Atlas B748 at Hong Kong on Sep 24th 2017, immediate wrong turn after takeoff

Last Update: September 17, 2021 / 16:28:30 GMT/Zulu time

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Incident Facts

Date of incident
Sep 24, 2017

Classification
Incident

Airline
Atlas Air

Departure
Hong Kong, China

Destination
Anchorage, United States

Aircraft Registration
N856GT

Aircraft Type
Boeing 747-8

ICAO Type Designator
B748

An Atlas Air Boeing 747-800 freighter on behalf of Cathay Pacific, registration N856GT performing freight flight CX-86 from Hong Kong (China) to Anchorage,AK (USA), was in the initial climb out of Hong Kong's runway 07R around 23:45L (15:45Z) being handed off from tower to departure when the crew initiated a premature right hand turn towards Lantau Island climbing over terrain rising up to 1500 feet MSL below safe altitude. The aircraft subsequently turned onto a heading parallel to the runway already past the island, then joined the departure route again and continued to Anchorage for a landing without further incident.

Residents on Lantau Island reported, just before midnight they were shaken out of bed by a low flying aircraft, that came very close to hit the mountains near the Discovery Bay Tunnel (DB tunnel) connecting the north and south of Lantau Island.

On Oct 23rd 2017 Hong Kong's Civil Aviation Department (CAD) released a preliminary report but removed it from their website on Oct 24th 2017 again. According to the news letter released by the Hong Kong government the preliminary report 4/2017 released by the CAD confirmed the aircraft missed the top of high ground Lo Fu Tau by 670 feet. The occurrence was rated a serious incident, the investigation is ongoing.

According to the (now removed) bulletin the aircraft veered right off the track shortly after takeoff and headed directly towards Lo Fu Tau, about one minute after the aircraft veered right ATC warned the crew instructing them to turn left back on track and increase climb to 5000 feet, the EGPWS activated when the aircraft was climbing through 2000 feet, the crew turned left and overflew the top of Lo Fu Tau (elevation 1525 feet MSL) 670 feet above at 2195 feet MSL. 3 minutes after the premature turn the aircraft rejoined the intended flight path and continued to Anchorage.

On Oct 25th 2017 the preliminary report was released again.

The aircraft had been cleared for the RASSE 1E RNAV Standard Instrument Departure (SID), the captain (ATPL, 31,970 hours total (!!), 1,100 hours on type) was pilot flying, a first officer was assisting as pilot monitoring, another first officer was in the observer's seat.

The CAD wrote:

At time 1544 hours, shortly after the aircraft took off from Runway 07R, the aircraft deviated to the right of the published SID track and headed towards the high ground at Lo Fu Tau of the Lantau Island. At time 1545 hours, the ATC informed the flight crew that the aircraft was off track and instructed the crew to turn left to resume the RASSE 1E SID. Shortly afterwards, the ATC informed the flight crew of terrain to the right of the aircraft and instructed the crew to expedite the climb to 5,000 feet.

At approximately 2,000 feet, the Enhanced Ground Proximity Warning System (EGPWS) on board the aircraft was triggered with Mode 2A visual and aural warning “Terrain, Terrain; Pull Up” annunciated. In response, the PF reacted and the aircraft turned left away from the high ground. The aircraft evaded the high ground by approximately 670 feet. Subsequently, the aircraft re-established the SID track at approximately time 1546 hours and continued without further incident. There was neither injury to personnel nor damage to the aircraft involved and no other air traffic was affected.

On Sep 17th 2021 Hong Kong's AAIA released their final report concluding the probable cause of the serious incident was:

Modification of the RF SID RASSE 1E while programming the SID into the FMC by overwritten waypoint PORPA, making PORSH the first active waypoint.

Contributing Factors

- CRM – assignment of the FOs’ duties and lack of communication amongst
the crew.

- The crew accepted the RF SID RASSE 1E with which they were not
familiar.

- The SID course and the first active waypoint were not verified.

The AAIA analysed:

The flight crew were based in Anchorage and two of them had flown together previously. The junior FO was inexperienced operating into HKIA.

Operating from an unfamiliar airport at night time would inevitably put additional pressure on the junior FO. The PIC would have been aware of this as he expected the senior FO to be the PM and the junior FO, acting as RFO, to watch the operation out of Hong Kong. It is very likely that the PIC had planned for the respective roles of the senior FO and the junior FO with regard to their experience for the flight. However, the respective flying duties of the senior FO and the junior FO were neither discussed nor assigned explicitly by the PIC among the three in the first place.

