torsdag 30. mai 2019

Norwegian i alvorlig hendelse i fjor - AAI rapport

Date:13-AUG-2018
Time:09:48 UTC
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8JP (WL)
Owner/operator:Norwegian Air International
Registration:EI-FJW
C/n / msn:42286/6088
Fatalities:Fatalities: 0 / Occupants: 166
Other fatalities:0
Aircraft damage:None
Category:Serious incident
Location:Edinburgh Airport (EDI) -    United Kingdom
Phase:Landing
Nature:International Scheduled Passenger
Departure airport:Stewart International Airport, NY (SWF)
Destination airport:Edinburgh Airport (EDI)
Investigating agency: AAIB
Narrative:
Norwegian Air International flight D8 1601 and easyJet flight U2 14 were involved in a runway incursion incident at Edinburgh Airport, U.K. 
Norwegian 1601 was a Boeing 737-800 (EI-FJW) from Stewart International Airport, NY, USA and easyJet flight 12 was an Airbus A320-214 (OE-IVC) bound for London-Luton Airport. 
At 09:36 hrs, EI-FJW’s pilot monitoring contacted Edinburgh Radar and was instructed to expect an ILS approach to runway 06. The radar controller gave the crew a series of vectors to position them for their approach before clearing them to complete the ILS procedure. He instructed them to maintain at least 160 KIAS until they reached 4 nm from touchdown. At 09:44, the crew were instructed to contact Edinburgh Tower. At this point the aircraft was 8.8 nm from touchdown. 
At 09:36, OE-IVC began its pushback from the parking stand and started engines. The commander, who was to be pilot monitoring for the flight to Luton, called for taxi and was given clearance to taxi down taxiway A to hold at A1 for runway 06. 
At 09:45:55, with EI-FJW at 6 nm from touchdown, the trainee controller cleared OE-IVC to line up on runway 06. The trainee controller initially did not extinguish the Stop Bar. 
At 09:46:00, another aircraft called ready for departure and the trainee controller was occupied with talking to them for nine seconds. Immediately after this, the commander of OE-IVC transmitted “stop bar” on the frequency to remind the trainee controller that it was still illuminated. The trainee controller extinguished the Stop Bar and, with this delay, OE-IVC did not move from the holding point until 09:46:29. 
At 09:47:01, with EI-FJW at 3 nm from touchdown, the trainee controller cleared OE-IVC for takeoff although the aircraft was not yet aligned with the runway ready to depart. The trainee controller also instructed the crew of EI-FJW that they could expect a late landing clearance. 
At 09:47:41, OE-IVC began to accelerate on its takeoff roll with EI-FJW just over 0.5 nm from touchdown. When EI-FJW reached 0.5 nm from touchdown, the pilot monitoring called the tower to remind them that they were not yet cleared to land. Shortly after EI-FJW called at 0.5 nm, the ATC training instructor took over the tower frequency from the trainee controller. 
At 09:48:13, OE-IVC left the ground, at which point EI-FJW was in the landing flare and was given a landing clearance. EI-FJW touched down at 09:48:15. 
As EI-FJW was over the runway at the same time as OE-IVC was completing its takeoff roll. At the closest point of approach, the two aircraft were separated by approximately 875 m, with OE-IVC being at 60 ft aal when EI-FJW touched down. 

AAIB Conclusion 
A succession of short delays to the departure of OE-IVC and the higher than normal speed approach of EI-FJW led to the rapid closure of the gap between EI-FJW and OE-IVC. The loss of spacing went unnoticed by both the trainee controller and the OJTI until EI-FJW came out of cloud which was just before the crew prompted them by calling at 0.5 nm. At this point the OJTI made the decision that it was safer to land EI-FJW than risk having two aircraft that he could not separate visually close to each other in cloud above the airport. 
The crew of OE-IVC were completely unaware of the developing situation as they could not see EI-FJW nor had the trainee controller instructed them either to be ‘ready immediate’ or cleared them for an ‘immediate takeoff’. 
The crew of EI-FJW were confident in the EDI air traffic controllers and were not initially concerned that they had not received a landing clearance. They were used to operations at LGW where traffic levels are significantly greater than EDI. They became concerned enough to prompt the controller at 0.5 nm but the reply only served to reinforce their confidence that the controller was on top of the situation. As a result, they did not decide to perform a go-around and continued to land once clearance was given. This led to a loss of separation between the aircraft at a critical phase of flight. 

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