Avianca A318 near Cali on Mar 27th 2018, GPWS alert and Alpha Floor

Last Update: April 30, 2020 / 20:05:17 GMT/Zulu time

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Incident Facts

Date of incident
Mar 26, 2018

Classification
Incident

Airline
Avianca

Flight number
AV-9745

Destination
Cali, Colombia

Aircraft Registration
N596EL

Aircraft Type
Airbus A318

ICAO Type Designator
A318

An Avianca Airbus A318-100, registration N596EL performing flight AV-9745 from Bogota to Cali (Colombia) with 75 passengers and 6 crew, was descending towards Cali following the MANGA 8 standard arrival route, when the crew received a GPWS alert "TERRAIN! TERRAIN! PULL UP!" at 14,000 feet MSL and a radar height of 1500 feet. The crew initiated an evasive maneouver, ALPHA FLOOR activated. The aircraft subsequently continued the approach for a safe landing in Cali.

Colombia's AIP rated the occurrence a serious incident and opened an investigation.

In preliminary information Colombia's AIP reported the captain acting as instructor for the first officer was pilot monitoring, the first officer undergoing line training was pilot flying. About 40nm ahead of the Cali VOR the crew received a GPWS alert "Terrain! Pull up!" while at 13,980 feet MSL, while the minimum safe altitude was 17,000 feet MSL. The crew initiated an evasive maneouver and climbed to 20,640 feet MSL, then continued the approach to Cali's runway 02 without another incident.

The recordings of the radar facility at Cali shows, that a minimum safe altitude alert activated at the controller's desk when the aircraft descended below 17,000 feet about 50.6nm ahead of Cali VOR. However, there was no warning transmitted to the aircraft by the controller. Radar contact with the aircraft was subsequently temporarily lost. The controller also did not notice that the aircraft subsequently climbed to 20640 feet.

Colombia's GRIAA released their final report in Spanish 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 Spanish 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 causes of the serious incident were:

Loss of situational awareness by the crew when erroneously programming a descent altitude limit of the MANGA8 arrival procedure without noticing their error and thus descending below MSA into mountaineous terrain until the GPWS activated with "PULL UP, TERRAIN!" warning.

Lack of monitoring of the first officer (pilot flying) by the training captain (pilot monitoring). The first officer, due to his little experience and being under training, should have been under strict control and feedback (CRM).

Failure of cockpit communication, there was no feedback on the procedures of the flight demonstrating high levels of complacency towards the first officer, who was in his initial operations training.

Contributing factors were:

- Failure of radar surveillance by Cali Approach Control, who did not detect and therefore did not warn the aircraft N596EL about its descent below MSA and below the altitudes required in MANGA8 standard arrival route.

- Lack of general as well as team experience by the first officer who acted as pilot flying.

The GRIAA reported the captain (51, ATPL, 14,000 hours total) was pilot monitoring as well as training captain supervising the first officer. The first officer (22, CPL, 235 hours total) was pilot flying on line training under supervision.

The crew was assigned the MANGA8 standard arrival procedure while descending towards Cali. The aircraft was descending through about 13980 feet MSL about 40.5nm northeast of Cali VOR, between OREGA and MANGA8 waypoint, already below MSA of 17,000 feet when the GPWS activate issuing an alert. The crew immediately initiate an evasive maneouver climbing to 20640 feet, which exceeded their cleared altitude.

Cali Approach has a radar system which a visual and aural warning system to prevent terrain closures, however the system was down due to configuration problems.

Nonetheless a visual alert was created on the ATC desk when the aircraft descended below the MSA of airways R564, the controller however did not radio the aircraft. The evasive maneouver was also not reported by the crew.

The transponder signal including Mode C of the aircraft was lost at 38.5nm before Cali VOR, shortly before the aircraft descended through 14,000 feet MSL. The transponder signals were picked up again when the aircraft climbed through FL194.

The aircraft resumed the approach via MANGA8 approach procedure and landed on Cali's runway 02 without further incident.

The GRIAA analysed the first officer had accumulated 35 flight hours on the A318. He programmed 14,000 feet into the FMS for MANGA8 standard arrival route when the MSA was 17,000 feet. CRM was lacking as there was no feedback from the captain or any confirmation of the setting before executing the descent.

The air traffic controller had low workload, N596EL was the only aircraft under his control. The controller clearly failed to notice the visual warning on his desk and did not radio the crew of N596EL as result.

Both crew lost situational awareness. The first officer programmed the FMS to descend to 14,000 feet when the minimum safe altitue was 17,000 feet. The captain did not notice this situation until the GPWS activated, took control of the aircraft and performed a sharp climb ending at an unapproved altitude. There had been lack of assertive communication between the pilots resulting in the lack of verification of the FMS altitude after the FMS was porgrammed.

The reaction of the captain to the GPWS was correct and quick, thus managing according to the TEM (Threat Error Management) model resulting in a maneouver that prevented controlled flight into terrain.
Incident Facts

Date of incident
Mar 26, 2018

Classification
Incident

Airline
Avianca

Flight number
AV-9745

Destination
Cali, Colombia

Aircraft Registration
N596EL

Aircraft Type
Airbus A318

ICAO Type Designator
A318

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