Wednesday, January 15, 2014

Ethiopian Airlines high-risk landing - result of an investigation

On December 18 eTN reported about a high-risk landing of an Ethiopian Airlines commercial plane in Arusha, Tanzania. Ethiopian Airlines is a member of the Star Alliance.

ETN acknowledges Mr.Richard Gomes’ as the source of this information. The findings shown below refer to the Arusha incident of Ethiopian Airlines’. The information is relayed here without any alterations or additional comments.



AIB Bulletin
AIB No. 15 Ref. CAV/INC/15/13 Category: 1.1
Aircraft Type: Boeing 767-383 ER Reg. ET-AQW Serial No. 24476
No. and type of Engines: Two Pratt and Whitney PW 4000
Year of Manufacture: 1989
Date and Time (UTC): 18 December 2013 at 0948 hours (1248 hours Local Time).
Location: Arusha Airport, northern Tanz
ania
Latitude: S 03 22.04′
Longitude: E 036 37. 48′
Elevation 4,550 ft
Type of Flight Commercial scheduled flight.
Persons on Board: Crew – 10 Passengers – 213
Injuries: Crew – Nil Passengers – Nil
Nature of Damage: There was no damage to the aircraft
Commander’s Licence: ATPL
Commander’s Age: 51 years
Commanders Experience: 11,000 hours of which 800 hours were on type.
Last 28 days: 30 hours.
Last 90 days: 200 hours.
Information Source: Telephone from Kilimanjaro ATS
ALL TIMES UTC

The Bulletin contains facts relating to the accident which have been determined up to the time of issue. This information is published to inform the public and the aviation industry of the general circumstance of the accident or incident at the preliminary stage and must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes available

SUMMARY
The incident was reported to the Air Accident Investigation Branch by the Kilimanjaro Air Traffic Services shortly after it occurred. The investigation started immediately.

Whilst descending for Kilimanjaro International Airport, the flight crew saw an airport (Arusha airport) and prematurely abandoned the given standard arrival procedure that would have taken them to the Kilimanjaro runway access. They subsequently landed at Arusha airport.

The failure of the flight crew to report at given reporting positions and the failure of the controller to ask for the aircraft position reports were factors which contributed to the incident.

History of the Flight
The aircraft was operating Ethiopian Airlines Flight ETH- 815, a scheduled commercial flight from Addis Ababa to Mombasa via Kilimanjaro International Airport (KIA). It was carrying 213 passengers and a crew of 10 including two pilots. The fuel load was 18,000 kg which gave an endurance of 0430 hours. The pilot in command testified that he was airborne at 0745 hours and climbed to a cruising altitude of 36,000 feet. The flight was uneventful.

Whilst descending to FL 240 the pilot made the first contact with the Kilimanjaro International Airport. He reported that he had been cleared by the Dar es Salaam Area Control Centre to descend to FL 240 estimating the reporting point LOSIN 0937 hours, and touchdown at Kilimanjaro at 0950 hours.

At 0929 hours the pilot was informed by the Kilimanjaro Approach that runway 09 (the runway with instrument arrival) was not available due to a disabled aircraft at the approach end. He was advised to use the reciprocal runway (runway 27) which had 3,300 metres available for the landing. This runway was not equipped with instrument landing system. The pilot acknowledged the clearance at 0931hours. He was cleared to FL 120 EVATO 1A arrival, and was advised to report on breaking visual for runway 27.

At 0943hours the pilot reported to have airport in sight and advised that he would be joining left downwind runway 27. The controller instructed Flight ETH-815 to report left base runway 27. The pilot acknowledged.

At 0945 hours the pilot requested the position of the disabled Caravan 1. The reply was 300 metres from the threshold of runway 09 and the available landing distance of 3,300 meters for runway 27. At 0946 hours the pilot reported left base. He was given the surface wind 080/02 and cleared to land.

