Dick Smith Flyer

Safety Incidents
Recent airline safety incidents - kept secret by the media
By Dick Smith
Aug 29, 2006, 18:19

Just over a week ago a reporter from the Canberra Times, Mr Paul Maley, phoned me alleging that I had been involved in an incident at Canberra Airport.  As I had not flown into Canberra Airport for over six months I explained that it was not I.

 

I said, “Why don’t you do an article about the many incidents involving airline aircraft, where airline passengers are at risk?” 

 

He said, “Oh, I don’t know of any.”

 

I have sent him the following list.

 

Here are some recent incidents from the ATSB weekly reports. Note how many are with professional pilots in airline aircraft.  Yes, as big as 747s.  Isn’t it amazing that some of these incidents – some very serious like inadvertently shutting down an engine in flight – are not mentioned in any way in the press.

 

Many will remember that when we introduced the US NAS system, two incidents were beaten up and used by the ATSB to reverse the Government airspace policy. 

 

It should be noted that there is one thing the incidents show. That is, we are all human and we can all make mistakes – whether we are a professional pilot with over 20,000 hours experience or a young student pilot.

 

Every time I read a safety incident I think, “What can I learn from this?" or "When will I do that?"

 

By the way, don’t hold your breath for the Canberra Times to actually mention any of these incidents.  For some reason current journalists keep the many airline incidents completely hidden from the public view.

 

 

The ATSB occurrence number is shown in brackets.

 

23/6/06 Orange Aerodrome (200604222)

A Saab SF340 airline aircraft and an airline Beech Baron were attempting to land at Orange airport in cloud.  The Saab was approaching from the east and was on final approach to runway 29.  The Baron was approaching from the west for a circling approach. Visual conditions were not established and the Baron commenced a missed approach. The Saab crew realised the aircraft were on a collision course and advised the Baron pilot. The baron turned to the south east and climbed while the Saab continued its approach.

 

1/7/06 Canberra (200603751)

The chartered Metro flared higher than normal in darkness which resulted in a hard landing.  The aircraft was substantially damaged.

 

2/7/06 Sydney (200604001)

While taxiing for take off, the crew of an airline Boeing 737 did not comply with the issued taxi instructions.

 

2/7/06 56 km SW Canberra (200604002)

On approach, the airline Metro SA227 was cleared to FL110 but was observed on radar to descend to FL105 before climbing to the assigned altitude.

 

3/7/06 Melbourne (200604009)

An airline Airbus departed from runway 34 while the aircraft’s electronic strip indicated runway 27.

 

3/7/06 Perth (200603765)

An airline Fokker F27 was taxiing out of the parking bay while a Fokker 50 was taxiing to the adjacent bay. The departing crew attempted to taxi between the adjacent bay and the terminal but the right wing struck a walkway roof, damaging the wing tip.

 

5/7/06 IFR Waypoint TAMMI (200604045)

An airline Airbus A340 was cleared on a standard arrival route but the crew did not comply with the requirement to cross TAMMI at or below 9,000 feet.  The aircraft was observed on radar to cross TAMMI at 10,700 ft.

 

6/7/06 57 km NW Canty (200604044)

The airline Boeing 777 was cleared on a standard arrival route but the crew did not comply with published tracking.  The controller advised the crew who corrected the aircraft’s track.

 

6/7/06 Sydney (200604054)

When taxiing for take off the crew of an airline Boeing 777 did not comply with the issued taxi instructions and the aircraft crossed the holding point for runway 16R on taxiway G before the crew were instructed to stop.

 

10/7/06 37km NW IFR waypoint KADAP (200604104)

After logging onto the CPDLC at the FIR boundary, the airline Airbus A340 was found to have diverted 20 miles to the right of track without a clearance.

 

12/7/06 Williamtown (200604090)

An airline Metro SA227 was on final approach to runway 30.  The crew initiated a go-around due to a vehicle on the runway.  The driver reported not hearing the crew call on final approach.

