On 23 May 2022, an Airbus A320 came extremely close to collision with terrain as the crew commenced a go around they did not obtain any visual reference during a RNP approach at Paris CDG for which they were using baro-VNAV reference to fly to VNAV/LNAV minima. The corresponding ILS was out of service. The Investigation has not yet completely established the context for the event but this has been confirmed to include the use of an incorrect QNH which resulted in the approach being continued significantly below the procedure MDA. Six Interim Safety Recommendations have been issued.

On 11 May 2018, a Bombardier CRJ1000 climbing on departure from Tambolaka and an ATR72-500 descending inbound there lost safe separation when during opposite turns in visual flight in uncontrolled airspace. Prompt response to both coordinated TCAS RAs resolved the conflict. The Investigation found the departing flight Captain mixed up left and right downwind circuit joining by the ATR 72 and that his inexperienced First Officer had not picked this up. It also noted that this Captain may not have been fit for duty and that all parties may have failed to fully recognise the limitations of ANSP ‘information’ service.

On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a smaller aircraft which had just landed on the same runway and was ahead until it appeared in the landing lights with rotation imminent. After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway. The Investigation attributed the conflict primarily to controller use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.

On 8 September 2020, an airport maintenance team driving at night on the centreline of the active runway at Birmingham were unaware that an inadequately secured 2 metre-long ladder had fallen from their pickup truck. Three aircraft then landed in the following half hour narrowly missing the ladder before it was discovered and the runway closed. The Investigation found that a more suitable alternative vehicle was available and that the completely inadequate method used to secure the ladder in their vehicle had failed to restrain it when the vehicle accelerated after passing the aiming point markings in the touchdown zone.

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 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 22 December 2018, a Boeing 747-400 crew began to climb from FL310 without clearance and prescribed separation was lost against both an opposite direction Boeing 777-300 at FL 320 and another same direction Boeing 777-300 cleared to fly at FL330. The Investigation found that the 747 crew had requested FL 390 and then misunderstood the controller’s response of “level available 350” as a clearance to climb and gave a non-standard response and began to climb when the controller responded instructing the flight to standby for higher. Controller attempts to resolve the resultant ‘current conflict warnings’ were only partially successful.

On 28 January 2019, a departing Embraer 170-200 narrowly avoided collision with part of a convoy of four snow clearance vehicles which failed to follow their clearance to enter a parallel taxiway and instead entered a Rapid Exit Taxiway and continued across the runway holding point before stopping just clear of the actual runway after multiple calls to do so. A high speed rejected takeoff led to the aircraft stopping just before the intersection where the incursion had occurred. The Investigation noted the prevailing adverse weather without attributing any specific cause to the vehicle convoy’s failure to proceed as cleared.

On 5 August 2019, a Cessa 560XLS touched down in runway undershot at Aarhus whilst making a night ILS approach there and damage sustained when it collided with parts of the ILS LOC antenna caused a fuel leak which after injury-free evacuation of the occupants then ignited destroying most of the aircraft. The Investigation attributed the accident to the Captain’s decision to intentionally fly below the ILS glideslope in order to touch down at the threshold and to the disabling of the EGWPS alerting function in the presence of a steep authority gradient, procedural non-compliance and poor CRM.

On 10 September 2017, an Airbus A380-800 cleared for an ILS approach at Moscow Domodedovo in visual daylight conditions descended below its cleared altitude and reached 395 feet agl whilst still 7nm from the landing runway threshold with a resultant EGPWS ‘PULL UP’ warning. Recovery was followed by an inadequately prepared second approach which was discontinued and then a third approach to a landing. The Investigation attributed the crew’s difficulties primarily to failure to follow various routine operating procedures relating to use of automation but noted that there had been scope for better presentation of some of these procedures.

On 6 November 2017, an Embraer E190 cleared for a normal visibility night takeoff at Nice began it on a parallel taxiway without ATC awareness until it had exceeded 80 knots when ATC noticed and a rejected takeoff was instructed and accomplished without any consequences. The Investigation found that although both pilots were familiar with Nice, their position monitoring relative to taxi clearance was inadequate and both had demonstrated a crucial lack of awareness of the colour difference between taxiway and runway lighting. Use of non-standard communications phraseology by both controllers and flight crew was also found to be contributory.

On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.

On 29 December 2011 a Golden Air ATR 72 making a daylight approach to runway 22R at Helsinki and cleared to land observed a Saab 340 entering the runway and initiated a low go around shortly before ATC, who had observed the incursion, issued a go around instruction. The Investigation attributed the breach of clearance by the Latvian-operated Saab 340 primarily to poor CRM, a poor standard of R/T and inadequate English Language proficiency despite valid certification of the latter.

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.

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.