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Accident and Serious Incident Reports: AGC

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Category: Air Ground Communication Air Ground Communication
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Definition

Reports relating to accidents and serious incidents which included Air-Ground Communication (AGC) as a causal factor.

Call Sign Confusion

  • B738/A319 en-route, south east of Zurich Switzerland, 2013 (On 12 April 2013, a Ryanair Boeing 737-800 took a climb clearance intended for another Ryanair aircraft on the same frequency. The aircraft for which the clearance was intended did not respond and the controller did not notice that the clearance readback had come from a different aircraft. Once the wrong aircraft began to climb, from FL360 to FL380, a TCAS RA to descend occurred due to traffic just transferred to a different frequency and at FL370. That traffic received a TCAS RA to climb. STCA was activated at the ATS Unit controlling both Ryanair aircraft.)
  • AT43/A346, Zurich Switzerland, 2010 (On 18 June 2010, an ATR 42 began a daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began take off from intersecting runway 16 with an ATC clearance. ATC were unaware of this until alerted to the situation by the crew of another aircraft which was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so prior to the runway intersection whilst the A340 continued departure on runway 16 .)
  • B738/B738, vicinity Oslo Norway, 2012 (On 31 October 2012, a Boeing 737-800 on go around after delaying the breaking off of a fast and high unstable ILS approach at Oslo lost separation in IMC against another aircraft of the same type and Operator which had just taken off from the same runway as the landing was intended to be made on. The situation was aggravated by both aircraft responding to a de-confliction turn given to the aircraft on go around. Minimum separation was 0.2nm horizontally when 500 feet apart vertically, both climbing. Standard missed approach and departure tracks were the same.)
  • A333 / A319, en-route, east of Lashio Myanmar, 2017 (On 3 May 2017, an Airbus A330 and an Airbus A319 lost prescribed separation whilst tracking in opposite directions on a radar-controlled ATS route in eastern Myanmar close to the Chinese border. The Investigation found that the response of the A330 crew to a call for another aircraft went undetected and they descended to the same level as the A319 with the lost separation only being mitigated by intervention from the neighbouring Chinese ACC which was able to give the A319 an avoiding action turn. At the time of the conflict, the A330 had disappeared from the controlling ACCs radar.)
  • B190 / B190, Auckland NZ, 2007 (On 1 August 2007, the crew of a Beech 1900 aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Beech 1900 that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.)

Loss of Communication

  • B733, en-route, northwest of Athens Greece, 2005 (On 14 August 2005, a Boeing 737-300 was released to service with the cabin pressurisation set to manual. This abnormal setting was not detected by the flight crew involved during standard checks. They took no corrective action after take-off when a cabin high altitude warning occurred. The crew lost consciousness as the aircraft climbed on autopilot and after eventual fuel exhaustion, the aircraft departed controlled flight and impacted terrain. The Investigation found that inadequate crew performance had occurred within a context of systemic organisational safety deficiencies at the Operator compounded by inadequate regulatory oversight.)
  • 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, 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.)
  • B738 / E135, en-route, Mato Grosso Brazil, 2006 (On 29 September 2006, a Boeing 737-800 level at FL370 collided with an opposite direction Embraer Legacy at the same level. Control of the 737 was lost and it crashed, killing all 154 occupants. The Legacy's crew kept control and successfully diverted to the nearest suitable airport. The Investigation found that ATC had not instructed the Legacy to descend to FL360 when the flight plan indicated this and soon afterwards, its crew had inadvertently switched off their transponder. After the consequent disappearance of altitude from all radar displays, ATC assumed but did not confirm the aircraft had descended.)
  • AT43, vicinity Oksibil Papua Indonesia, 2015 (On 26 August 2015, contact was lost with an ATR 42-300 making a descent to Oksibil supposedly using detailed Company-provided visual approach guidance over mountainous terrain. Its burnt out wreckage was subsequently located 10 nm from the airport at 4,300 feet aal. The Investigation found that the prescribed guidance had not been followed and that the Captain had been in the habit of disabling the EGPWS to prelude nuisance activations. It was concluded that a number of safety issues identified collectively indicated that the organisational oversight of the aircraft operator by the regulator was ineffective.)