 

12/7/06 Whyalla (200604211)

An airline Saab SF340 was approaching the circuit from the south east and was in communication with a departing Aero Commander. The Aero Commander crew indicated that they would fly to the west before departure. On joining left downwind, the Saab crew received a TCAS Resolution Advisory. The crew responded to the climb command and observed the Aero Commander to the west and in close proximity.

 

13/7/06 Melbourne (200604224)

Incident between an airline Dash 8 and another airline aircraft. The first aircraft departed on a Cowes three departure and was cleared to climb to 5,000 feet.  The second aircraft departed one minute later on an Owens One departure and was also cleared to 5,000 feet. The first aircraft entered cloud at 3,000 feet with the second aircraft less than 3 miles behind. Separation standards were infringed.

 

14/7/06 IFR waypoint Berow (200604124)

During a standard instrument arrival the crew of an airline 737 did not comply with the requirement to reach 9,000 feet by waypoint BEROW. The aircraft was observed on radar to pass BEROW at FL117.

 

14/7/06 Mt Isa (200604168)

During the approach the Ground Proximity Warning System of the airline Boeing 737 airline aircraft activated. The aircraft was on base leg for a circling approach with a 35 degree bank angle.

 

17/7/06 41km SE Mackay (200604215)

The tower controller incorrectly issued a clearance to FL150 when a “maintain 9,000” instruction had been issued to the airline Dash 8 by the sector controller.

 

17/7/06 IFR waypoint SUNKI (200604135)

Mauritius ATC coordinated the flight at FL350.  The crew reported at the Melbourne airspace boundary maintaining FL330 and requested FL350.

 

17/7/06 Tamworth (200604232)

A CT4 aircraft was inbound from the north west at 5,000 feet and was cleared to pass overhead the field then to track for an ILS approach to runway 30R.  An airline Metro aircraft was departing from runway 30R and was cleared to take off and turn right initially to 4,000 feet.  ATC instructed the airline crew to climb to 5,000 feet, when it was in an area of confliction with the CT4.

 

18/7/06 IFR waypoint RAINY (200604103)

The crew of an airline Boeing 767 had been issued with a Biboohra One standard arrival round but did not comply with the heading requirement specified in the procedure.

 

18/7/06 Sydney (200604153)

During a missed approach procedure from runway 16R, the crew of an airline Boeing 777 did not comply with the standard published procedure or with verbal instructions from ATC.

 

18/7/06 IFR waypoint BULGA (200604156)

While on descent the crew of an airline Airbus A340 did not comply with the requirement to be at BULGA by FL250. The aircraft was observed on radar crossing BULGA at FL260.

 

18/7/06 56km ESE Canberra (200604214)

During approach, ATC cleared the airline Boeing 737 to descend to FL110 and continue on its present heading to maintain separation from another aircraft at FL160. The pilot queried the clearance while making a right turn.  ATC instructed the crew to turn left and maintain FL170.

 

19/7/06 Perth (200604242)

While taxiing after landing the crew of an airline Embraer Brasilia EMB-120 aircraft crossed runway 34 without a clearance.

 

20/7/06 Sydney (200604176)

After landing on runway 16R, the crew of an airline Airbus A340 did not comply with an instruction to vacate the runway via taxiway L.  The aircraft was vacated via taxiway A4 – a taxiway documented as not available for the aircraft type.

 

20/7/06 Adelaide (200604264)

As the crew of an airline Boeing 737 set take off thrust, they received a configuration warning and rejected the take off.  A cockpit check revealed the flaps set to zero instead of five degrees.  The crew set the flaps for take off and the aircraft departed normally.

 

21/7/06 IFR waypoint ARRAN (200604183)

The crew of an airline Airbus A320 inadvertently read back and complied with a radar heading intended for another aircraft.  The controller did not detect the error and the aircraft was transferred to another sector.  The crew of the aircraft for which the heading was intended advised ATC of the error.

 

21/7/06 56km S Canberra (200604186)

ATC issued the crew of an airline Boeing 737 with a radar heading intended for another aircraft.  The 737 crew complied with the heading.

 

21/7/06 72 km S Jabiru ALA (200604192)

When the airline Beech 1900 aircraft was enroute at FL210, ATC instructed the pilot to be ready for descent.  The pilot commenced descent without a clearance.

