Accident and Serious Incident Reports: AGC
Accident and Serious Incident Reports: AGC
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Reports relating to accidents and serious incidents which included Air-Ground Communication (AGC) as a causal factor.
Call Sign Confusion
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concluded that the ATC procedure involved was potentially hazardous and made a safety recommendation that it should be withdrawn.
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.
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.
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.
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 .
Loss of Communication
On 23 February 2019, a Raytheon B200 King Air which had recently departed Saanen was passing FL155 for cleared altitude FL240 when a total electrical failure occurred. On subsequently making contact with ATC on a hand-held personal radio, the pilot advised his intention to exit controlled airspace and complete an already commenced visual diversion to Lausanne which was then done. It was found that failure to use the prescribed normal checklists had resulted in an undetected electrical system selection error which had led to the successive discharge of both main batteries when corresponding alerts and warnings also went unnoticed.
On 10 March 2017, a Boeing 787-8 lost contact with ATC over central Romania whilst the Captain was taking his second in-seat controlled rest and flight continued through Romanian and then, in daylight and without clearance, into Hungarian airspace. After well over an hour out of contact, military fighter interception prompted the re-establishment of normal communication. It was found that whilst the Captain was asleep, both speakers had been off and the First Officer had not been wearing her headset although she claimed that normal ATC communications had occurred whilst admitting that they had not been written down as required.
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.
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.
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.
Incorrect Readback Missed
On 21 March 2022, an Airbus A320 level at FL 360 lost separation with another Airbus A320, which continued its descent beyond its cleared level. A predictive conflict alert prompted the controller to issue multiple calls confirming the clearance limit but with no response. When both aircraft tracks crossed at FL 360, lateral separation was reduced to 3.8 nm. It was concluded that the immediate cause of the conflict was the failure of the descending aircraft to respond to ATC alerting calls, but that its origin was an undetected incorrect readback of the descent clearance.
On 24 October 2021, a Bombardier DHC8-400 inbound to Belagavi initially advised to expect a non-precision approach to runway 08 was subsequently cleared for an equivalent approach to runway 26. An approach to runway 08 was then flown without ATC intervention or pilot error recognition, but with no actual consequences. The error was attributed to pilot expectation bias and distraction and controller failure to order a go-around after eventually realising what was happening. The context that had facilitated the errors was considered to be procedure and performance inadequacy at both the aircraft operator and ATC.
On 20 October 2021, the flight crew of a Bombardier CRJ1000 making a LNAV/VNAV approach at Nantes using Baro-VNAV minima read back an incorrect QNH which was not noticed by the controller. The crew then flew the approach approximately 530 feet below the procedure vertical profile which led to the MSAW system being activated and advised to the flight. The crew response was delayed until the controller had twice repeated the correct QNH after which the error was recognised and the vertical profile corrected. The investigation noted that neither the operator’s procedures nor aircraft instruments allowed straightforward crew detection of their error.
On 23 May 2022, an Airbus A320 came within six feet of the ground without crew awareness during a go around from a RNP BaroVNAV approach after failing to obtain visual reference. The descent below minimum altitude followed use of an incorrect QNH passed by ATC but not identified as such. The lack of an EGPWS warning was due to the non-current EGPWS version for which upgrading had not been mandated. It was concluded that the regulatory intention in Europe to transition from ILS to RNP approaches had not led to any recognition of the potential impact on operational safety.
On 28 November 2020, a Boeing 737-300F taxiing for an early morning departure at Singapore Changi crossed an illuminated red stop bar in daylight and entered the active runway triggering an alert which enabled the controller to instruct the aircraft to immediately exit the runway and allow another aircraft already on approach to land. The Investigation found that the flight was the final one of a sequence of six carried out largely overnight as an extended duty predicated on an augmented crew. The context for the crew error was identified as a poorly managed operator subject to insufficient regulatory oversight.
Phraseology
On 25 October 2022, a Boeing 777-300ER encountered deteriorating weather conditions after initiating a delayed arrival diversion from Singapore Changi to nearby Batam where four approaches were flown and a ‘MAYDAY Fuel’ declared before a landing was achieved. By this time, the fuel remaining was “significantly below final reserve” although the actual figure was not published in the Investigation Report. It was concluded that the delay in commencing the diversion and the inappropriate attempt to perform an autoland on RWY04 at Batam airport by the flight crew contributed to the potentially hazardous circumstances.