Without having been assigned by the PIC, the senior FO and the junior FO assumed their duties as RFO and PM, respectively when they entered the cockpit. At this juncture, as there had been no communication initiated to discuss the arrangement, the PIC, the PM and the RFO could have perceived that it was mutually accepted even though it would have been contrary to the PIC’s original planning. This arrangement would have been
contrary to the PIC’s original planning.

Anticipated SID

Before push-back as part of his pre-flight duties, the PIC had already loaded the company filed flight plan, the anticipated Runway 07R and RASSE 3A SID in the FMS. Also, he gave a preliminary departure briefing to the PM. The PM then did an independent route verification including the RASSE 3A SID. At that stage, the crew were mentally prepared for the RASSE 3A SID that they were anticipating.

Issue of the RADIUS-TO-FIX (RF) RASSE 1E SID Clearance

The flight was operated under a wet lease by CPA with flight number CPA86. As per the Operational Instruction 39/15, ATC assigned the RADIUS-TO-FIX (RF) RASSE 1E SID in accordance with the standing agreement with CPA.

Acceptance of the RASSE 1E SID Clearance

For the departure preparation, the crew of CPA86 followed paragraph 3.1.1 – START-UP PROCEDURES of the Jeppesen Airport Briefing Page stating that approved aircraft planning to fly the Radius-to-Fix SID shall make request when obtaining ATC clearance, using recommended phraseology – “Request Radius-to-Fix SID”. No request was made by the crew of CPA86 as they did not plan to fly the RF SID in the first place.

As Atlas Air was not a local airline and as Operational Instruction 39/15 was an arrangement between local airlines and ATC, the crew of CPA86 would not have known the reason they were given a RF SID clearance without making an initial request to ATC and accepted it.

Time Pressure

Once an ATC clearance has been received, unless there is a specific time restriction included in the clearance, any delay in being ready to push-back, start engines or taxi may result in the clearance being cancelled. Being new to the Hong Kong operational environment and concerned being able to push-back on time, the PM felt pressured but did not communicate this to the PIC.

Technical Misunderstanding

The crew was not familiar with the RF RASSE 1E SID and it was the first time that the crew received this clearance. Having been given the RASSE 1E SID that was unanticipated, unfamiliar and compounded with time pressure, the crew accepted the clearance. After discussion amongst the crew and possibly due to the perceived time constraint, it was eventually decided that waypoint PORPA was not part of the SID. The SID was thus manually modified, making waypoint PORSH as the first active waypoint after takeoff. By doing so, the SID course magenta line would have veered to the right.

Situational Awareness

It is critical that the loaded flight plan and SID be cross-checked to ensure that discrepancies between the flight plan and the ATC route clearance do not exist. The CDU should be used to cross check the route entry and the ND should be used for illustration during the cross-check and reference made to the approved chart to ensure the SID entered is as published.

During the Before Takeoff checklist and Takeoff/Departure Review there were no questions raised by the crew as they taxied for departure. Both NDs remained in the AMM display mode, that shows only an illustration of the airport diagram, between the time the SID was amended and just prior to takeoff. Not having selected the MAP display mode that shows the SID course during this period would preclude the crew from cross-checking, thus noticing and analysing the veering of the SID course magenta line to the right.

Had the RASSE 1E SID not been amended and a cross-check been done with either ND selected on the Map display mode, the crew would have seen the illustration of RASSE 1E SID (see Figure 7). As the crew amended the SID with both NDs on the AMM display mode, they would not have seen the illustration of the un-amended RASSE 1E SID in the first place. When the NDs were eventually selected to the MAP display mode at the very last moment just prior to takeoff, the right veering of the SID course would appear to be less conspicuous as the crew had not looked at the depiction of the un-amended RASSE 1E SID, with which they could compare to notice the difference. It was also not noticed that the display indicated that the first active waypoint PORSH was not on the runway heading.

It was not a requirement of the operator’s SOP to have the TERRAIN page superimposed on the MAP display mode in the Before Takeoff checklist and Takeoff/Departure Review. It is very likely that the crew before takeoff would not have been aware of the amended RASSE 1E SID course that turns right towards waypoint PORSH would cross the terrain to the south of the airport after airborne.

As a result, the flight departed on Runway 07R and once airborne the aircraft commanded a right turn toward the first waypoint PORSH. The crew were then alerted by both ATC and EGPWS warnings.
Incident Facts

Date of incident
Sep 24, 2017

Classification
Incident

Airline
Atlas Air

Departure
Hong Kong, China

Destination
Anchorage, United States

Aircraft Registration
N856GT

Aircraft Type
Boeing 747-8

ICAO Type Designator
B748

This article is published under license from Avherald.com. © of text by Avherald.com.
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