Ryanair B738 at Alicante on Jan 6th 2011, landed without clearance
Last Update: March 11, 2013 / 12:32:48 GMT/Zulu time
Incident Facts
Date of incident
Jan 6, 2011
Classification
Incident
Airline
Ryanair
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
The incident was caused by the crewÂ’s failure to request landing clearance, believing subconsciously they already had this clearance, and by the deficient supervision and monitoring by the ATC stations involved (Valencia TACC and ALC TWR), which became aware of the aircraftÂ’s landing only after the fact.
The CIAIAC reported that the captain (47, ATPL, 14,335 hours total, 6,326 hours on type) was pilot monitoring, the first officer (22, CPL, 2,300 hours total, 2,050 hours on type) was pilot flying. The aircraft had been cleared for a VOR Z approach to runway 28 and had been cleared for the approach and to report established. The aircraft subsequently landed safely on runway 28 without establishing contact with the tower. Contact was established after the crew called on the approach frequency after landing and was instructed to switch to tower frequency. The tower protocol such noticed: "RYR54WP lands without clearance despite being called on 118.15 and the emergency frequency 121.5. Pilot admits mistake".
Neither cockpit voice nor flight data recorders were preserved and could not be used for the investigation, the quick access data recorder was available but provided no useful data.
The Alicante Approach Controller provided testimony that he had instructed the aircraft to report when established. A few minutes later he detected that he had not removed the flight strip from his active flights and called tower to ask whether the aircraft had reported, tower replied the aircraft was already on the ground.
The tower controller said, he attempted to call the aircraft on his frequency and the guard frequency, however received no response. There was no attempt made to call the aircraft on the approach frequency.
The crew provided testimony they didn't recall to have been transferred to tower, and if they had been they did not acknowledge the transfer, hence ATC would have needed to take additional steps. Only after landing they recognized they were still on the approach frequency and switched to tower. They were under the impression that they had been cleared to land, there was no other communication around as they were the last aircraft to land that day. At that point they also realised, the second receiver was still tuned to the ATIS frequency rather than the guard frequency as per company policy and the volume turned down due to permanent chatter on the guard frequency.
The CIAIAC analysed that the approach controller coordinated the hand off with tower, after receiving the okay to hand the aircraft off to tower 8nm out, the controller however did not relay the frequency to the crew, probably awaiting the crew's report "fully established".
According to internal ATC procedures tower should have called approach if the aircraft did not report on his frequency before 5nm out, however, such a call did not happen.
Weather conditions were clear, the runway was visible way out, the crew had been cleared directly to 8nm out and descend on pilot's discretion, they were cleared for the approach and may subconsciously believed that they were cleared to land. Only after landing the crew noticed the landing lights were not turned on, and subsequently discovered they were still on approach frequency and on ATIS. Turning the landing lights on is the last point of the landing checklist which should be executed after receiving landing clearance indicative of the landing checklist not having been processed.
The report contains a contradiction between factual representation and analysis: while the report states in the factual portion (tower interview) at 1.6.3: "The aircraft did not acknowledge contacting the tower on 118.15 MHz. The aircraft was called on that frequency and on the emergency 121.5 MHz band, but no reply was received." with no other factual representation as e.g. citing tower tapes that such calls could not be heard, the last paragraph of the analysis states: "Since the TWR had not attempted to contact the aircraft prior to the landing either on the tower or on the emergency frequency, and since the flight progress strip had been generated at 21:08 and the TWR controller was aware of this aircraftÂ’s imminent arrival, it follows that the TWR controller was also unaware that the aircraft had landed without clearance, which confirms that he had a mistaken impression of the actual conditions present in and around the airport, a situation that could have posed a risk to operations."
A number of safety recommendations were released as result of the investigation including to Ryanair to prevent reducing volume of the second radio on guard frequency and to enhance the landing checklist to specifically require a landing clearance to be obtained, to AENA to revise procedures to ensure transfer of aircraft as well as supervision and monitoring of aircraft.
Incident Facts
Date of incident
Jan 6, 2011
Classification
Incident
Airline
Ryanair
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
This article is published under license from Avherald.com. © of text by Avherald.com.
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