently determined from their TA that they should descend and did so. The conflict, in Class 'C' airspace, was attributed to inappropriate clearance issue by the TWR controller and their inappropriate separation monitoring thereafter.

A320 / A320, vicinity Delhi India, 2020 On 29 February 2020, an Airbus A320 inbound to Delhi lost separation against an outbound A320 from Delhi on a reciprocal track and the conflict was resolved by TCAS RA activation. The Investigation found that the inbound aircraft had correctly read back its descent clearance but then set a different selected altitude. Air Traffic Control had not reacted to the annunciated conflict alert and was unable to resolve it when the corresponding warning followed and it was noted that convective weather meant most aircraft were requesting deviations from their standard routes which was leading to abnormally complex workload.

A320 / A320, Zurich Switzerland, 2011 On 15 March 2011 two Swiss International Airlines’ Airbus A320 aircraft were cleared for simultaneous take off on intersecting runways at Zurich by the same controller. As both approached the intersection at high speed, the Captain of one saw the other and immediately rejected take off from 130 knots, stopping just at the edge of the intersection shortly after the other aircraft had flown low overhead unaware of the conflict. The Investigation noted a long history of similar incidents at Zurich and concluded that systemic failure of risk management had not been addressed by the air traffic control agency involved.

A320 / A321, vicinity Barcelona Spain, 2016 On 25 July 2016, an Airbus A320 and an Airbus A321 both departing Barcelona and following their ATC instructions came into conflict and the collision risk was removed by the TCAS RA CLIMB response of the A320. Minimum separation was 1.2 nm laterally and 200 feet vertically with visual acquisition of the other traffic by both aircraft. The Investigation found that the controller involved had become preoccupied with an inbound traffic de-confliction task elsewhere in their sector and, after overlooking the likely effect of the different rates of climb of the aircraft, had not regarded monitoring their separation as necessary.

A320 / A346, en-route, Eastern Indian Ocean, 2012 On 18 January 2012, ATC error resulted in two aircraft on procedural clearances in oceanic airspace crossing the same waypoint within an estimated 2 minutes of each other without the prescribed 1000 feet vertical separation when the prescribed minimum separation was 15 minutes unless that vertical separation existed. By the time ATC identified the loss of separation and sent a CPDLC message to the A340 to descend in order to restore separation, the crew advised that such action was already being taken. The Investigation identified various organisational deficiencies relating to the provision of procedural service by the ANSP concerned.

A320 / AT76, Yangon Myanmar, 2017 On 18 September 2017, a departing Airbus A320 was instructed to line up and wait at Yangon but not given takeoff clearance until an ATR72 was less than a minute from touchdown and the prevailing runway traffic separation standard was consequently breached. The Investigation found that the TWR controller had been a temporarily unsupervised trainee who, despite good daylight visibility, had instructed the A320 to line up and wait and then forgotten about it. When the A320 crew, aware of the approaching ATR72, reminded her, she “did not know what to do” and the trainee APP controller had to intervene.

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.

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 / B738, en-route, north northwest of Sofia Bulgaria, 2016 On 4 June 2016, a Boeing 737-800 instructed to climb from FL340 to FL380 by the controller of one sector in Bulgarian upper airspace came into sufficiently close proximity to an Airbus A320 under the control of a different sector controller to trigger co-ordinated TCAS RAs. Separation was eventually restored after the 737 followed its RA despite the A320, which had already deviated from its clearance on the basis of a prior TCAS TA without informing ATC, ignoring their RA. The Investigation found that the root cause of the conflict had been inadequate coordination between two vertically separated ATC sectors.

A320 / B738, vicinity Barcelona, Spain 2018 On 6 July 2018, a Boeing 737-800 being positioned to join the intermediate approach sequence in the Barcelona CTR was obliged to take lateral avoiding action against an Airbus A320 ahead. The Investigation found that although both aircraft were in the same sector at the time, the controller had overlooked the presence of the A320 which had been transferred to the next sector before entering it prior to the controller involved routinely taking over the position. An on-screen alert to the developing conflict had not been seen by the controller. Minimum separation was 1.1nm laterally and 200 feet vertically.

A320 / B738, vicinity Delhi India, 2016 On 30 January 2016, an Airbus A320 crew cleared for an ILS approach to runway 11 at Delhi reported established on the runway 11 LLZ but were actually on the runway 09 LLZ in error and continued on that ILS finally crossing in front of a Boeing 737-800 on the ILS for runway 10. The Investigation found that the A320 crew had not noticed they had the wrong ILS frequency set and that conflict with the 737 occurred because Approach transferred the A320 to TWR whilst a conflict alert was active and without confirming it was complying with its clearance.

A320 / B738, vicinity Dubai UAE, 2012 On 22 April 2012, an Airbus A320 and a Boeing 737 came into close proximity near Dubai whilst on the same ATC frequency and correctly following their ATC clearances shortly after they had departed at night from Sharjah and Dubai respectively. The Investigation found that correct response by both aircraft to coordinated TCAS RAs eliminated any risk of collision. The fact that the controller involved had only just taken over the radar position involved and was only working the two aircraft in conflict was noted, as was the absence of STCA at the unit due to set up difficulties.

