Taban MD88 at Karaj on Nov 16th 2018, went around from very low height at wrong airport
Last Update: January 18, 2019 / 14:44:03 GMT/Zulu time
Iran's CAO have opened an investigation into the occurrence rated a serious incident. The CAO added that there had been three GPWS alerts (without providing further details). The first officer's CPL had expired on Nov 3rd 2018.
Karaj Airport, also known as Payam International Airport, is located about 23.8nm west of Tehran Mehrabad, Fath airport about 5.5nm short of Karaj's runway 30 threshold. Karaj's runway 30 is 12,000 feet/3,660 meters long, Fath Airport's runway 31L is 1000 meters/3300 feet long.
On Jan 17th 209 Iran's CAO released their final report in Persian only (Editorial Notes: 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 causes of the serious incident were:
The main factor for the incident is considered human error as detailed below. Flight captain as the PIC has the higher share of the errors:
- Nonadherence to company standard operating procedures by performing a visual approach in low visibility
- Ignoring a company directive by performing a visual approach to Payam airport
- Failure to use navigation instruments to properly identify the destination airport
- Hasty attempt to land in order to avoid delays on the return flight
- F/O’s unfamiliarity with Payam airport and its surroundings
The flight was uneventful until after the aircraft had established on final approach course while performing a VOR/DME approach to Payam Airport's runway 30 having been cleared down to 6200 feet MSL earlier and having been cleared for the approach. At 07:54:20Z the crew reported they had the runway in sight and were handed off to Payam Tower. The crew reported on Payam Tower at 07:55Z, was cleared to land on runway 30, winds were reported from 160 degrees at 5 knots, the aircraft was 7nm before the threshold of Payam's runway 30 at that point. A minute later the crew called "Going Around" three times, at 07:56:23Z the radar showed the aircraft at 4nm before the threshold of runway 30 at 4100 feet MSL (Fath airport elevation 3999 feet MSL). The aircraft entered downwind to reposition for another approach, received landing clearance again at 07:58Z, but again went around at 07:59z. The crew advised they intended to proceed to short final, received vectors and was cleared to land again at 08:01z. This time the aircraft landed safely on runway 30 of Payam Aerodrome, turned around to backtrack the runway to the apron and vacated the runway via taxiway B.
The captain (63, ATPL, no experience data provided) was pilot monitoring, the first officer (38, CPL, 2400 hours total, 2000 hours on type), whose CPL license had expired 13 days earlier, was pilot flying. She had undergone training in the European Union, her last proficiency test had been conducted on Jun 12th 2018 and was valid until Dec 12th 2018.
The CAO reported that the occurrence had not been reported to them. Consequently both CVR and FDR data of the occurrence flight were lost, however, it was possible to retrieve the QAR data of the flight which indicated:
- At 13 NM from Payam, the aircraft was at 8,000 FT, speed 168 KT, heading 286, landing gears down and flaps were at 27 degrees.
- At 8 NM from Payam, altitude was 6,300 FT, speed 153 KT, heading 308 and flaps at 37 degrees.
- At 7.5 NM from Payam, altitude was 6,300 FT, speed 153 KT heading 311 and the pilot disengaged autopilot and auto throttle.
- At 7 NM from Payam (2.5 NM from Fath) the aircraft descended with a high vertical rate, reaching 1,528 AGL (5,340 AMSL). At this time, the EGPWS produces several Glide Slope warnings due to the unusual and out of place descent.
- The system then issues Terrain warnings throughout the descent from 4,640 to 4,100 AMSL
- During the first Go Around, the aircraft reaches a bank angle of 46.4 degrees left.
- During the next turn to final, the aircraft reaches a bank angle of 51.6 degrees.
- In both cases, Bank Angle warnings were issued.
- In total, there were 13 instances of ‘Glide Slope’ and ‘Terrain’ warnings during the incident
(Editorial note: There are several Glideslope warnings mentioned, the word Glideslope was actually written in English in the otherwise Persian report hence this is no misinterpretation. The report does not explain however, why the glideslope warnings occurred and whether an ILS had been tuned. Payam Airport, although not publishing an ILS or LOC approach, features a LOC and Glideslope transmitter for runway 30 according to the aerodrome chart published by AIP Iran)
The CAO reported that the captain in post flight interviews reported the VOR indication had fluctuations. However, the fluctuations were not written up in the tech log, no other aircraft landing at Payam prior or past the occurrence aircraft reported such difficulities, hence the fluctuations could not be verified.