On 24 October 2021, a Bombardier DHC8-400 inbound to Belagavi initially advised to expect a non-precision approach to runway 08 was subsequently cleared for an equivalent approach to runway 26. An approach to runway 08 was then flown without ATC intervention or pilot error recognition, but with no actual consequences. The error was attributed to pilot expectation bias and distraction and controller failure to order a go-around after eventually realising what was happening. The context that had facilitated the errors was considered to be procedure and performance inadequacy at both the aircraft operator and ATC.
On 20 July 2020, a Boeing 787-10 making an ILS approach to runway 09L at Paris CDG unexpectedly received landing clearance for runway 09R after transferring to TWR. The crew readback added explicit reference to the implied need to sidestep but elicited no further controller response and visual realignment to 09R followed. The controller then cleared a departing A320 to enter 09R but when its crew saw the 787 on very short final after crossing the holding point, they stopped, informed TWR and directly instructed the 787 to go-around. Investigation confirmed the controller’s error and noted their failure to monitor approaching traffic.
On 20 October 2021, the flight crew of a Bombardier CRJ1000 making a LNAV/VNAV approach at Nantes using Baro-VNAV minima read back an incorrect QNH which was not noticed by the controller. The crew then flew the approach approximately 530 feet below the procedure vertical profile which led to the MSAW system being activated and advised to the flight. The crew response was delayed until the controller had twice repeated the correct QNH after which the error was recognised and the vertical profile corrected. The investigation noted that neither the operator’s procedures nor aircraft instruments allowed straightforward crew detection of their error.
On 24 October 2021, a Shorts SD360 intending to land at the international airport serving Ndola did so at the recently closed old international airport after visually navigating there in hazy conditions whilst unknowingly in contact with ATC at the very recently opened new airport which had taken the same name and radio frequencies as the old one. The Investigation found multiple aspects of the airport changeover and re-designation had been mismanaged, particularly but not only failure to publish new flight procedures for both airports and ensure that NOTAM communication of the changes internationally had been effective.
Language Clarity
On 12 November 1996, an Ilyushin IL76TD and an opposite direction Boeing 747-100 collided head on at the same level in controlled airspace resulting in the destruction of both aircraft and the loss of 349 lives. The Investigation concluded that the IL76 had descended one thousand feet below its cleared level after its crew had interpreted ATC advice of opposite direction traffic one thousand feet below as the reason to remain at FL150 as re-clearance to descend to this lower level. Fifteen Safety Recommendations relating to English language proficiency, crew resource management, collision avoidance systems and ATC procedures were made.
On 5 April 2019, a Boeing 737-500 crew declared an emergency shortly after departing Madrid Barajas after problems maintaining normal lateral, vertical or airspeed control of their aircraft in IMC. After two failed attempts at ILS approaches in unexceptional weather conditions, the flight was successfully landed at a nearby military airbase. The Investigation found that a malfunction which probably prevented use of the Captain’s autopilot found before departure was not documented until after the flight but could not find a technical explanation for inability to control the aircraft manually given that dispatch without either autopilot working is permitted.
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.
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 realised that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.
On 21 September 2012, two aircraft came into conflict in Class 'A' airspace whilst under radar control at night and loss of separation was resolved by TCAS RA responses by both aircraft. Investigation found that one of the aircraft had passed a procedurally-documented clearance limit without ATC clearance or intervention and that situational awareness of its crew had been diminished by communications with the conflicting aircraft being conducted in Spanish rather than English. A Safety Recommendation on resolving the persistent problem of such language issues was made, noting that a similar recommendation had been made 11 years earlier.
Multiple Language use on Frequency
On 31 December 2022, an Airbus A320 crew cleared to land on runway 23 at Bordeaux in good day visibility had not noticed a stationary light aircraft at the runway threshold. Only a call from the concerned light aircraft pilot on a busy frequency prompted the controller to order the A320 to go around which it did from just over 100 feet agl before passing overhead the unseen DR400 light aircraft at 178 feet agl. The controller, who was covering GND/TWR/APP/INFO positions due to short staffing, had forgotten their earlier instruction to the light aircraft to line up and wait.
