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Procedures in Context

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Capt Ed Pooley's presentation to the 2019 Safety Forum included reference to a number of safety events held on SKYbrary:


  • B773, Dubai UAE, 2016 : On 3 August 2016 the crew of a Boeing 777-300 rejected a landing at Dubai after a touchdown beyond the TDZ was followed by an automated 'LONG LANDING' Advisory Callout. Four seconds later, the aircraft became airborne again but with the thrust at Idle, it reached approximately 85 feet above the runway before sinking back onto it and impacting rear fuselage first at 900 fpm. The right engine-pylon assembly detached and an intense fuel-fed fire started as the aircraft came to a stop and it was quickly destroyed by impact and fire. All 300 occupants escaped, 23 with minor injuries.
  • B733, vicinity Kosrae Micronesia, 2015: On 12 June 2015, a Boeing 737-300 crew forgot to set QNH before commencing a night non-precision approach to Kosrae which was then flown using an over-reading altimeter. EGPWS Alerts occurred due to this mis-setting but were initially assessed as false. The third of these occurred when the eventual go-around was initially misflown and descent to within 200 feet of the sea occurred before climbing. The Investigation noted failure to action the approach checklist, the absence of ATC support and the step-down profile promulgated for the NDB/DME procedure flown as well as the potential effect of fatigue on the Captain.
  • B738, Belfast International UK, 2017: On 21 July 2017, a Boeing 737-800 taking off from Belfast was only airborne near the runway end of the runway and then only climbed at a very shallow angle until additional thrust was eventually added. The Investigation found that the thrust set had been based on an incorrectly input surface temperature of -52°C, the expected top of climb temperature, instead of the actual surface temperature. Although inadequate acceleration had been detected before V1, the crew did not intervene. It was noted that neither the installed FMC software nor the EFBs in use were conducive to detection of the data input error.
  • A333, Kathmandu Nepal, 2015: On 4 March 2015, the crew of a Turkish Airlines A333 continued an automatic non precision RNAV approach below the prescribed minimum descent altitude without having obtained any element of visual reference and when this was acquired a few seconds before the attempted landing, the aircraft was not aligned with the runway centreline and during a 2.7g low-pitch landing, the left main gear touched down on the grass. The aircraft then left the runway completely before stopping with a collapsed nose gear and sufficient damage to be assessed a hull loss. None of 235 occupants sustained serious injury.
  • A343, vicinity Paris CDG France, 2012: On 13 March 2012, an A340-300 crew cleared for a Cat 3 ILS approach at Paris CDG with LVP in force failed to descend at a rate which would allow the aircraft to capture the ILS GS and at 2nm from the runway, when still 2500 feet above runway height, the ILS GS mode engaged on a false upper lobe of about 10° and as a result of the consequent rapid pitch up and speed reduction, aircraft control was almost lost. After a period of further confusion, a go around was initiated and the subsequent approach was uneventful.
  • B738, vicinity Christchurch New Zealand, 2011: On 29 October 2011, a Boeing 737-800 on approach to Christchurch during the 68 year-old aircraft commander's annual route check as 'Pilot Flying' continued significantly below the applicable ILS minima without any intervention by the other pilots present before the approach lights became visible and an uneventful touchdown occurred. The Investigation concluded that the commander had compromised the safety of the flight but found no evidence to suggest that age was a factor in his performance. A Safety Recommendation was made to the Regulator concerning the importance of effective management of pilot check flights.
  • A320, Hiroshima Japan, 2015: On 14 April 2015, a night RNAV(GNSS) approach to Hiroshima by an Airbus A320 was continued below minima without the prescribed visual reference and subsequently touched down 325 metres before the runway after failing to transition to a go around initiated from a very low height. The aircraft hit a permitted ground installation, then slid onto the runway before veering off it and stopping. The aircraft sustained extensive damage and an emergency evacuation followed with 28 of the 81 occupants sustaining minor injuries. The Investigation noted the unchallenged gross violation of minima by the Captain.