 

22/7/06 Sydney (200604580)

Air traffic control asked the crew of an Airbus A320 to turn onto a heading of 360 to intercept the runway 34L localiser but the aircraft rolled out on the heading of 340.

 

23/7/06 IFR waypoint DERAL (200604277)

The pilot of a Metro reported tracking on a route different to that indicated on the flight data record.

 

24/7/06 90km S Natya (200604271)

An airline Boeing 777 was cruising at FL350 when the controller issued an instruction to descend at 250 knots. The crew initiated a descent to FL250.  The aircraft was re-cleared to descend to FL210.

 

24/7/06 Sydney (200604292)

The pilot of an airline Boeing 747 did not comply with ATC instructions to cancel the take off clearance.

 

24/7/06 Melbourne (200604339)

Two airline Dash 8s departed from the same runway using visual separation standards. When the first aircraft commenced an early turn and was obscured by cloud, visual separation standards were infringed.

 

25/7/06 IFR waypoint RAZZI (200604338)

During the climb, the 767 autopilot was disengaged when the aircraft exceeded its FL380 clearance. The aircraft then descended to FL340.

 

25/7/06 IFR Waypoint ROTAP (200604282)

The pilot of an airline Fokker F28 did not comply with the published left hand holding pattern at ROTAP.  The aircraft was observed on radar to fly a right holding pattern.

 

26/7/06 Alice Springs (200604330)

After departure the crew of an airline Boeing 717 transferred frequencies without instruction.

 

26/7/06 IFR Waypoint TAMMI (200604316)

The airline Boeing 747 was cleared on a standard arrival route but the crew did not comply with a requirement to cross TAMMI at 9,000 feet.  The aircraft was observed on radar at FL120.

 

27/7/06 Perth (200604328)

When taxiing for take off, the crew of an Airbus A330 airline aircraft did not comply with the taxi instructions and entered a taxiway not suitable for the aircraft type, and infringed the runway 06 strip.

 

28/7/06 Sydney (200604341)

When taxiing after landing the crew of an airline Boeing 737 did not comply with taxi instructions.

 

28/7/06 Sydney (200604345)

When taxiing for take off, the crew of an airline Airbus A330 did not comply with taxi instructions and the aircraft entered a taxiway not suitable for the aircraft type.

 

28/7/06 Sydney (200604347)

After landing, the crew of an Airbus A330 did not vacate the runway in accordance with the instructions issued by the ADC.

 

28/7/06 70km N Sydney (200604364)

When the airline PA-31-350 was assigned 8,000 feet on approach the pilot reported maintaining 9,000 feet.  The aircraft was later observed on radar to have descended to 7,500 feet without a clearance.

 

28/7/06 Perth (200604366)

While departing on a standard instrument departure, the airline Bae146 jet flew through airspace that had been released to Pearce air traffic control, resulting in loss of separation assurance with an aircraft on the TACAN arc.

 

28/7/06 46km NNE Sydney (20060437)

On descent, the airline Metro aircraft was assigned 6,000 feet.  The pilot subsequently reported descending through 4,800 feet.

 

29/7/06 Sydney (200604551)

An Airbus A320 crossed the extended centreline while turning onto final approach.

 

29/7/06 Sydney (200604370)

After landing, the crew of an airline Boeing 737 did not comply with an instruction to vacate the runway at the nominated taxiway and the aircraft entered a taxiway not suitable for the aircraft type.

 

29/7/06 Sydney (200604362)

The approach controller cancelled the Embraer Brasilia’s approach clearance and instructed the crew to go around from a 2 mile final.  A facility failure resulted in two-way communication with the tower not being established.

 

29/7/06 Sydney (200604374)

When assigned a heading to intercept final for runway 34L, the airline Airbus A330 aircraft was observed on radar to pass through final.

 

29/7/06 Hamilton Island (200604360)

An airline Airbus A320 was on final to runway 14 and a chartered Tiger Moth was tracking to Shute Harbour via Hamilton Island. Separation standards were infringed.