Incorrect Readback Missed

  • 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.)
  • B742 / A320, Frankfurt Germany, 2006 (On 12 January 2006, an Air China Boeing 747-200 which had just landed at Frankfurt failed to correctly understand and read back its taxi in clearance and the incorrect readback was not detected by the controller. The 747 then crossed another runway at night and in normal visibility whilst an A320 was landing on it. The A320 responded by increased braking and there was consequently no actual risk of collision. The controller had not noticed the incursion and, in accordance with instructions, all stop bars were unlit and the RIMCAS had been officially disabled due to too many nuisance activations.)
  • B734, Sharjah UAE, 2015 (On 24 September 2015, a Boeing 737-400 cleared for a night take-off from Sharjah took off from the parallel taxiway. The controller decided that since the taxiway was sterile and the aircraft speed was unknown, the safest option was to allow the take-off to continue. The Investigation noted that the taxiway used had until a year previously been the runway, becoming a parallel taxiway only when a new runway had been opened alongside it. It was noted that the controller had "lost visual watch" on the aircraft and regained it only once the aircraft was already at speed.)
  • AT75 / B739, Medan Indonesia, 2017 (On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.)
  • A320 / 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.)

Phraseology

  • AT72 / B732, vicinity Queenstown New Zealand, 1999 (On 26 July 1999, an ATR 72-200 being operated by Mount Cook Airlines on a scheduled passenger flight from Christchurch to Queenstown entered the destination CTR without the required ATC clearance after earlier cancelling IFR and in marginal day VMC due to snow showers, separation was then lost against a Boeing 737-200 being operated IFR by Air New Zealand on a scheduled passenger flight from Auckland to Queenstown which was manoeuvring visually (circling) after making an offset VOR/DME approach in accordance with a valid ATC clearance.)
  • Vehicles / B722, Hamilton ON Canada, 2013 (On 19 March 2013 a Boeing 727 freighter was cleared to take off on a runway occupied by two snow clearance vehicles. The subsequent cancellation of the take off clearance was not received but a successful high speed rejected take off was accomplished on sight of the vehicles before their position was reached. The Investigation attributed the occurrence to the controller's failure to 'notice' the runway blocked indicator on his display and to his non-standard use of R/T communications. The late sighting of the vehicles by the aircraft crew was due to the elevated runway mid section.)
  • E190 / A320, Toronto ON Canada, 2016 (On 30 January 2016, an Embraer 190-100 crew lined up on their assigned departure runway in good visibility at night without clearance to do so just as an Airbus A320 was about to land on it. The Investigation attributed the incursion to crew error arising from misinterpretation by both pilots of a non-standard Ground Controller instruction to position alongside another aircraft also awaiting departure at the hold when routinely transferring them to Tower as an instruction to line up on the runway. The failure to use the available stop bar system as a basis for controller incursion alerting was identified.)
  • B77W, en-route, northeast of Los Angeles USA, 2016 (On 16 December 2016, a Boeing 777-300 which had just departed from runway 07R at Los Angeles was radar vectored in Class ‘B’ airspace at up to 1600 feet below the applicable minimum radar vectoring altitude. The Investigation found that the area controller’s initial vectoring had been contrary to applicable procedures and their communication confusing and that they had failed to recover the situation before it became dangerous. As a result, as the crew were responding in night IMC to a resulting EGPWS ‘PULL UP’ Warning, the aircraft had passed within approximately 0.3 nm of obstructions at the same altitude.)
  • B763 / B763, Kansai Japan, 2007 (On 20 October 2007, at night, a Boeing 767-300 operated by Air Canada was taxiing for Runway 24L at Kansai International Airport for take-off. Meanwhile, another Boeing 767-300, operated by Japan Airlines, had been given landing clearance and was on approach to the same runway. After an incorrect readback, the Air Canada B767 entered the runway to line up. As a consequence of the runway incursion, the B767 on approach executed a go-around on the instructions of air traffic control.)

