RAF-Avia SF34 at Helsinki on Dec 29th 2011, runway incursion

Last Update: April 2, 2013 / 16:24:20 GMT/Zulu time

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Incident Facts

Date of incident
Dec 29, 2011

Classification
Incident

Cause
Runway incursion

Airline
RAF-Avia

Aircraft Type
SAAB 340

ICAO Type Designator
SF34

Finland's Onnettomuustutkintakeskus (Aircraft Accident Investigation Board, AIBF) released their final report concluding the probable causes of the serious incident were:

The serious incident occurred because the flight crew of NEF025 misinterpreted the traffic information, crossed the illuminated stop bar and taxied onto the active runway 22R without an air traffic control clearance. Inadequate multi-crew cooperation on board NEF025 and subsidiary phraseology which the ATC used in addition to standard phraseology were contributing factors.

There were moderate rain showers at the time of the occurrence, visibility was 6000 meters/20,000 feet, temperature was +4 degrees C, dew point +3 degrees C.

The AIBF reported that the ATR had been on an ILS approach to runway 22R, when the crew detected the runway was occupied by another aircraft and initiated a go-around reaching their lowest point at 108 feet AGL.

The Saab 340 had been cleared by tower east, controlling runway 22L: "NEF025 via CL cross RWY15 taxi to Y hold short of RWY 22L" and received the read back: "Via Y to RWY 22L crossing approved NEF025". Before NEF-25 reached the hold short line runway 22L tower east cleared the aircraft to cross runway 22L, taxi to holding point WD and report on tower west, the crew did not read back the frequency change and consequently contacted Helsinki Radar instead of tower west. The tower west controller illuminated the stop bar lights at taxiway WD to make sure the Saab would not taxi onto runway 22R and broadcasted into the blind "NEF025 this is TWR one landing before you". A moment later the Saab reported on tower west, tower west advised: "NEF025 one landing". A short time later the controller noticed the Saab had taxied past the illuminated stop bar/hold short line and instructed the ATR to go around, by that time the crew had already initated their go-around.

The AIBF reported that tower subsequently informed the crew of NEF-25 of the runway incursion, received an apology and instructed the crew to phone the ATC supervisor after landing at their destination in Mariehamn (Aland), the supervisor however never received such a call.

The Saab was flown by a captain (60, ATPL, 16,500 hours total, 650 hours on type) and a first officer (55, CPL, 2,050 hours total, 700 hours on type).

The AIBF analysed with respect to ATC performance:

"TWR-E issued the following taxi clearance to NEF025: ‘NEF025 via CL cross RWY15 taxi to Y hold short of RWY 22L’. NEF025 read it back as follows: ‘Via Y to RWY 22L crossing approved NEF025’. The read-back does not contain any mention of crossing RWY 15. However, it refers to RWY 22L, which can also be interpreted as a clearance to cross RWY 22L. TWR-E did not react to the errors in the read-back. Well before NEF025 reached holding point Y TWR-E cleared them to cross RWY 22L and taxi to holding point WD. Therefore, it remains uncertain whether NEF025 would have stopped there or continued across RWY 22L."

and went on:

"In order to make certain that NEF025 would not taxi onto the runway the TWR-W controller switched on the red stop bar. A moment after this NEF025 contacted TWR-W which replied, as required, by using the aircraft’s call sign, and provided the following traffic information: ‘NEF025 one landing’. When traffic information is provided, it would be safer to repeat the air traffic control clearance, as applicable, in addition to the traffic information."

The AIBF reported the first officer of NEF-25 reported in post flight interviews that tower west had talked about "lining" and understood they were cleared to line up. The commander said the controller had said "line up".

The AIBF analysed: "The investigation group listened to the radiotelephony recordings. On the grounds of these, corroborated by the analysis of the audio expert, the TWR-W controller used the phrase ‘one landing’, which NEF025 read back as ‘landing’. Typically, the word lining is never used on its own. Rather, it is included in phrases such as line up or lining up."

and went on: "In view of safe operations it is important to strictly adhere to standard radiotelephony phraseology in aviation."