When the controller failed to see to the aircraft, he tried to raise it on the Kilimanjaro frequency but there was no reply. It was during the repeated calls that he received a telephone call from the Arusha tower informing him that ET-AQW had landed at Arusha airport.

The aircraft made a safe landing on runway 27 of Arusha airport and stopped within the length of the runway. During an attempted 180 degrees turn, the nose and main landing gear wheels exited the runway and were stuck in soft soil. There was no damage to the aircraft. There were also no injuries to the 223 persons on board.
The aircraft was later towed back to the runway and made a successful takeoff for Kilimanjaro International airport on 20 December 2013 at 0849 hours. It arrived at Kilimanjaro at 0857 hours with a crew of 5 and no passengers.

Damage to aircraft
There was no damage to the aircraft.

The weather
It was a bright, sunny day. The weather does not appear to be a significant factor in this incident.

Arusha airport
Arusha airport elevation 4,550 feet has one runway 09/27 which is 1,640 metres long and 30 metres wide. The surface is tarmac (PCN 15) and was in good condition at the time of the incident. The runway has no turning pads.

The airport is used by light and medium aircraft. There is one NDB, AR 391 KHz. Arusha airport is 27 nautical miles (50 km) west of Kilimanjaro International Airport.

Kilimanjaro International Airport
Kilimanjaro International Airport, elevation 2,930 feet has one runway 09/27 which is 3,600 metres long and 46 metres wide. The surface is tarmac and was in good condition at the time of the incident. The navigational aids include one Instrument Landing System KK frequency 110.9 KHz; One VOR, KV 115.3 MHz; One NDB KB 293 KHz and two locators, KL 283 KHz; KO 298 KHz. Most of the navigational aids support instrument approach procedures for runway 09.

The airport has several standard arrival procedures (STARS) and Flight ETH-815 was cleared for EVATO 1A arrival into Kilimanjaro.
It was the second time that the pilot in command was flying to Kilimanjaro. He had previously flown into the airport as an observer. However, the co-pilot had flown into Kilimanjaro three times before in the right seat, the last time being September 2013.

Discussion
The investigations have so far found no technical problems with the aircraft that could have contributed to this incident. This was corroborated by the company’s Captain who subsequently flew the aircraft out of Arusha.

The pilot reported nothing unusual during takeoff, climb, cruise and descent. However, the pilot failed to report at the mandatory reporting point, LOSIN. He was also not asked by the Kilimanjaro Approach to do so. The only position report he made was 43nm (80 km) from the Kilimanjaro VOR, KV.

During the descent he saw an airport and prematurely abandoned the given arrival procedure (EVATO 1A) which would have taken him to position TESOV, and subsequently to the Kilimanjaro runway axis.

He subsequently joined left downwind for runway 27 Arusha Airport while believing that he was proceeding to land at Kilimanjaro. His downwind position report was not challenged by the Kilimanjaro controller, who should have had him in sight in that position.
Safety Recommendations
It is recommended that:
1. Flight crew and air traffic controllers should always follow the published standard procedures.
2. Flight crew should always make use of the available navigational aids.
3. Flight crew should familiarize themselves with geographical features surrounding airports of operation.
4. Controllers should always watch closely air traffic in the circuit pattern.
5. Kilimanjaro International Airport should be equipped with a good surveillance system to monitor aircraft movements, for example, radar.

Further work
Further investigations into the circumstances of this serious incident are ongoing.
The Tanzania AAIB investigations are conducted in accordance with ICAO Annex 13 to the Chicago Convention of International Civil Aviation and The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2011.

The sole objective of the investigation of an accident or incident under these Regulations is the prevention of future accidents and incidents. It is not the purpose of such an investigation to apportion blame or liability.

Accordingly, it is inappropriate that AAIB reports should be used to assign fault or blame or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose.

Extracts may be published without specific permission providing that the source is duly acknowledged, the material is reproduced accurately and is not used in a derogatory manner or in a misleading context.
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