Language Clarity

  • B742 / B741, Tenerife Canary Islands Spain, 1977 (On 27 March 1977, a KLM Boeing 747-200 began its low visibility take-off at Tenerife without requesting or receiving take-off clearance and a collision with a Boeing 747-100 backtracking the same runway subsequently occurred. Both aircraft were destroyed by the impact and consequential fire and 583 people died. The Investigation attributed the crash primarily to the actions and inactions of the KLM Captain, who was the Operator's Chief Flying Instructor. Safety Recommendations made emphasised the importance of standard phraseology in all normal radio communications and avoidance of the phrase "take-off" in ATC Departure Clearances.)
  • B763, en-route, Northern France, 1998 (On 9 January 1998, a Boeing 767-300 operated by United Airlines experienced an electrical systems malfunction subsequently attributed to arcing in a faulty electrical loom. The crew elected to divert to London Heathrow where emergency evacuation was carried out on a taxiway upon landing.)
  • GLEX/F2TH, vicinity Ibiza Spain, 2012 (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.)
  • B735, vicinity London Heathrow UK, 2007 (On 7 June 2007, a Boeing 737-500 operated by LOT Polish Airlines, after daylight takeoff from London Heathrow Airport lost most of the information displayed on Electronic Flight Instrument System (EFIS). The information in both Electronic Attitude Director Indicator (EADI) and Electronic Horizontal Situation Indicators (EHSI) disappeared because the flight crew inadvertently mismanaged the Flight Management System (FMS). Subsequently the crew had difficulties both in maintaining the aircraft control manually using the mechanical standby instruments and communicating adequately with ATC due to insufficient language proficiency. Although an emergency situation was not declared, the ATC realized the seriousness of the circumstances and provided discrete frequency and a safe return after 27 minutes of flight was achieved.)
  • AT75 / B739, Medan Indonesia, 2017 (On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.)

Multiple Language use on Frequency

  • C25A / Vehicle, Reykjavik Iceland, 2018 (On 11 January 2018, a privately-operated Cessna 525A Citation with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within “less than a metre” of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated. The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking. It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.)
  • 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.)
  • SH33 / MD83, Paris CDG France, 2000 (On the 25th of May, 2000 a UK-operated Shorts SD330 waiting for take-off at Paris CDG in normal visibility at night on a taxiway angled in the take-off direction due to its primary function as an exit for opposite direction landings was given a conditional line up clearance by a controller who had erroneously assumed without checking that it was at the runway threshold. After an aircraft which had just landed had passed, the SD330 began to line up unaware that an MD83 had just been cleared in French to take off from the full length and a collision occurred.)
  • GLEX/F2TH, vicinity Ibiza Spain, 2012 (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.)

CPDLC

Flight Crew Oxygen Mask Use

  • A320, en route, north of Marseilles France, 2013 (On 12 September 2013, pressurisation control failed in an A320 after a bleed air fault occurred following dispatch with one of the two pneumatic systems deactivated under MEL provisions. The Investigation found that the cause of the in-flight failure was addressed by an optional SB not yet incorporated. Also, relevant crew response SOPs lacking clarity and a delay in provision of a revised MEL procedure meant that use of the single system had not been optimal and after a necessary progressive descent to FL100 was delayed by inadequate ATC response, and ATC failure to respond to a PAN call required it to be upgraded to MAYDAY.)
  • E195, en-route, Irish Sea UK, 2008 (On 1 August 2008, an en-route Embraer 195 despatched with one air conditioning pack inoperative lost all air conditioning and pressurisation when the other pack’s Air Cycle Machine (ACM) failed, releasing smoke and fumes into the aircraft. A MAYDAY diversion was made to the Isle of Man without further event. The Investigation found that the ACM failed due to rotor seizure caused by turbine blade root fatigue, the same failure which had led the other air conditioning system to fail failure four days earlier. It was understood that a modified ACM turbine housing was being developed to address the problem.)