With respect to the flight crew actions of NEF-25 the AIBF analysed:

"After TWR-E issued the following taxi clearance to NEF025: ‘NEF025 via CL cross RWY15 taxi to Y hold short of RWY 22L’, the pilots read it back incorrectly: ‘Via Y to RWY 22L crossing approved NEF025’. This read-back can also be interpreted as per-mission to cross RWY 22L.

As NEF025 reported it was approaching holding point WD, TWR-E told them to contact TWR-W. NEF025 did not read this back. They mistakenly switched over to Helsinki Ra-dar (TAR) frequency. Helsinki Radar told them that they were on the wrong frequency and advised them to call TWR-W on 118.850 MHz.

It is possible that NEF025 was on the wrong frequency right at the time when TWR-W cleared BLF218 to land on RWY 22R. As a result, the pilots of NEF025 may have had poor situation awareness regarding the aircraft that was cleared to land on RWY 22R."

and went on:

"The pilot-in-command of NEF025 slowed their taxi speed, almost coming to a halt at the stop bar, approximately 80 m before holding point WD. This was probably due to the il-luminated stop bar, and they were also approaching their taxi clearance limit. The pilots remembered having seen the yellow runway guard lights, but not the red stop bar. Nonetheless, the surface movement radar recording shows that the red stop bar lights were illuminated as NEF025 crossed them.

When the co-pilot of NEF025 contacted TWR-W, the controller informed them: ‘NEF025 one landing’. The co-pilot read back: ‘Landing’. Having understood this as a line up clearance, the pilot-in-command entered the runway. The co-pilot was uncertain of the clearance, but did not confirm it from the ATC. On the basis of the radiotelephony re-cording, the controller did not clear NEF025 to taxi onto the runway."

The AIBF analysed that the captain of the Saab told in post flihgt interviews the first officer had reported the approach sector clear, the first officer stating that he usually scans the approach sector visually and on TCAS but may have missed the scan this time.

The AIBF analysed: "The investigation revealed shortcomings in NEF025Â’s multi-crew cooperation and communication. The co-pilot was not certain whether they had been cleared to the runway. The crew did not sufficiently communicate with regard to the possible mistake, nor did they confirm the matter from the ATC. Furthermore, NEF025 taxied across the illuminated stop bar. Moreover, they did not apply multi-crew cooperation regarding the fact that the approach sector was clear.

The missing CVR recording significantly hampered the investigation of multi-crew cooperation."

The AIBF analysed that the language skills of both crew of NEF-25 were "limited as regards understanding air traffic control clearances or communicating with the ATC in English" although the captain held a certificate stating his English skills was matching proficiency level 4 (operational) and the first officer had been certified proficiency level 5 (advanced), both had completed their assessments in Czech Republic in 2011. The AIBF won the impression of their language skills being limited in post flight interviews and their performance recorded on ATC tapes.

As result of the investigation all RAF Avia flight operations were suspended by Latvian Civil Aviation Authority between Mar 19th 2012 and April 30th 2012 in order to have all flight crew undergo refresher training, language training and proficiency checks before resuming flight operations. Flight crew were permitted to resume flying duties after showing sufficient proficiency.

Two additional safety recommendations were issued to Latvian CAA to ensure RAD Avia crews were familiar with stop bar procedures and were in possession of sufficinet multi-crew cooperation skills. Two more safety recommendations were issued to Finland's CAA to ensure standard phraseology and proper monitoring of readbacks by ATC, repeating clearances when issuing traffic information and introducing a runway incursion alerting system.
Incident Facts

Date of incident
Dec 29, 2011

Classification
Incident

Cause
Runway incursion

Airline
RAF-Avia

Aircraft Type
SAAB 340

ICAO Type Designator
SF34

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