Iran Aseman F100 at Shiraz on Aug 7th 2018, runway incursion

Last Update: December 13, 2018 / 18:10:36 GMT/Zulu time

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Incident Facts

Date of incident
Aug 7, 2018

Classification
Report

Cause
Runway incursion

Airline
Iran Aseman Airlines

Flight number
EP-3771

Departure
Tehran Mehrabad, Iran

Destination
Shiraz, Iran

Aircraft Registration
EP-ATC

Aircraft Type
Fokker 100

ICAO Type Designator
F100

An Iran Aseman Airlines Fokker 100, registration EP-ATC performing flight EP-3771 from Tehran Mehrabad to Shiraz (Iran), was on final approach to Shiraz's runway 29L being cleared to land, when tower instructed another aircraft, a Karun Airlines Fokker 100 registraton EP-SUS performing flight NV-2503 from Shiraz to Khark (Iran), to line up runway 29R and wait.

After EP-ATC touched down on runway 29L tower cleared EP-SUS already waiting in position for takeoff, EP-SUS began to accelerate for takeoff. Tower subsequently instructed EP-ATC to hold short of runway 29R at B4, which was correctly read back by the crew. Tower observed EP-ATC at high taxi speed nearing the hold short line at B4 and called the aircraft twice to stop, however, without response or reaction.

In the meantime the crew of the departing EP-SUS noticed the crossing aircraft, assessed they would rotate well ahead of the intersection, in addition the crossing aircraft would be off the runway again once they reached that intersection, and decided to continue takeoff. 19 seconds after EP-ATC crossed the runway EP-SUS became airborne.

Tower immediately complained to the crew of EP-ATC, this time the crew responded and apologized for a mistake in understanding the taxi clearance.

Iran's CAO released their final report in Persian 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; thanks a lot to a native Persian speaker who volunteered to help with the translation) concluding the probable cause of the serious incident was:

The EP-ATC flight crews' course of actions in not following the control tower's instruction and lack of crew resource management in the cockpit of that aircraft are identified as the main cause of the serious incident, though control tower and the departing aircraft crew's course of actions are also identified as contributing factors to this serious incident.

Iran's CAO using CCTV surveillance cameras as well as FDR data analysed EP-SUS became airborn on runway 29R about 25 seconds after commencing their takeoff roll and were already climbing out when overflying intersection B4, at that time EP-ATC had already crossed runway 29R.

The CAO reported the first officer of EP-ATC was communicating with tower on one radio, the other radio was tuned to a company frequency with a lot of active but unrelated transmissions ongoing, so that the captain could not clearly hear and could not follow the tower instructions.

The CAO analysed due to lack of cockpit resource management the captain also did not receive the instructions from the first officer or read them back, probably also because the airport were their home airport. The crew also had not received any runway incursion training.

The CAO analysed that the crew of EP-SUS noticed the crossing aircraft well below V1 but assessed they had sufficient distance left and being sure the crossing aircraft would already have left when they reached that point, they continued the takeoff and also did not report or complain to ATC.

Tower did not notify the departing aircraft of the runway incursion although required to do so. In addition tower did not issue a stop instruction to the departing aircraft with the consideration of causing a possible tail strike or runway excursion.
Incident Facts

Date of incident
Aug 7, 2018

Classification
Report

Cause
Runway incursion

Airline
Iran Aseman Airlines

Flight number
EP-3771

Departure
Tehran Mehrabad, Iran

Destination
Shiraz, Iran

Aircraft Registration
EP-ATC

Aircraft Type
Fokker 100

ICAO Type Designator
F100

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