Take off without clearance

  • B463 / PA38 Birmingham UK, 1999 (On 28 April 1999, a BAe 146-300 departing Birmingham began its daylight take off from Runway 33 without ATC clearance just prior to the touchdown of a PA38 on the intersecting runway 06. Collision was very narrowly avoided after the Controller intervened and the BAe 146 rejected its take off, just missing the PA38 which had stopped just off the runway 33 centreline. The Investigation noted the 146 pilots belief that a take off clearance had been issued but also that no attempt appeared to have been made to read it back or confirm it with the First Officer.)
  • DH8B, Kangerlussuaq Greenland, 2017 (On 2 March 2017, a DHC8-200 took off from Kangerlussuaq in normal day visibility without clearance and almost immediately overflew three snow clearance vehicles on the runway. The Investigation identified a number of likely contributory factors including a one hour departure delay which the crew were keen to reduce in order to remain within their maximum allowable duty period and their inability to initially see the vehicles because of the runway down slope. No evidence of crew fatigue was found; it was noted that the vehicles involved had been in contact with TWR on a separate frequency using the local language.)
  • B190 / B190, Auckland NZ, 2007 (On 1 August 2007, the crew of a Beech 1900 aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Beech 1900 that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.)
  • B744 / MD90, New Chitose Japan, 2008 (On 16 February 2008, during daylight and in poor visibility, a Boeing 747-400, operated by Japan Airlines, was holding on a taxiway next to runway 01R of New Chitose Airport, Japan. A Douglas MD-90-30 operated by the same airline landed on the same runway and was still on the runway when the B747 was cleared to line up and wait. Shortly after lineup the B747 began its takeoff roll without receiving such clearance and subsequently was instructed to abort the takeoff. The crew of the B747 successfully rejected the takeoff.)
  • B742 / B741, Tenerife Canary Islands Spain, 1977 (On 27 March 1977, a KLM Boeing 747-200 began its low visibility take-off at Tenerife without requesting or receiving take-off clearance and a collision with a Boeing 747-100 backtracking the same runway subsequently occurred. Both aircraft were destroyed by the impact and consequential fire and 583 people died. The Investigation attributed the crash primarily to the actions and inactions of the KLM Captain, who was the Operator's Chief Flying Instructor. Safety Recommendations made emphasised the importance of standard phraseology in all normal radio communications and avoidance of the phrase "take-off" in ATC Departure Clearances.)
  • AS32 / B734, Aberdeen UK, 2000 (For reasons that were not established, a Super Puma helicopter being air tested and in the hover at about 30 feet agl near the active runway at Aberdeen assumed that the departure clearance given by GND was a take off clearance and moved into the hover over the opposite end of the runway at the same time as a Boeing 737 was taking off. The 737 saw the helicopter ahead and made a high speed rejected take off, stopping approximately 100 metres before reaching the position of the helicopter which had by then moved off the runway still hovering.)
  • E195 / A320, Brussels Belgium, 2016 (On 5 October 2016, an Embraer 195 took off at night without clearance as an Airbus A320 was about to touch down on an intersecting runway. The A320 responded promptly to the ATC go-around instruction and passed over the intersection after the E195 had accelerated through it during its take-off roll. The Investigation found that the E195 crew had correctly acknowledged a 'line up and wait' instruction but then commenced their take-off without stopping. Inadequate crew cross-checking procedures at the E195 operator and ATC use of intermediate runway access for intersecting runway take-offs were identified as contributory factors.)
  • C25A / Vehicle, Reykjavik Iceland, 2018 (On 11 January 2018, a privately-operated Cessna 525A Citation with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within “less than a metre” of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated. The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking. It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.)
  • B738, Eindhoven Netherlands, 2012 (On 11 October 2012, the crew of a Ryanair Boeing 737-800 did not change frequency to TWR when instructed to do so by GND whilst already backtracking the departure runway and then made a 180° turn and took off without clearance still on GND frequency. Whilst no actual loss of ground or airborne safety resulted, the Investigation found that when the Captain had queried the receipt of a take off clearance with the First Officer, he had received and accepted a hesitant confirmation. Crew non-compliance with related AIP ground manoeuvring restrictions replicated in their airport briefing was also noted.)

