Report: Iran A319 at Tabriz on Oct 7th 2020, landed on wrong runway
An Iran Air Airbus A319-100, registration
EP-IEP performing flight IR-449 from Isfahan to Tabriz (Iran) with 97 passengers
and 9 crew, was on a VOR/DME 1 approach to Tabriz's runway 12L and was cleared
to land on runway 12L, however, touched down and rolled out on runway 12R. Tower
made the crew aware of landing on the wrong runway after roll out, the crew
apologized.
A similar occurrence had happened earlier
the year, see Incident: Iran AT72 at Tabriz on Feb 10th 2020, landed on wrong
runway.
Iran's CAO released their final report in
Person only (Editorial Note: To serve the purpose of global prevention of the
repeat of causes leading to an occurrence an additional timely release of all
occurrence reports in the only world spanning aviation language English would be
necessary, a Persian only release does not achieve this purpose as set by ICAO
annex 13 and just forces many aviators to waste much more time and effort each
in trying to understand the circumstances leading to the occurrence. Aviators
operating internationally are required to read/speak English besides their local
language, investigators need to be able to read/write/speak English to
communicate with their counterparts all around the globe).
The report concludes the probable cause of
the serious incident was:
Captain's Error.
Contributing was the first officer's error
and poor judgement with respect to organizatorical factors.
The CAO reported the captain was pilot
monitoring, the first officer pilot flying. The crew received clearance to land
on runway 12L. The crew focussed on another incoming Mahan flight while
conducting the approach, as result both crew forgot their landing clearance had
been issued for 12L. There was no communication between the two crew to verify
their landing clearance and the runway ahead. The crew realized only after
landing and the warning by tower, that they had landed on the wrong
runway.
The CAO analysed the flight was the crew's
third flight of the day. The captain had been called in out of stand by for
unscheduled duty after having had just 10 hours of rest, in violation of the
company's planning requirements. Following the flight the captain was asked for
his license and presented wrong (outdated) papers, he had forgotten to take the
correct papers with him (but was properly licensed).
The first flight of the day, Tehran to
Tabriz, flown by the captain, had been cleared to land on and landed on Tabriz's
runway 12R after requesting runway 12R. Usually Tabriz uses concrete runway
12L/30R for landings and asphalt runway 12R/30L for departures. On departure to
Isfahan the crew requested runway 12L for departure due to the aircraft weight
and departed from runway 12L. On the third flight, captain being pilot
monitoring, ATC used the default runway 12L for landing, the crew did not put in
a request for runway 12R. At the time the crew discussed another Mahan flight on
approach to Tabriz, Tabriz Approach indicated landing runway 12L to both
aircraft. Based on the mindset of the previous flights the crew approached
runway 12R but forgot to request the runway and forgot their landing clearance
had been for runway 12L.
The pilot flying did not pay sufficient
attention to the communication between pilot monitoring and ATC, the pilot
monitoring mistook the clearance to land on 12L as clearance to land on
12R.
Weather did not have any effect on the
incident.
Both pilots demonstrated weaknesses in
Cockpit Resource Management, Cockpit Management and Task Sharing and as result
lost Situational Awareness.
Ingen kommentarer:
Legg inn en kommentar
Merk: Bare medlemmer av denne bloggen kan legge inn en kommentar.