A320 / B738, vicinity Launceston Australia, 2008 On 1 May 2008 an Airbus A320-200 being operated by JetStar on a scheduled passenger flight from Melbourne to Launceston, Tasmania was making a missed approach from runway 32L when it came into close proximity in night VMC with a Boeing 737-800 being operated by Virgin Blue and also inbound to Launceston from Melbourne which was manoeuvring about 5nm north west of the airport after carrying out a similar missed approach. Minimum separation was 3 nm at the same altitude and the situation was fully resolved by the A320 climbing to 4000 feet.

A320 / B739, Yogyakarta Indonesia, 2013 On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.

A320 / B789 / A343, San Francisco CA USA, 2017 On 7 July 2017 the crew of an Airbus A320, cleared for an approach and landing on runway 28R at San Francisco in night VMC, lined up for the visual approach for which it had been cleared on the occupied parallel taxiway instead of the runway extended centreline and only commenced a go-around at the very last minute, having descended to about 60 feet agl whilst flying over two of the four aircraft on the taxiway. The Investigation determined that the sole direct cause of the event was the poor performance of the A320 flight crew.

A320 / C56X, vicinity Geneva Switzerland, 2011 On 17 August 2012, a Swiss A320 being positioned under radar vectors for arrival at Geneva was inadvertently vectored into conflict with a Cessna Citation already established on the ILS LOC for runway 23 at Geneva. Controller training was in progress and the Instructor had just taken control because of concerns at the actions of the Trainee. An error by the Instructor was recognised and de-confliction instructions were given but a co-ordinated TCAS RA still subsequently occurred. STCA was activated but constraints on access to both visual and aural modes of the system served to diminish its value.

A320 / CRJ2, Port Elizabeth South Africa, 2014 On 10 July 2014, the crew of a Bombardier CRJ200 on a visual go around from an approach to runway 26 at Port Elizabeth took visual avoiding action overhead of the aerodrome to ensure safe separation from an Airbus A320 which had just taken off. Both aircraft also received TCAS RAs. Minimum achieved separation from radar was 370 metres laterally and 263 feet vertically. The Investigation noted that the go around resulted from the TWR controller, who was supervising a student controller, clearing the A320 to enter the runway and take off when the CRJ200 was on short final to land.

A320 / CRJ2, Sofia Bulgaria, 2007 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.

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.

A320 / E195, vicinity Brussels Belgium, 2018 On 23 February 2018, an Embraer 195LR and an Airbus A320 on SIDs departing Brussels lost separation after the 195 was given a radar heading to resolve a perceived third aircraft conflict which led to loss of separation between the two departing aircraft. STCA and coordinated TCAS RA activations followed but only one TCAS RA was followed and the estimated minimum separation was 400 feet vertically when 1.36 nm apart. The Investigation found that conflict followed an error by an OJTI-supervised trainee controller receiving extended revalidation training despite gaining his licence and having almost 10 years similar experience in Latvia.

A320 / F50, Adelaide Australia, 2016 On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.

A320 / GLID, vicinity Memmingen Germany, 2015 On 6 April 2015, the crew of an A320 under radar control in Class E airspace and approaching 4000 feet made a very late sighting of a glider being flown by a student pilot which appeared ahead at a similar altitude. The glider pilot reported having seen a 'cone of light' coming towards him. Both aircraft took avoiding action as practicable and passed within a recorded 450 metres with the A320 passing an estimated 250 feet over the glider. The glider was not fitted with a transponder and was not required to be, and the controller had only secondary radar.

A320 / SF34, vicinity London Stansted UK, 2019 On 12 February 2019, an Airbus A320 under the command of a Captain reportedly undergoing line training supervised by a Training Captain occupying the supernumerary crew seat was slow to follow ATC instructions after breaking off from an unstabilised approach at London Stansted caused by the First Officer’s mismanagement of the approach and lost separation at night as it crossed approximately 600 feet above a Saab 340B climbing after takeoff. The Investigation found that flight crew workload had been exacerbated after the Captain under supervision unnecessarily delayed taking over control and had then not done so in the prescribed way.

A320 / SW4, Calgary AB Canada, 2016 On 2 December 2016, the crew of an Airbus A320 passing 100 knots on takeoff at Calgary saw another aircraft crossing an intersection ahead but continued because they considered that, as the other aircraft was already more than half way across, it would be clear before they reached that point. The Investigation found that the GND Controller had cleared the other aircraft to cross after forgetting that the runway was active and under TWR control. It was concluded that the response of the ANSP SMS process to a history of identical controller errors and related reports had been inadequate.

A320 / Vehicle, London Gatwick UK, 2018 On 3 February 2018, a runway inspection vehicle was cleared onto the active runway at London Gatwick ahead of an aircraft which had just touched down and driven towards it having been cleared to do so because the aircraft crew’s confirmation that they would clear the runway before reaching the vehicle was considered by the controller as a clearance limit. The Investigation found that the associated runway inspection procedure had not been adequately risk-assessed and noted that many issues raised by it had still not been addressed by the time it was completed eighteen months later.

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