 

29/7/06 IFR waypoint WELSH (200604375)]

While on approach, the airline Saab SF 340 aircraft was assigned 9,000 feet but the pilot read back 7,000 feet and the controller did not detect the error.  The error was detected when the aircraft was transferred to the approach controller.

 

29/7/06 41km W IFR waypoint Torra (200604373)

The pilot of a Saab SF340 airline pilot reported tracking on a route different to the flight plan held in the TAAATS system.

 

29/7/06 Port Macquarie (200604384)

An airline Dash 8 was approaching the Port Macquarie circuit when the crew observed an aircraft on the TCAS 600 feet below and behind.  After establishing a communication with the other aircraft (a CT4) the Dash 8 crew received a resolution advisory to climb.

 

29/7/06 Darwin (200604425)

The crew of an airline Airbus A330 selected an incorrect track from Darwin to IKUMA. ATC provided radar vectors to intercept the correct track.

 

30/7/06 Sydney (200604369)

While taxiing for take off, the crew of an airline Boeing 767 did not change to the tower frequency in accordance with documented instructions.

 

30/7/06 Cocos Island (200604465)

The Ilyushin aircraft was cleared into Australian airspace at FL270 enroute to Cocos Island. The Melbourne Sector controller checked with Brisbane HF for the aircraft’s ETC at Cocos Island and was informed that the aircraft had landed.  The sector controller had not issued a descent clearance.

 

30/7/06 Ballina (200604523)

An Airbus A320 crew joining downwind for landing sighted a light aircraft climbing below. Communication was established and separation arranged.

 

31/7/06 IFR Waypoint LIDIT (200604405)

Port Moresby ATC incorrectly coordinated the aircraft’s flight level as FL350 to Brisbane ATC. The Boeing 777 entered Brisbane airspace at FL370.

 

31/7/06 19km W IFR waypoint SHARK (200604410)

The aircraft was cleared to descend to FL290 but the pilot read back 250.  The controller did not notice the incorrect read back resulting in a loss of separation assurance with outbound traffic.

 

1/8/06 Albury (200604401)

The Saab crew on approach did not comply with a requirement to reach 4,400 feet by 6 DME.  The pilot reported overhead outbound at 5,000 feet on descent for the runway 25 VOR approach.

 

2/8/06 IFR Waypoint Boree (200604447)

The Boeing 737s electronic details indicated a flight level of FL280.  The aircraft was actually maintaining FL260.

 

2/8/06 IFR waypoint Berow (200604448)

While conducting a Boree Three arrival, the crew of an airline Airbus A330 did not comply with the vertical navigation requirement to be at 9,000 feet or below by Berow. The aircraft passed Berow at 10,500 feet.

 

2/8/06 IFR waypoint APISO (200604473)

The pilot of an airline Boeing 747 did not obtain a clearance to enter the Australian FIR.

 

2/8/06 IFR waypoint SHEED (200604476)

During a Lizzi one arrival to runway 34, the Boeing 747 turned left before waypoint SHEED without clearance.

 

3/8/06 Sydney (200604483)

While cleared on a standard arrival route, the crew of an Airbus A340 did not comply with the requirement to cross waypoint WHALE at or below 9,000 feet.  The aircraft was observed by radar at 10,800 feet.

 

3/8/06 Sydney (200604502)

During descent, the crew of an airline Boeing 737 inadvertently switched off the number two hydraulic processor instead of the engine anti ice.

 

4/8/06 Perth (200604484)

On departure the crew of a Boeing 717 airline aircraft switched from the tower frequency to the departure frequency without instruction.

 

4/8/06 Perth (200604494)

On departure the crew of a Boeing 717 airline aircraft switched from the tower frequency to the departure frequency without instruction.

 

4/8/06 Perth (200604487)

On departure the crew of a Fokker F27 airline aircraft switched from the tower frequency to the departure frequency without instruction.

 

4/8/06 Perth (200604488)

On departure the crew of an Embraer Brasilia EMB-120 airline aircraft switched from the tower frequency to the departure frequency without instruction.

 

4/8/06 46km SW Parkes (200604490)

The crew of a Boeing 737 airline aircraft did not correctly select the appropriate radio frequency and air traffic control were unable to communicate with the crew for 20 minutes.

