On 13 January 2023, in good night visibility, an augmented crew Boeing 777-200 failed to comply with its departure taxi clearance and with its Captain taxiing crossed a runway in front of a 737 taking off. ATC responded to an automated conflict warning by cancelling the takeoff clearance and a high speed rejected takeoff was initiated from approximately 105 knots with minimum separation as the 777 cleared the edge of the 737 takeoff runway approximately 300 metres. The Investigation concluded that the 777 operator’s risk controls and the airport’s methods for detecting and preventing dangerous runway conflicts were both inadequate.

On 15 October 2022 an airport authority vehicle entered an active runway without clearance with a Boeing 737-8 on short final which was instructed to and completed a go around. The experienced driver involved had correctly read back a clearance to remain at the holding point on reaching it but did not stop and it was found the insufficiently obvious nature of the installed signage was contributory. Drivers were found to have routinely used to cross active runways to save time instead of using the available perimeter road as per the airport authority directives.

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 21 June 2022, a Boeing 737-9 cleared for a visual approach and landing on runway 28C at Pittsburgh landed on the adjacent runway 28L instead. The controller stated that having become aware that the aircraft was lined up with the wrong runway in the absence of any potential hazards, he had decided not to intervene. The crew said that a transient avionics fault on final approach had reduced their opportunity to ensure correct runway alignment but this fault was found to have cleared much earlier. It was noted that runway 28L had sequenced approach lighting whereas 28C had none.

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 25 November 2021, a Fokker F50 departing Helsinki experienced an engine malfunction that resulted in an uncommanded propeller feathering. The associated engine continued to run until shutdown, during which time it began to overspeed. The aircraft landed safely, but the failure experienced was untrained, and this led to both direct and indirect consequences that resulted in a suboptimal crew response to the emergency. The Investigation also highlighted opportunities to improve aspects of the air traffic control emergency response during such emergencies and identified language proficiency certification issues.

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 28 September 2022, a Boeing 787-9 and an Airbus A330-200 were successively cleared for takeoff from Sydney having been instructed to follow the same SID and climb to the same level - FL280. The A330 climbed faster than the controller anticipated and turned towards the next waypoint inside the preceding aircraft, resulting in a loss of separation. The Investigation found that the SID concerned did not provide separation assurance to aircraft with different performance characteristics because aircraft had to satisfy two separate conditions prior to turning which meant the turning point was not a fixed position.

On 23 January 2020, a Bombardier CRJ700 making a HUD-supported manual Cat 3a ILS approach to Lyon Saint-Exupéry in freezing fog conditions deviated from the required flight path localiser and reached a minimum of 265 feet agl before a go around was initiated without initially being flown in accordance with standard procedures. The Captain involved was relatively new to type and had not previously flown such an approach in actual low visibility conditions. The Investigation was not able to determine exactly what contributed to the approach and initial go around being misflown but identified a number of possible contributors.

On 1 November 2021, a deHavilland DHC6-300 crew en-route to Fort Simpson realised that they had insufficient fuel on board to reach their intended destination and therefore decided to attempt a diversion to the nearest available airport at Fort Providence. As fuel available dwindled, one engine was shut down but after an inadvertent fuel tank selection, the initially intended diversion was no longer possible and a forced landing in a bog was successfully accomplished. The Training Captain involved had developed a habit of performing checklists silently and from memory after gaining all his professional pilot experience at the same operator.

On 1 December 2021, a lightly loaded Boeing 737-800 became airborne near the end of the runway at Kuusamo with only engine run-up thrust set with only the abnormally low climb rate alerting the crew to their error. Serial failure by both pilots to follow relevant normal takeoff procedures followed after the type-experienced First Officer had been surprised when the aircraft began to move because his inexperience in brake use resulted in insufficient brake pressure being applied during the engine run-up. The Captain’s failure to notice the error was associated with allowing himself to be distracted by a non-urgent radio call.

On 6 January 2018, a Boeing 737-900 and an Airbus A320 both inbound to Surabaya with similar estimated arrival times were cleared to hold at the same waypoint at FL100 and FL110 respectively but separation was lost when the A320 continued below FL110. Proximity was limited to 1.9nm laterally and 600 feet vertically following correct responses to coordinated TCAS RAs. The Investigation found that all clearances / readbacks had been correct but that the A320 crew had set FL100 instead of their FL110 clearance and attributed this to diminished performance due to the passive distraction of one of the pilots.

On 16 June 2021, a Boeing 737-400 was taxiing for departure at night after push back from stand when the ground crew who completed the push back arrived back at their base in the tug and realised that the tow bar they had used was not attached to it. The aircraft was prevented from taking off and it was then found that it had taxied over the unseen towbar and sustained damage to both nose gear tyres such that replacement was necessary. The Investigation concluded neither ground crew had checked that the area immediately ahead of the aircraft was clear.

On 3 January 2019, prescribed vertical separation was lost between a Bombardier DHC8-400 and a Piaggio P180 on converging cruise tracks at FL 220 and only restored after a resulting TCAS RA was followed. The Investigation found both aircraft were being flown in accordance with their clearances and that the controller involved had not been aware of corresponding traffic and conflict alerting system activations. A specific traffic display fault which arose from failure to follow a routine software upgrade procedure correctly and the shift supervisor failing to recognise the need to act as controller when workload increased were assessed contributory.