Wings AT72 at Sintang on Jun 19th 2018, landed at wrong airport
Last Update: December 16, 2021 / 19:26:51 GMT/Zulu time
Incident Facts
Date of incident
Jun 19, 2018
Classification
Incident
Airline
Wings Air
Flight number
IW-1370
Departure
Pontianak, Indonesia
Destination
Sintang Tebelian, Indonesia
Aircraft Registration
PK-WHF
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
Susilo Airport had been in use until April 26th 2018. On April 26th 2018 00:00Z (07:00L) the new Tebelian Airport (runway 09/27 length 1660 meters) replaced Susilo Airport (runway 08/26 length 1300 meters) maintaining the airport ICAO and IATA identifiers of Susilo Airport, Susilo Airport was shut down.
Indonesia's NTSC reported the aircraft departed Pontianak with the intended destination Sintang Tebelian but landed at Sintang Susilo Airport, which had been closed and operations of which had been moved to Tebelian. The occurrence was rated a serious incident and is being investigated.
On Aug 6th 2018 the NTSC released their preliminary report stating with respect to the airports and their transition:
Sintang District on West Kalimantan formerly had Susilo Airport located on the middle of the town. Susilo Airport had been closed for operation since 26 April 2018. The airport operation moved to new airport of Tebelian Airport which located on the South of town. The un-serviceability white cross mark on runway of Susilo Airport has not been completed at that time of occurrence.
The NTSC stated in the synopsis:
On 19 June 2018, an ATR 72-212 aircraft was being operated by Wings Abadi Airlines (Wings Air) on a scheduled passenger flight from Supadio International Airport, Pontianak (WIOO) with intended destination of Tebelian Airport (WIOS), Sintang. The flight was inadvertently landed at Susilo Airport which had been closed for operation.
Prior to departure, the pilot received the flight documents from the Flight Operation Officer (FOO) (editorial note: which contained the charts for Susilo Airport, see below) and no briefing related to the closing of Susilo Airport and moved to Tebelian Airport.
The information available on the aircraft library and website (aimindonesia) contained information of Susilo Airport which had been closed for operation since 26 April 2018. The information related to Tebelian Airport was available on the link of AIP Supplement on the website.
The pilot reviewed the Notice to Airman (NOTAM) related to Sintang Aerodrome and noted some changes airport data of such as elevation, threshold runway elevation and Non-Directional Beacon (NDB) identification and frequency. The pilot compared the changes of the Sintang Aerodrome information with the information contained on the Airport Visual Guidance (AVG) provided by the aircraft operator which published on 2 March 2018 and effective since 9 March 2018.
At 0149 UTC, the aircraft landed on runway 08 of Susilo Airport. Prior to land, the pilot could not recall that they saw the white cross mark on the runway which indicates the runway was closed or unserviceable.
The NTSC reported that following discovery that the aircraft had landed at Susilo rather than Tebelian personnel was dispatched to Susilo to check the runway and ensure safety for the departure of the aircraft. Following a runway inspection and established safety at the runway ends the aircraft departed Susilo and positioned to Tebelian arriving at Tebelian with a delay of about one hour.
Two safety recommendations with respect to keep documentation up to date have been issued to the airline, 3 further safety recommendations to the Directorate General of Civil Aviation with respect to ensure markings of airports being completed before release of amendment of aerodrome certification as well as ensuring that only current information is provided in the AIP publications and overdue information is being removed.
In December 2021 the KNKT released their final report concluding the probable causes of the serious incident were:
- Reassignment of the location indicator WIOS, NDB and AFIS VHF Frequency in conjunction with incomplete departure briefing, unaware to the content of AIP Supplement number 07/18, and out of date information in the file management system made the pilots unaware of the Susilo Airport had been closed for operation and the establishment of the new airport.
- The unfinished crossed white mark and the appearance of all normal runway markings made the pilot continued to land in the Susilo Airport.
The KNKT analysed:
Pilot Awareness of the New Airport
The PIC had been flown several times in the West Kalimantan area and the last flight to Sintang was three months before the occurrence flight when the Susilo Airport was still operating. While for the SIC, the occurrence flight was the first flight to West Kalimantan area, including to Sintang. The occurrence flight was the first flight for both pilots to fly to the Tebelian Airport. Both pilots did not aware the detail content of the AIP Supplement number 07/18 which provided information of the establishment of new airport in Sintang named Tebelian Airport that replaced the Susilo Aiport.
The FOO recalled that the PIC had been flown in the West Kalimantan area several times and assumed that the PIC had been aware that the airport operation in Sintang had been moved from Susilo Airport to the Tebelian Airport. Therefore, the closed of Susilo Airport and new establishment of Tebelian Airport was not included in the FOO briefing.
The Airport Visual Guidance (AVG) in the aircraft document library for aircraft operated in West Kalimantan area had been updated on May, while PK-WHF was operating in Surabaya. Therefore, the aircraft document library of PK-WHF including the AVG had not been updated. The Airport Visual Guidance (AVG) for WIOS airport in the aircraft document library and in the web-based file management system were contained information for Susilo Airport.
During flight preparation, the pilots discussed of information available on the NOTAM. The pilots noticed different information of runway designation number previously were 08/26 which changed to 09/27 and airport name in the NOTAM compared to the AVG. The pilots also found some similarity of the information between NOTAM and AVG including the airport location indicator, AFIS radio frequency, and NDB identification and frequency. The pilots assumed that the differences were to correct the typography and to update the data, and did not expect that the new airport had been established.
