Zagros MD83 at Queshm on Dec 30th 2023, approached wrong airport

Last Update: April 15, 2024 / 17:31:30 GMT/Zulu time

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Incident Facts

Date of incident
Dec 30, 2023

Classification
Report

Airline
Zagros Airlines

Flight number
ZO-4035

Departure
Tehran Mehrabad, Iran

Destination
Queshm, Iran

Aircraft Registration
EP-ZAQ

Aircraft Type
McDonnell Douglas MD-83

ICAO Type Designator
MD83

A Zagros Airlines McDonnell Douglas MD-83, registration EP-ZAQ performing flight ZO-4035 from Tehran Mehrabad to Queshm (Iran) with 127 passengers and 9 crew, was on approach to Queshm's runway 05 but aimed for a local airstrip 5nm from Queshm's Internation Airport. After the controller queried the crew, the crew initiated a go around, then spotted the correct runway, joined a downwind and landed without further incident on the correct runway.

Iran's CAA released their final report concluding the probable causes of the incident were:

1) Lack of the knowledge of the pilots about existence strip in Qeshm Island,

2) Some pilots of the airline were aware about the strip but no operational warning was issued.

3) Choosing wrong intercepting heading to perform NDB plan turning to the final of RWY05,

4) Failure to use FMS facilities after leaving IAF position,

5) Fluctuation of ADF needle in RMI of the aircraft due to error in NDB aids to navigation in the shore line,

6) Inaccuracy and insufficient supervision of the pilots over the flight instrument,

7) Failure to comply with the standard procedures in accordance with OM-A/OM-B/FCOM (failure to use the automation system), and

8) Lack of CRM and proper communication between the pilot in command and the copilot in accordance with OM-A and OM-B regulations and failure using the Standard Callout, mentioned in the company’s regulations on “disagreement between pilot in command and copilot on recognizing the correct RWY”.

The final report described the sequence of events:

At 08:57 UTC, IZG 4035 in contact with Bandar Abbas Approach (APP) section reported turning final to Qeshm RWY and APP delivered flight to Qeshm Airport Flight information officer (AFISO) on Freq; 118.05.

At 8:58 UTC, pilot contacted with Qeshm AFISO and reported final position for RWY 05. AFISO asked “confirm you have runway insight” that pilot reported “not yet”. After some seconds the pilot reported “RWY insight” and received clearance for landing on RWY 05.

At 08:59 UTC, BND approach controller asked Qeshm AFISO about sawing the flight and AFISO told she reported RWY insight. The controller warned that the flight is going to south the airport and may planned to land on local strip. So, AFISO called the flight and pilot replied” Going around”. BND controller confirmed AFISO about its climbing and joining left downwind.

At the moment, the captain made error and considered a local strip, which was 5 miles away from the main RWY of Qeshm airport, as the intended RWY of Qeshm Airport for landing. Being advised by the first officer that the main RWY might be at the left side, the captain banked to left on heading 34 degree but since he could not see the main RWY of Qeshm airport, he made a banking to the right again to align for the final of the wrong strip. Then, he disconnected the auto pilot and continued to descend, while all the operations were being implemented without any advice to the first officer on DFGC change.

The pilot banked to the left and right for several times to align but finally, due to being un-stabilized, decided to go-around and climbed to 2000 feet above MSL while the landing gears were still extended. Afterwards, the captain asked for left downwind to land on the wrong strip, but by banking to the left, the pilots saw the main RWY of Qeshm airport. Since they were at the right hand downwind of the main RWY, they followed up the visual approach plan and finally landed on the main RWY of Qeshm airport at 09:06 UTC.

The report analysed:

The captain was pilot flying and copilot (PM) was pilot non flying. After passing overhead of Qeshm airport , the captain descended to FL160 with an approximate speed of 220 kts, then he extended landing gears and banked to the right for joining the final RWY 05 on heading 60 deg.

The flight in contact with Bandar Abbas Approach (APP) section reported turning final to Qeshm RWY and APP delivered flight to Qeshm Airport Flight information officer (AFISO). Then the pilot saw a strip and due to good vision on strip thought that the strip is intended RWY so, ignored to follow IFR principles and continue to land on strip with visual references to compensate flight delay. The copilot mentioned that in this time, I reported to the captain that this cannot be Qeshm RWY but the captain did not pay attention to his message. Due to short arc for joining strip final, aircraft had un-stabilized approach to a local strip then EGPWS warning “Terrain, Terrain” was generated on 700 feet from field elevation. EGPWS warning was generated due to operating at airport or runway not in the FMS database.

The captain referred to OM part A, and made go-around;

“An approach that becomes un-stabilized below 1,000 feet above airport elevation in below IMC or 500 feet in VMC requires an immediate go-around. Any time an approach is not stabilized at the minimum stabilized height or becomes un-stabilized below the minimum stabilized height, a go-around should be conducted “

At 08:59 UTC, BND approach controller that was seeing the flight on radar (AMD), asked Qeshm AFISO about the flight and AFISO told: pilot reported RWY insight. The controller warned that the flight is going to south the airport and may planned to land in local strip. So, AFISO called the flight and pilot replied” Going around”. BND controller confirmed AFISO about its climbing and joining left downwind. This communication was made after go-around of the flight.

The pilot made go-around and climbed to 2000 feet above MSL while the landing gears were still extended. Afterwards, the captain asked to join left downwind to attempt again for landing on the wrong strip, but due banking to the left, the copilot saw the main RWY of Qeshm airport and informed the captain. Since they were at the right hand downwind of the main RWY, they followed up the visual approach and finally landed on the main RWY of Qeshm airport at 09:06 UTC.