Iran AT72 at Tabriz on Feb 10th 2020, landed on wrong runway
Last Update: February 25, 2020 / 22:09:52 GMT/Zulu time
Iran's AIB 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).
The report concludes the probable cause of the serious incident was:
The AIB reported there had been vehicles for snow removal on runway 30R, however, had been sent off the runway by ATC, so that no obstacles were on the runway when the ATR touched down on runway 30R unexpectedly. An accident was thus avoided.
The AIB analysed that based on ATIS information from Tabriz airport, which indicated better braking action (medium to good) for runway 30L. The crew had prepared for runway 30R and had FMS etc. set up for that approach. After requesting and receiving clearance for the ILS approach to runway 30L the crew changed the FMS setup, however, did not replace the ILS frequency.
While on final approach the crew noticed the PAPI lights. The PAPI lights for runway 30L are to the right of the runway and the PAPI lights for runway 30R to the left of the runway (in other words, both sets of PAPIs are between the runways, the distance between the runways is 190 meters only). The crew however assumed, the PAPI's for the left hand runway would be left and the PAPIs for the right hand runway at the right of the runway (not between the runways).
Due to the close proximity of the two runways with just 190 meters between them only one runway is active. The PAPIs for runway 30R were therefore off (tower had switched them off).
The crew thus saw the PAPI's for runway 30L, assumed the PAPI's were to the left of their runway and thus did not detect their error of following the ILS to runway 30R (with the wrong ILS frequency still tuned). The ident (morse code) of the ILS was not checked.
The AIB concluded analysis that there were several weaknesses while performing the flight in:
- Crew Resource Management
- Cockpit Management
- Task Sharing
- lack of ILS Ident SOP
- unfamiliar airport layout
- preflight briefing not performed well
- FMS handling
- ineffective company training for type conversion
The captain had 6,800 hours total having flown Airbusses most of the time, 1700 hours were on ATRs. The first officer had 650 hours total with 450 hours on type. The first officer had been pilot flying but handed control to the captain, then couldn't set the FMS. The captain helped with the FMS but forgot to retune the ILS frequency. Runway edge and approach lights were off. Due to low cloud ceiling the crew saw the runway very late and landed on the wrong runway.
The AIB released, amongst other safety recommendations, a recommendation that all lights of both runways should be operational in night and reduced visibility operations.
OITT 101800Z 06008KT 1800 -SN BR SCT010 OVC070 M09/M11 Q1016 A3001 NOSIG=
OITT 101730Z 05010KT 1600 -SN BR SCT010 OVC070 M09/M11 Q1016 A3001=
OITT 101700Z 05010KT 2000 -SN BR SCT010 OVC070 M09/M11 Q1016 A3001 NOSIG=
OITT 101630Z 06012KT 2000 -SN BR SCT010 OVC070 M08/M11 Q1015 A3000=
OITT 101600Z 06010KT 0800 R30/P2000 SN FG SCT010 OVC070 M08/M11 Q1015 A2998 NOSIG=
OITT 101530Z 07010KT 0800 R30/P2000 SN FG SCT010 OVC070 M08/M11 Q1014 A2995=
OITT 101500Z 07010KT 0600 R30/P2000 SN FG SCT010 OVC070 M08/M11 Q1014 A2995 NOSIG=
OITT 101430Z 05010KT 0900 R30/P2000 SN FG SCT010 OVC070 M08/M10 Q1014 A2995=
OITT 101400Z 05014KT 0900 R30/P2000 SN FG SCT010 OVC070 M08/M10 Q1014 A2995 NOSIG=
OITT 101330Z 06010KT 0900 R30/P2000 SN FG SCT010 OVC070 M07/M10 Q1013 A2994=
OITT 101300Z 06008KT 0900 R30/P2000 SN FG SCT010 OVC070 M07/M10 Q1013 A2994 NOSIG=
This article is published under license from Avherald.com. © of text by Avherald.com.
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