Prior the departure, the pilots noticed that the WIOS airport on the aircraft navigation display was on the south or right side of the flight profile that was created refer to AVG. The experience of inaccurate airport coordinate and un-updated airport data on the AIP made the pilots decided to follow the AVG.
During approach, the pilot contacted the ACO by using call sign of Susilo Info in the Susilo Info radio frequency. The pilot contact was replied by Tebelian Info at the same radio frequency, thereafter the pilot changed to call the ACO using call sign of Tebelian Info. The pilots assumed that the call sign changed was part of the airport data changes as the communication was made using the same radio frequency that was used by Susilo ACO.
In addition, the same location indicator of WIOS and NDB identification code and frequency also made the pilots sure that the Susilo Airport was still operating and did not suspect that new airport has been established.
The unaware of the detail content of AIP Supplement number 07/18, absence briefing of the closing Susilo Airport and un-updated AVG have made the establishment of new airport was not known by the pilots.
Some differences in the NOTAM compared to AVG while other information did not change including the airport location indicator made the pilot did not aware that Susilo Airport had been closed for operation.
Awareness of the Closed Runway
After the pilot reported the runway had in sight, the ACO advised to the pilot that the runway was clear. The ACO did not aware of the aircraft position as the ATS provided in Sintang airspace was flight information service which did not provide clearance and did not require for the ACO to have visual contact with the aircraft.
The ACO did not aware that the aircraft approached to runway in Susilo Airport until after the aircraft landed, therefore the ACO was unable to advise the pilot.
According to the MOS Part 139 Volume I, a runway which is permanently closed shall be marked by cross on each end of the runway and all normal runway markings shall be obliterated.
The pilots recalled that the runway had normal markings and did not recall seeing white cross mark on the runway threshold. During the occurrence flight, crossed white mark had been painted over the runway designated number but had not been completed and all normal markings were still visible except the runway designated number.
The incomplete crossed white mark and the appearance of all normal runway markings made the pilot did not aware that the runway had been closed for operation.
Standard of Closing an Airport
The Susilo Airport had been closed permanently on 26 April 2018 or about two months prior to the occurrence flight. The normal markings were still visible and the cross marks on the runway end had not been finished.
The Tebelian Airport was operating immediately after the Susilo Airport was closed.
Tebelian Airport used the same location indicator of WIOS, NDB identification and AFIS VHF radio frequency that were used for Susilo Airport.
The location indicator that was assigned for Susilo of WIOS was re-assigned for Tebelian, this was not in accordance with ICAO recommended practice. Reassigning location indicator might make the pilot did not aware of establishment of new airport,particularly when the airports are in the same city. The DGCA has not established regulation to accommodate the ICAO recommended practice regarding the location indicator reassignment.
The DGCA has not established system or procedure related to closing of an airport to ensure a closed airport has met the requirement standard. The markings requirement for the closing of Susilo Airport was not oversighted by the DGCA and made the Susilo Airport was closed without proper runway closing markings.
Distribution of Aeronautical Information
The information for the closing of Susilo Airport contained in the AIP supplement number 07/18 which was published on 1 March 2018. This AIP supplement can be accessed online from on the AIP Supplement webpage of AIM Indonesia. On the day of the occurrence flight, the airport information of Sintang on the webpage of AIP Volume IV contained information of the Susilo Airport while the information of the Tebelian Airport was available on the AIP Supplement webpage of the AIP.
The supplement webpage accommodated the revision of the AIP. The revision normally contains of updating information of an airport. The contents of the supplement webpage was sorted by issued date while the AIP Volume IV contents was sorted by the airport name in alphabetical order.
There was no information on the AIP for the user to refer to the supplement webpage. This made the user of the AIP would look directly to the AIP webpage that contain the airport information and overlook the information available on the supplement webpage.
The separation of the webpage for new information in the AIP supplement webpage and keeping the out of date information in the AIP webpage resulted in overlook of the new information.
Following the AIP revision, the Wings Air Flight Standard department has updated the AVG for WIOS airport with the Tebelian Airport information. Until the occurrence flight, the information of operation of Tebelian Airport and closing of Susilo Airport had not been updated on the web-based file management system.
On 16 May 2018, the navigation database in the aircraft FMS was updated, including the information of Tebelian Airport.
On 30 to 31 May 2018, personnel of Flight Standard Department updated the document library at Pontianak, as ATR base operation in West Kalimantan. PKWHF aircraft library had not been updated as the aircraft was operating in Surabaya area.
On 18 June 2018 which was two days prior the occurrence, the PK-WHF aircraft operation moved to West Kalimantan area. The monitoring system of Wings Air was unable to detect the current publication on the aircraft library of PK-WHF during the positioning from Surabaya to West Kalimantan resulted in missing of information of the Tebelian Airport.
In addition, the monitoring system of Wings Air was also unable to update the current publication in the web-based file management system in timely manner. The web-based file management system contained old airport information that has been closed for two months.
The updated AVG had not been uploaded in the Wings Air file management system and aircraft document library had make the pilot utilized the out of date information.
Incident Facts
Date of incident
Jun 19, 2018
Classification
Incident
Airline
Wings Air
Flight number
IW-1370
Departure
Pontianak, Indonesia
Destination
Sintang Tebelian, Indonesia
Aircraft Registration
PK-WHF
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
This article is published under license from Avherald.com. © of text by Avherald.com.
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