onsdag 11. november 2020

Landing på feil runway - Alvorlig hendelse - Iran - Curt Lewis

 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 Following the flight the captain was asked for his license and presented wrong (outdated) papers, he had forgotten to take the correct papers with him (but was properly licensed).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.

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