On 12 April 2019, a Boeing 717-200 commenced a go around at Strasbourg because the runway ahead was occupied by a departing Bombardier CRJ700 which subsequently, despite co-ordinated TCAS RAs, then came to within 50 feet vertically when only 740 metres apart laterally as the CRJ, whose crew did not see the 717, passed right to left in front of it. The Investigation attributed the conflict primarily to a series of flawed judgements by the TWR controller involved whilst also noting one absent and one inappropriate ATC procedure which respectively may have provided a context for the resultant risk.
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.
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.
On 17 March 2017, a Bombardier CRJ 700 which had just landed on runway 35R at Lyon Saint-Exupéry was about to cross runway 35L as cleared when its crew saw the departing Airbus A319 on runway 35L accelerating towards their intended crossing position and braked to a stop before entering the runway. The Investigation found that both aircraft had complied with all instructions issued by the TWR controller and concluded that safety management processes at the airport were not commensurate with the incursion risk involved and had been unchanged since an almost identical incident a year previously.
CPDLC
On 14 September 2022, a Boeing 787-9 inbound to Mumbai lost separation against a Boeing 787-8 also inbound to Mumbai on the same airway when it began a descent from FL410 to FL340 at night without clearance close to an air traffic control sector boundary. ATC soon observed the error but a delay in achieving contact with the 787-9 resulted in it descending to FL389 before being instructed to return to its cleared level. As it passed through FL390 descending and then again when climbing, it came within 3nm of the same-direction 787-8 which was level as cleared at FL390.
Flight Crew Oxygen Mask Use
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.
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.
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.
On 24 June 1982, a Boeing 747-200 had just passed Jakarta at FL370 in night VMC when it unknowingly entered an ash cloud from a recently begun new eruption of nearby volcano, Mount Galunggung, which the crew were unaware of. All engines failed in quick succession and a MAYDAY was declared. Involuntary descent began and a provisional diversion back to Jakarta, which would necessitate successful engine restarts to clear mountainous terrain en-route was commenced. Once clear of cloud with three successful engines restarts and level at FL120, the diversion plan was confirmed and completed with a visual approach from the overhead.
Take off without clearance
On 27 February 2023, an Embraer 190 was flaring for an imminent night touchdown on runway 04R at Boston in normal visibility when a Learjet 60 began takeoff from intersecting runway 09. As the Embraer descended through 30 feet AGL, the Learjet entered runway 04R, taking two seconds to cross it. The incursion had triggered an ATC alert and just after the crossing, the Embraer was instructed to go around and did so from around 10 feet AGL. The Investigation found that the Learjet crew correctly read back their line up and wait clearance but then took off without clearance.
On 24 October 2020, an Airbus A350-900 took off in daylight from runway 07R at Barcelona without a clearance to do so when an Airbus A320 was on approach to land on runway 02 which involves an approach path that crosses over runway 07R and lateral separation was reduced to 2.8nm. The Investigation attributed the inadvertent failure to await clearance to “some form of reduced alertness” on the part of the crew.
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.
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.
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.
Landing without clearance
On 24 October 2021, a Shorts SD360 intending to land at the international airport serving Ndola did so at the recently closed old international airport after visually navigating there in hazy conditions whilst unknowingly in contact with ATC at the very recently opened new airport which had taken the same name and radio frequencies as the old one. The Investigation found multiple aspects of the airport changeover and re-designation had been mismanaged, particularly but not only failure to publish new flight procedures for both airports and ensure that NOTAM communication of the changes internationally had been effective.
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.
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.
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.
On 17 October 2014, two recently type-qualified Airbus A319 pilots responded in a disorganised way after a sudden malfunction soon after take-off from Zurich required one engine to be shutdown. The return to land was flown manually and visually at an excessive airspeed and rate of descent with idle thrust on the remaining engine all the way to a touchdown which occurred without a landing clearance. The Investigation concluded that the poor performance of the pilots had been founded on a lack of prior analysis of the situation, poor CRM and non-compliance with system management and operational requirements.
Military Formation Clearance
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.
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).
On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.
Military/Civil Coordination
On 13 July 2022, an Airbus A330-300 inbound to Madrid and descending on the 32L ILS and a Cessna Citation 550 which had just departed from Torrejón Air Base lost separation. The aircraft came within 400 feet vertically and 0.6nm horizontally after the Citation failed to follow its assigned and acknowledged departure clearance. A TCAS RA "DON’T CLIMB" message was annunciated on the A330 as the opposite-direction Citation, which the A330 crew subsequently reported having had briefly in sight, passed just above it. Detection of the conflict risk to ILS traffic inbound to Madrid was delayed by sub-optimal civil/military ATC coordination.