 

4/8/06 Sydney (200604505)

The crew of a Boeing 767 airline aircraft did not comply with an ATC instruction to exit runway 16L at taxiway T4. The aircraft exited at taxiway T3.

 

5/8/06 Sydney (200604516)

The Boeing 737 airline aircraft departed Sydney from runway 16R and was cleared for a right turn onto heading 260.  On first contact with Departures, the crew reported turning left onto heading 120.

 

5/8/06 Griffith (200604519)

The crew of an airline Saab SF340 reported that on departure, a Piper Seneca aircraft passed within 1 nautical mile at the same altitude. The other pilot reported radio problems.

 

7/8/06 37 km NNW Melbourne (200605750)

A STAR issued to an inbound Boeing 737 included a requirement to reach 9,000 feet by 20 DME Melbourne.  The SID issued to a departing Boeing 737 required it to reach 10,000 feet before coming into conflict with the other aircraft. ATC cancelled the vertical requirement for the first aircraft due to traffic. When ATC recognised a conflict, the second aircraft was radar vectored but lateral separation was reduced below minimum requirements.

 

8/8/06 IFR Waypoint Helli (200604632)

An airline Metro SA227 diverted from its cleared track and turned left towards the Marshal Restricted area.  ATC noticed the turn and vectored the aircraft back onto its cleared track.

 

9/8/06 IFR waypoint DOMOM (200604600)

The crew of an airline Boeing 777 and another aircraft made almost simultaneous requests for clearance to FL390.  The controller cleared both aircraft to FL390, thinking that both requests came from the same aircraft.  The error was detected by a CLAM alert.

 

9/8/06 Sydney (200604606)

On departure the Boeing 737 airline aircraft was cleared to 5,000 feet but was observed on radar to climb above the cleared altitude.

 

10/8/06 IFR waypoint Sapda (200604615)

Jakarta ATC coordinated the flight at FL390. The 737 crew reported at the FIR boundary to Brisbane ATC at FL410.

 

3/9/06 Rockhampton (200605596)

After landing, the crew of an airline Dash 8 did not comply with the instruction to vacate onto a nominated taxiway and the aircraft had to backtrack.  A Boeing 737 sequenced to land was sent around by ATC.

 

6/9/06 70km NE IFR waypoint WYLOO (200605274)

During cruise prior to top of descent, the right engine of the Boeing 717 was inadvertently shut down.  The engine was restarted and the aircraft landed safely.

 

13/9/06 Ballidu VOR (200605425)

As the airline BAe146 reached FL290, the crew heard a bang and felt a severe vibration through the floor for 10 seconds.  All indications were normal and there were no warnings. ATC declared an uncertainty phase. The aircraft returned to Perth and landed safely. Engineering inspection revealed left and right centre wing spoilers seal damage.

 

14/9/06 56 km NW IFR waypoint ALIRA (200605527)

An airline EMB-120 was inbound to Broome when an airline Saab taxied for departure on the reciprocal track. ATC provided traffic but withheld clearance from the Saab while waiting for a report from the EMB-120. The EMB-120 reported leaving FL180 on descent, the Saab crew reported maintaining FL190.  The Saab had entered CTA without a clearance and separation standards were infringed.

 

15/9/06 Armidale (200605526)

During descent the aircraft’s TCAS activated a TA. The crew were aware of another aircraft in their vicinity but thought it was further away. The crew received an RA and responded.

 

16/9/06 Perth (200605473)

Following two unsuccessful approaches in fog and with a reduced fuel quantity, the crew declared an emergency prior to commencing a successful autoland approach to runway 21.

 

16/9/06 IFR waypoint ONOXA (200605497)

ATC could not establish communications with a Fokker F28.  ATC amended the flight level of another aircraft to ensure separation.  Normal communication was re-established.

 

21/9/06 Sydney (200605601)

The crew of an Airbus A340 did not comply with the requirement of the STAR to be at or below WHALE at 9,000 feet.  They crossed WHALE at FL115.