The CAO analysed that the captain had been to Payam Airport 5 times already, the first officer however had not been to the aerodrome yet and had not been briefed about the aerodrome and its surrounding terrain. According to company procedures the captain was required to fly the aircraft on that route, however, there was no limit imposed on the first officer to fly the route. Yet, handing controls to the first officer and permitting her to land at Payam on her first flight into the aerodrome posed a great and unnecessary risk.
Payam does not feature ATIS, weather information is provided upon first contact with approach control. The captain such took note of the weather information received: "OIIP INFO B TIME 0730 Z 120/06kt 4000 BR SCT035 OVC 090 07/04 QNH1022". However, such information was not available in the airport's systems as well as Iran's Met Organisation. The valid METAR had been issued at 07:00Z.
Visibility for the approach to Payam was above the required minima, the approach was therefore permitted. About 8nm before touchdown the aircraft descended below clouds. The CAO continued to analyse:
At 8 NM from the airport, the flight descended below the cloud layers, and the pilot, while ignoring DME indication, felt close to the airport and visually searched for the runway. Given the limited visibility, the pilot visually acquired Fath airport runway 31L before having Payam in sight and mistook it for Payam runway 30, hence requested a visual approach. Taban Air SOP require that for a visual approach, the minimum visibility must be at least 5km meaning that a visual approach was not permitted in this case. Also a company directive (no. 180) had previously disallowed visual approaches at Payam altogether. The crew’s decision to perform a visual approach despite company policies and without checking the navigation instruments exhibits poor CRM.
Payam information unit approved the landing, unable to see the aircraft due to low visibility. The pilot then decided to disengage the autopilot due to high altitude and started a sharp descent toward the runway which resulted in the EGPWS warnings. Eventually, failing to descend to proper altitude in time, the crew initiated a Go Around and informed the tower, requesting left downwind. Since the flight was IFR, the crew should have followed the published missed approach procedure instead of a visual maneuver to left downwind. Also Payam Information unit shouldn’t have allowed the visual maneuver without having the aircraft in sight and without coordination with Mehrabad radar.
The flight positioned on final runway 31L again and prepared to land when the captain, who had flown to Payam before, realized the mistake and initiated a second Go Around. QAR data show that the aircraft descended to 3 FT (1m) before climbing again. The flight climbed on the same heading until Payam was in sight and continued to a safe landing on runway 30.
The ATS unit at Payam didn’t inform Mehrabad radar about the two go arounds and since it had no information about attempted landings at Fath (due to low visibility), the incident was not reported to CAO.
With respect to the first officer's CPL the CAO analysed:
The first officer had finished her pilot training courses in EU and upon returning to Iran, was employed by Taban Air. She had more than 2400 hours logged, including 2000 hours on MD. When new Air Crew regulation was put in action by CAO, the validity of her type rating was extended until 03/11/2018. According to article ARA.FCL.215(a) the validity of the rating should have been extended until the end of November which did not happen in this case. Later, rating validity extensions were delegated to airline instructors who also failed to check if the rating validity was properly extended. The extension was signed by the instructor while the field for the new expiration date was left empty.
With respect to Payam Aerodrome the CAO analysed:
It is located in G airspace and the ATS unit provides AFIS only. The airport was recently authorized to accept passenger flights. Flights are handled according to a local agreement between Payam and Mehrabad ATS units. According to the agreement, any missed approaches must be reported to Mehrabad approach radar, which did not happen in this case.
Nevertheless, the radar controller noticed the unusual approach and investigated via telephone.
OIIP 160900Z 15006KT 2500 DZ BR SCT020 SCT035 OVC080 07/05 Q1022=
OIIP 160800Z 16006KT 2500 BR SCT020 SCT035 OVC080 07/05 Q1022=
OIIP 160700Z 14008KT 2000 RA BR SCT020 SCT035 OVC080 06/05 Q1022=
OIIP 160600Z 15010KT 1500 BR SCT020 SCT035 OVC080 06/05 Q1022=
OIIP 160500Z 16004KT 2500 DZ BR SCT020 SCT035 OVC080 06/05 Q1021=
This article is published under license from Avherald.com. © of text by Avherald.com.
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