On 24 October 2021, a Shorts SD360 intending to land at the international airport serving Ndola did so at the recently closed old international airport after visually navigating there in hazy conditions whilst unknowingly in contact with ATC at the very recently opened new airport which had taken the same name and radio frequencies as the old one. The Investigation found multiple aspects of the airport changeover and re-designation had been mismanaged, particularly but not only failure to publish new flight procedures for both airports and ensure that NOTAM communication of the changes internationally had been effective.
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.
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.
Provision of Aircraft Performance Data
On 12 January 2022, an Embraer 170 and a Cessna 525 crossed tracks without the prescribed minimum separation, with neither ATC nor the Embraer crew being aware. Although ATC had issued acknowledged clearances to keep the Embraer 1,000 feet above the Cessna, it actually passed beneath it, violating minimum lateral separation. The underlying cause of the event was found to be an unrectified recurrent intermittent fault in one of the Cessna’s air data systems. Poor Cessna crew/controller communication during the event, systemically poor safety culture at its operator, and shortcomings in the Textron Aircraft Maintenance Manual were considered contributory.
On 6 June 2020, a Boeing 787-10 on approach at Abu Dhabi began a low go around from an RNAV(RNP) approach when it became obvious to the crew that the aircraft was far lower than it should have been but were unaware why this occurred until an ATC query led them to recognise that the wrong QNH had been set with recognition of the excessively low altitude delayed by haze limiting the PAPI range. The Investigation found that advice of MSAW activations which would have enabled the flight crew to recognise their error were not advised to them.
ATC Clearance Cancelled
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.
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.
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.
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 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.
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.
Blocked Transmission
On 10 June 2021, an Embraer 170-200LR was cleared to line up and wait on runway 27 at San Diego with a Boeing 737-800 already cleared to land on the same runway. The occupied runway led to ASDE-X activation which prompted a controller go-around instruction to the 737 when it was less than a mile from the runway displaced threshold but this was blocked by an undetected simultaneous transmission from the B737. The 737 manoeuvred around the E170 that was vacating the runway as per the ATC instruction, before touching down beyond it.
On 18 October 2022, an Airbus A321 on approach to Venice in thick fog was observed on TCAS by a Boeing 737-800 crew awaiting takeoff clearance from the same runway after a lineup and wait instruction. When no takeoff clearance followed, the 737 crew transmitted, advising its position without any response. The crew then transmitted on 121.5, instructing the A321 to go around, and they received no response. They were about to vacate the runway when the controller instructed the A321 to go around, which only occurred as it approached 100 feet AGL. The controller involved had failed to plug in his headset properly.
On 7 March 2020, an Embraer ERJ190 was taking off at Toronto when it struck a bird and commenced and reported a high speed rejected takeoff. This call was not heard by ATC who then cleared a Boeing 777-300 to line up and takeoff on the same runway. As the 777 accelerated, its crew saw the ERJ190 ahead and also commenced a high speed rejected takeoff, successfully avoiding a collision. The Investigation found that the air/ground status of both aircraft was configured in accordance with current design standards in a way which prevented activation of the ground collision prevention system.
On 13 February 2019, a Boeing 787 departing Amsterdam was given a non-standard long pushback by ATC in order to facilitate the use of its stand by an incoming flight and when a Boeing 747 was subsequently given a normal pushback by a single tug driver working alone who was unaware of the abnormal position of the 787 and could not see it before or during his pushback, a collision followed. The Investigation concluded that the relevant airport safety management systems were systemically deficient and noted that this had only been partially rectified in the three years since the accident.
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
- A310 / B736, en-route, Southern Norway, 2001: On 21 February 2001, a level bust involving a PIA A310 led to loss of separation with a SAS B737 with apparently uncoordinated Airborne Collision Avoidance System (ACAS) RA near Oslo.
- AS32 / B734, Aberdeen UK, 2000: On 27 July 2000, at Aberdeen UK, a British Airways B737 was forced to make a high speed rejected takeoff when a hovering AS332 helicopter moved without ATC clearance to a position 30 feet above the upwind end of the takeoff runway during the B737's take off roll.
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