Final Term Assignment of

Aircraft Accident Investigation-2

Course instructor:

W/C Imran Ahmad Khan

Course:

BS Aviation Management
Semester 8th

Submitted by:

Muhammad Arslan Aslam

BAM -9234

Topic
As student of Aviation Management, Discuss following and prove your logic by giving suitable examples.

A non Compatibility of Runway/Apron/Airway/any Aerodrome facility with aircraft performance and capability leads to accident.

A non Compatibility of Runway/Apron/Airway/any Aerodrome facility with aircraft performance and capability lead to an accident.

O doubt that compatibility of Runway/Apron or any other facility of an aerodrome requires to conduct safe and efficient air traffic operations. There is hell of aircraft around the world; of different kind, used for different purposes like commercial (both passenger and cargo airplanes), military, having different characteristics in size, power, design and instrumentation. These require standard aerodrome facilities and procedures to operate keeping in between the circle of safety, for instance, Airbus A380 may be land at Allama Iqbal International Airport (AIIAP) Lahore but may not be able to taxi on taxiways because they may have lower PCN (Pavement Classification Number) according to aircraft or taxiways may not be wide enough to be able it to taxi. It means that some of aerodrome facilities at AIIAP are not compatible for the operation of A380.Another example is that an airplane approaching an aerodrome to land at runway and it provides NDB approach procedure only to land and aircraft have not ADF (Automatic Direction Finder) that shows direction and align the aircraft with the runway centre line, in this case aircraft is not compatible for NDB approach procedure of that specified aerodrome. The compatibility of aerodrome facilities depends upon the adequate surface condition, serviceable facility, proper and standardized markings and sign boards, FOD (Foreign Object Damage) on runway or on apron, Lighting system, NOTAMs issued, Runway length, Pavement, Navigational Aids available at an aerodrome and their calibration and the most important air traffic services availed by the traffic. Following mentioned air accidents are evident in which the compatibility of aerodrome facilities does not match with aircraft capability and performance.

Aerodrome Facility/Runway
In Linate airport disaster, aerodromes movement area was not compatible to continue operations especially in low visibility because functioning ground radar system was not fully installed even it was handed over to the airport authority some years ago and taxiways sign boards didnt meet regulations. Runway Incursion was made due to lacking of aerodrome facilities in low visibility condition.

Linate Airport Disaster

The Linate Airport disaster occurred on 8 October 2001 at Linate Airport in Milan, Italy, when Scandinavian Airlines Flight 686, a McDonnell Douglas MD-87 airliner carrying 110 people bound for Copenhagen, Denmark, collided on take-off with a Cessna, business jet carrying four people bound for Paris, France. All 114 people on board the two aircraft were killed, as were four on the ground. A further four people on the ground were injured The accident occurred in thick fog, with visibility reduced to less than 200 meters (656 ft).The Cessna Citation was instructed to taxi from the western apron along the northern taxiway (taxiway R5), and

then via the northern apron to the main taxiway which runs parallel to the main runway, a route that would have kept it clear of the main runway. Instead, the pilot taxied along the southern taxi route

(taxiway R6), crossing the main runway toward the main taxiway which lay beyond it.

Causes
The accident was investigated by the Agenzia Nazionale per la Sicurezza del Volo (ANSV). Its final report was published on 20 January 2004, and concluded that the "immediate cause" of the accident was the incursion of the Cessna aircraft on to the active runway. However, the ANSV stopped short of placing the blame unequivocally on the Cessna pilots, its report having identified a number of deficiencies in the airport layout and procedures. Linate Airport was operating without a functioning ground radar system at the time, despite having had a system delivered some years beforehand, which had not been fully installed. The new system finally came online a few months later. Guidance signs along the taxiways were later found not to meet regulations; after mistakenly turning onto the R6 taxiway that led to the runway, there were no signs by which the Cessna pilots could recognize where they were. When they stopped at a taxiway stop-marking and correctly reported its identifier (S4), the ground controller disregarded this identification because it was not on his maps and was unknown to him. Furthermore, neither pilot of the Cessna was certified for landings with visibility less than 550 meters (1,804 ft), but had landed at the airport anyway a few minutes before the disaster. On 16 April 2004, a Milan court found four persons guilty for the disaster. Airport director Vincenzo Fusco and air-traffic controller Paolo Zacchetti were both sentenced to eight years in prison; sentences of six and a half years were given to Sandro Gualano, former head of the air traffic controllers' agency, and Francesco Federico, former head of the airport.

Aerodrome Facility (Runway; out of service centre line lighting system and poor communication by ATCO)
In the following mentioned disaster, air traffic control services and runway were not compatible for the operation in low visibility because air traffic controllers were listening football match on radio at tower and clear instructions were not given to air crew due to noise of match and runway centerline lights were out of service in lower visibility.