  • A320, Tehran Mehrabad Iran, 2016: On 13 August 2016, an Airbus A320 departed the side of the runway at low speed during takeoff from Tehran Mehrabad and became immobilised in soft ground. The Investigation found that the Captain had not ensured that both engines were simultaneously stabilised before completing the setting of takeoff thrust and that his subsequent response to the resulting directional control difficulties had been inappropriate and decision to reject the takeoff too late to prevent the excursion. Poor CRM on the flight deck was identified as including but not limited to the First Officer’s early call to reject the takeoff being ignored.
  • B738, vicinity Amsterdam Netherlands, 2009: On 25 February 2009, the crew of a Turkish Airlines Boeing 737-800 lost control of their aircraft on final approach at Amsterdam after they had failed to notice that insufficient thrust was being used to keep the aircraft on the coupled ILS glideslope. An attempt to recover from the resultant stall was not successful and the aircraft crashed. The Investigation concluded that a go around should have been flown from 1000 feet as the approach was already unstable and that the attempt at recovery after the stall warning was not in accordance with the applicable procedure or crew training.
  • 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.
  • A320, Halifax NS Canada, 2015: On 29 March 2015, an Airbus A320 crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.
  • B738, Sint Maarten Eastern Caribbean, 2017: On 7 March 2017, a Boeing 737-800 crew making a daylight non-precision approach at Sint Maarten continued it without having established the required visual reference to continue beyond the missed approach point and then only realised that they had visually ‘identified’ a building as the runway when visibility ahead suddenly improved. At this point the approach ground track was corrected but the premature descent which had inadvertently been allowed to occur was not noticed and only after the second of two EGPWS Alerts was a go-around initiated at 40 feet above the sea.
  • B738, Rome Ciampino Italy, 2008: On 10 November 2008, a Boeing 737-800 about to land at Rome Ciampino Airport flew through a large and dense flock of starlings, which appeared from below the aircraft. After the crew had made an unsuccessful attempt to go around, they lost control due to malfunction of both engines when full thrust was applied and a very hard impact half way along the runway caused substantial damage to the aircraft. The Investigation concluded that the Captain’s decision to attempt a go around after the encounter was inappropriate and that bird risk management measures at the airport had been inadequate.
  • B738, en-route, west of Canberra Australia, 2017: On 13 March 2017, the crew of a Boeing 737-800 responded to an increase in indicated airspeed towards Vmo after changing the FMS mode during a high speed descent in a way that more abruptly disconnected the autopilot than they were anticipating which resulted in significant injuries to two of the cabin crew. The Investigation found that the operator’s customary crew response to an overspeed risk at the airline concerned was undocumented in either airline or aircraft manufacturer procedures and had not been considered when an autopilot modification had been designed and implemented.

  ATC/Airport Events

  • A333, Montréal QC Canada, 2014: On 7 October 2014, an Airbus A330-300 failed to maintain the runway centreline as it touched down at Montréal in suddenly reduced forward visibility and part of the left main gear departed the runway edge, paralleling it briefly before returning to it and regaining the centreline as the landing roll was completed. The Investigation attributed the excursion to a delay in corrective action when a sudden change in wind velocity occurred at the same time as degraded visual reference. It was found that the runway should not have been in use in such poor visibility without serviceable lighting.
  • 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.
  • B773 / B738 / B738, Melbourne Australia, 2015: On 5 July 2015, as a Boeing 777-300ER was departing Melbourne, two Boeing 737-800s which were initially on short final for intersecting runways with their ground separation dependent on one receiving a LAHSO clearance, went around. When both approaching aircraft did so, there was a loss of safe terrain clearance, safe separation and wake vortex separation between the three aircraft. The Investigation attributed the event to the actions of an inadequately supervised trainee controller and inappropriate intervention by a supervisory controller. It also identified a systemic safety issue generated by permitting LAHSO at night and a further flaw affecting the risk of all LAHSO at Melbourne.
  • 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.


  • 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.

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