Landing without clearance

  • A319, vicinity Zurich Switzerland, 2014 (On 17 October 2014, two recently type-qualified Airbus A319 pilots responded in a disorganised way after a sudden malfunction soon after take-off from Zurich required one engine to be shutdown. The return to land was flown manually and visually at an excessive airspeed and rate of descent with idle thrust on the remaining engine all the way to a touchdown which occurred without a landing clearance. The Investigation concluded that the poor performance of the pilots had been founded on a lack of prior analysis of the situation, poor CRM and non-compliance with system management and operational requirements.)
  • A319, Mumbai India, 2013 (On 12 April 2013, an Airbus A319 landed without clearance on a runway temporarily closed for routine inspection after failing to check in with TWR following acceptance of the corresponding frequency change. Two vehicles on the runway saw the aircraft approaching on short final and successfully vacated. The Investigation concluded that the communication failure was attributable entirely to the Check Captain who was in command of the flight involved and was acting as 'Pilot Monitoring'. It was considered that the error was probably attributable to the effects of operating through the early hours during which human alertness is usually reduced.)
  • TBM8, Birmingham UK, 2011 (On 12 January 2011, a privately operated Socata TBM850 light aircraft on a flight from Antwerp to Birmingham lost radio contact with ATC whilst in IMC on a non precision approach to runway 15 prior to the issue of a landing clearance and prior to checking in on the ATC TWR frequency. It continued the approach to obtain the required visual reference before landing over the top of a DHC8-400 aircraft which had lined up ready for take off in accordance with ATC instructions. No damage or personal injury resulted from the close proximity.)

Military Formation Clearance

  • F15 / E145, en-route, Bedford UK, 2005 (On 27 January 2005, two USAF-operated McDonnell Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)
  • F15 / B752, en-route, South East of Birmingham UK, 2000 (On 22 November 2000, near Birmingham UK, a dangerous loss of vertical and lateral separation occurred between a Boeing B757-200 being operated by Britannia Airways on a passenger flight and a formation flight of two F-15Es being operated by the United States Air Force (USAF).)
  • EUFI / A321, en-route, near Clacton UK, 2008 (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)

Military/Civil Coordination

  • EUFI / A321, en-route, near Clacton UK, 2008 (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)
  • F15 / E145, en-route, Bedford UK, 2005 (On 27 January 2005, two USAF-operated McDonnell Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)

Provision of Aircraft Performance Data

ATC Clearance Cancelled

  • Vehicles / B722, Hamilton ON Canada, 2013 (On 19 March 2013 a Boeing 727 freighter was cleared to take off on a runway occupied by two snow clearance vehicles. The subsequent cancellation of the take off clearance was not received but a successful high speed rejected take off was accomplished on sight of the vehicles before their position was reached. The Investigation attributed the occurrence to the controller's failure to 'notice' the runway blocked indicator on his display and to his non-standard use of R/T communications. The late sighting of the vehicles by the aircraft crew was due to the elevated runway mid section.)
  • B738/B738, vicinity Queenstown New Zealand, 2010 (On 20 June 2010, a Boeing 737-800 being operated by New Zealand company Pacific Blue AL on a scheduled passenger flight from Auckland to Queenstown lost IFR separation assurance against a Boeing 737-800 being operated by Qantas on a scheduled passenger flight from Sydney to Queenstown whilst both aircraft were flying a go around following successive but different instrument approaches at their shared intended destination. There were no abrupt manoeuvres and none of the respectively 88 and 162 occupants of the two aircraft were injured.)
  • 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.)

Blocked Transmission

  • AT43/A346, Zurich Switzerland, 2010 (On 18 June 2010, an ATR 42 began a daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began take off from intersecting runway 16 with an ATC clearance. ATC were unaware of this until alerted to the situation by the crew of another aircraft which was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so prior to the runway intersection whilst the A340 continued departure on runway 16 .)
  • B738/B738, vicinity Oslo Norway, 2012 (On 31 October 2012, a Boeing 737-800 on go around after delaying the breaking off of a fast and high unstable ILS approach at Oslo lost separation in IMC against another aircraft of the same type and Operator which had just taken off from the same runway as the landing was intended to be made on. The situation was aggravated by both aircraft responding to a de-confliction turn given to the aircraft on go around. Minimum separation was 0.2nm horizontally when 500 feet apart vertically, both climbing. Standard missed approach and departure tracks were the same.)
  • SF34 / B190, Auckland NZ, 2007 (On 29 May 2007, a Saab 340 aircraft that was holding on an angled taxiway at Auckland International Airport was inadvertently cleared to line up in front of a landing Raytheon 1900D. The aerodrome controller transmitted an amended clearance, but the transmission crossed with that of the Saab crew reading back the line-up clearance. The pilots of both aircraft took action to avoid a collision and stopped on the runway without any damage or injury.)

Misunderstanding

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