Tenerife airport disaster

The Tenerife airport disaster occurred on Sunday, March 27, 1977, when two Boeing passenger aircraft collided on the runway of Los Rodeos Airport (now known as Tenerife North Airport) on the Spanish island of Tenerife, one of the Canary Islands. With a total of 583 fatalities, the crash is the deadliest accident in aviation history.

Causes
The investigation concluded that the fundamental cause of the accident was that Captain Van Zanten took off without takeoff clearance. The investigators suggested the reason for his mistake might have been a desire to leave as soon as possible in order to comply with KLM's duty-time regulations, and

before the weather deteriorated further. The sudden fog greatly limited visibility. The control tower and the crews of both planes were unable to see one another. Another finding was the simultaneous radio transmissions, with the result that neither message could be heard. Factors were considered contributing but not critical: Use of ambiguous non-standard phrases by the KLM co-pilot ("We're at take off") and the Tenerife control tower ("OK").The Pan Am aircraft had not exited the runway at C-3.The airport was (due to rerouting from the bomb threat) forced to accommodate a great number of large aircraft, resulting in disruption of the normal use of taxiways. The Pan Am crew was highly irritated due to extra delay, they were about to leave the runway by C-4 but it was told the crew to leave the runway via C-3.The controller had work load and was on duty the whole day. A football match was listened on radio at tower.

Latent (Hidden) Conditions

Here were some latent conditions available that led to the accident: Bomb Blasts at Las Palmas Airport There was a bomb blast at Las Palmas Gran Canaria Airport so due to the warning of second bomb, airport was closed and all traffic was diverted to Tenerife North Los Rodeos International Airport. Diversion to Tenerife Airport Diversion of a number of flights to the Tenerife North Los Rodeos International Airport was a contributing factor in the development of a distressful environment. Airport saturation It was small airport and it was saturated with too many flights even the aircraft are parked on taxiways. Transmission of Football match on radio, at tower Radio transmission of foot ball was at tower and when controller communicated, a shrill noise was listened in the cock pit of both Flights RWY centre line lighting out of service Crew of both KLM and Pan Am was informed about unserviceable of runway centerline lights.

Aerodrome Facility (Unserviceable straight taxiway centerline lights (some dim lights), Taxiways centerline marking removed and runway threshold and closure marking removed)
In this accident, Boeing 747 of Singapore airlines aligned with the wrong runway and took off and collided with concrete barriers and crashed, it was due to unavailable taxiway centerline marking and taxiway centre line lighting operated in low visibility at night were inactive towards correct runway 05L; one of them was dim at the distance of 25m and other was not illuminated. Another contributing factor is that runway there was no threshold marking and closed 05R runway markings there. The other markings and sign boards were not according to the standard pattern. The PIC followed curved lights to the 1st runway that was closed due to construction and did not switch on PVD (Para Visual Display), it was his mistake. The taxiway

markings, lights and close runway marking and threshold marking were not supportable to the operation of air traffic. (Non compatible)

Taipei International Airport Disaster

Singapore Airlines Flight 006 (SQ006) was a scheduled passenger flight from Singapore to Los Angeles International Airport via Chiang Kai-shek Airport (now Taiwan Taoyuan International Airport) in Taiwan. On 31 October 2000, at 15:17 UTC, 23:17 Taipei local time, a Boeing 747-412, on the route attempted to take off from the wrong runway in Taipei during a typhoon, destroying the aircraft and killing 83 of the 179 occupants.

Causes
Singaporean officials protested that the report did not present a full account of the incident and was incomplete, as responsibility for the accident appeared to have been placed mainly on the flight crew of SQ006, while other equally valid contributing factors had been played down. The team from Singapore that participated in the investigation felt that the lighting and signage at the airport did not measure up to international standards. Some critical lights were missing or not working. No barriers or markings were put up at the start of the closed runway, which would have alerted the flight crew that they were on the wrong runway. The Singapore team felt that these two factors were given less weight than was proper, as another flight crew had almost made the same mistake of using runway 05R to take off days before the accident. Singapore Airlines also issued a statement after the release of the ASC report. In their statement, Singapore Airlines reiterated the points brought up by the Singapore investigators and added that air traffic control (ATC) did not follow their own procedure when they gave clearance for SQ006 to take off despite ATC's not being able to see the aircraft. Singapore Airlines also clarified that the para visual display (PVD) was meant to help the flight crew maintain the runway centerline in poor visibility, rather than to identify the runway in use.

Incident on Apron (due to not spatial separation between taxiway and parking area and defaulted stop markings for road traffic)
In this incident, separation between taxiway and parking gate is not compatible and stop markings for ground traffic are also not suitable according to daily operations at Frankfurt airport Germany.

Collision of stationary bus with Airbus A340-300 engine no. 4 (Frankfurt Germany, 2008)
On 21 August 2008, an Airbus A340-300 being operated by an undisclosed operator by a German-licensed flight crew on a scheduled passenger flight from Teheran to Frankfurt collided with a stationary bus with only the driver on board whilst approaching the allocated parking gate in normal daylight visibility. The No 4 engine impacted the bus roof as

shown in the photograph reproduced from the official report. None of the occupants of either the aircraft or the bus were injured.

Cause
An investigation was carried out by the German BFU. It was found that neither the aircraft nor the passenger bus had any technical deficiencies and that the AGNIS (Azimuth Guidance for Nose-In Stand) and the associated stop device PAPA (Parallax Parking Aid) for the assigned gate, B26, was not operating at the time of the collision and that a marshaller was allocated to attend. The diagram below, taken from the official report, shows the relative positions of the aircraft and the bus at the collision and their previous tracks. It was noted that there was no airport procedure specifying the limit of aircraft movement when arriving at gate B26 and finding the AGNIS/PAPA deactivated and no marshaller in position at the head of the stand, whereas this circumstance would require an aircraft to wait off the gate. The Investigation concluded that the immediate cause of the collision was an insufficient distance between the passenger bus and the taxiway of the Airbus A340 and that the three systemic causes were as follows:

The spatial separation between the taxi area road and the taxiway G towards parking position B26 was insufficient. Coming from the east, the position of the first stop line marking on the taxi area road did not allow for an unrestricted view of the parking position B26. The vehicle drivers coming from the east had to decide during the drive on the taxi area road whether to stop at the first or second stop line marking. They also had to take into consideration whether an aircraft was taxiing to parking position B26 or to the A-B area.

Incident on Airway (Volcanic Ash encountered)

In this incident, New KLM B747 was compatible with the route and unfortunately the route was not compatible for flying purpose at that time(otherwise it was compatible) and if some one did want to fly then he had to divert from route or airway for some period.

KLM Flight 867

On 15 December 1989, KLM Flight 867 en route to Narita International Airport, Tokyo from Amsterdam was descending into Anchorage International Airport, Alaska when all four engines failed. The Boeing 747-400, less than 6 months old, flew through a thick cloud of volcanic ash from Mount Redoubt, which had erupted the day before. All four engines failed leaving only critical systems on backup electrical

power. One report assigns the engine shutdown to the turning of the ash into a glass coating inside the engines that fooled the engine temperature sensors and led to an auto-shutdown of all four engines. After descending more than 14,000 feet, Captain Karl van der Elst and crew were finally able to restart the engines and safely land the plane. In this case the ash caused more than US$80 million in damage to the aircraft (requiring all four engines to be replaced), but no lives were lost and no one was injured. Another example of non compatibility of route is of British Airways Flight 9, sometimes referred to by its call sign Speed bird 9 or Jakarta incident, was a scheduled British Airways flight from London Heathrow to Auckland, with stops in Bombay, Madras, Kuala Lumpur, Perth, and Melbourne. On 24 June 1982, the route was flown by the City of Edinburgh, a 747-236B. The aircraft flew into a cloud of volcanic ash thrown up by the eruption of Mount Galunggung (approximately 180 kilometers (110 mi) south-east of Jakarta, Indonesia).

Compatibility of Aerodrome facility or any other facility or service is much important in aviation because safety is its first priority. Compatibility means operations are held smoothly, safely and efficiently and according to the requirements and fulfillment of aircraft performance and capabilities. Airways are made after evaluation and judgment of all aspects like, geographical location or natural phenomena occurred at there in between but some airways still have some threats to be faced like, volcanic ash at a certain height or an airway where less separation have to be maintained.

Recommendations
1. The airport management or airport personnel should adopt proactive approach to identify the hazards and it is responsibility of every person belonging inside the airports airside area, to keep in attention of operational personnel about the existing hazard like if a FOD is found at the apron near parking area and marshaller/ any other person should notify the hazard to airport authority. 2. All aerodrome facilities like signs, lighting system, ground radar system etc. should be advanced and new version and should be changed according to the rules and regulations, requirement and fulfillment of the operation at the aerodrome. 3. Any threat existing on the airway should be notified to the air crew and it is responsibility of the crew to plan an immediate diversion from its route when it is necessary to change course due to hazard. 4. The Civil Aviation Authority of any country or any other responsible authority should do calibration of all navigational facilities and aids after an adequate period of time.