 

21/9/06 Adelaide (200605675)

As cleared, the Boeing 737 lined up on runway 05 after another aircraft had landed.  The airline Saab SF-340 was approaching runway 05 and the controller cleared the Saab to land.  The controller then realised the 737 was still on the runway and instructed the Saab to go around.

 

21/9/06 Sydney (200605767)

The SMC did not provide adequate taxi instructions to the arriving Boeing 767 or the departing Boeing 737.  Neither crew were given a “give way” or “pass behind” instruction. The 737 crew noticed a potential conflict and stopped their aircraft.

 

24/9/06 50km W Scone (200605725)

The aircraft had been assigned FL300.  Due to frequency congestion the crew became confused and left FL300.  ATC instructed the crew to return to FL300.

 

24/9/06 IFR waypoint LARAB (200605620)

The crew of a Boeing 737 flying a scheduled service between Darwin and Bali reported the failure of the left engine and declared an emergency. The aircraft returned to Darwin and landed safely.

 

28/9/06 Mr Isa (200605778)

A Charter Cessna 402 was inbound on the 126 radial and heard the pilot of a Baron report departing on the 120 radial. The Cessna 402 pilot took immediate avoidance action and the aircraft passed within 300 metres. No previous transmissions were heard from the Baron pilot.

 

28/9/06 IFR waypoint NEEDL (200605746)

The crew of an airline Dash 8 did not comply with the STAR requirement to be at or below FL150 by waypoint NEEDL.  The crew reported that an incorrect coordinate had been entered into the GPS.

 

28/9/06 Sydney (200605801)

While on approach the crew of a Boeing 737 inadvertently changed from the approach frequency to the tower frequency without instruction. The ADC issued a visual approach. The aircraft passed through final by approximately 2 nautical miles before correcting back to the centre line.

 

28/9/06 Brisbane (200605824)

The crew of an Airbus A320 were instructed to hold short of taxiway B. The aircraft later infringed taxiway B.

 

30/9/06 IFR waypoint TASKA (200605825)

During the outbound climb ATC instructed the crew to turn left to ensure separation with inbound traffic.  Initially there was no response but communications were re-established at ATC repeated the left turn instruction.  On radar the controller then observed the aircraft commencing a right turn.

 

1/10/06 IFR waypoint RERON (200605826)

A Boeing 747 and a Boeing 737 were on the same track at the same flight level. Procedural separation was established before they left radar coverage. At a later check of position estimates ATC noted there was a closing speed and amended the cruising level of the second aircraft. There was an infringement of horizontal separation.

 

2/10/06 Sydney Aerodrome (200605920)

An Airbus A340 was cleared for take off on runway 16R while the Boeing 747 was on final for the same runway.  When he A340 became airborne, the 747 was 1,000 metres past the threshold and had not touched down.

 

3/10/06 56km SSE IFR waypoint DIGLA (200605918)

A Boeing 747 was tracking GEKKO direct ANZAC at FL370.  A Westwind had departed Alice Springs for Darwin and the crew requested FL370.  The Alice Springs controller coordinated the proposed level with Carpentaria Sector but did not establish who would be responsible for separation, resulting in an infringement of separation standards.

 

4/10/06 Melbourne (200605938)

Due to some passengers not arriving and a late load adjustment, the crew of an Airbus A320 noted that the aircraft’s centre of gravity was in the aft section of the envelope but within limits.  During take off the pitch rate increased rapidly and the crew counteracted this.  During the flight 16 passengers were re-seated in the forward cabin and the crew re-computed the centre of gravity for landing.

 

4/10/06 Hamilton Island (200605995)

The Airbus A320 was cleared to track outbound on the 141 VOR radial.  The aircraft initially tracked in accordance with the clearance but was later observed on TSAD crossing the 160 degree radial.  ATC instructed the crew to re-intercept the 141 radial.

 

6/10/06 11km N Jandakot (200606018)

An Aero Commander was tracking inbound to Perth via Canning Bridge but deviated from the standard inbound track potentially conflicting with aircraft departing from Perth’s runway 21. Departures were cancelled until the Aero Commander was established in the GAAP CTR.

 

7/10/06 IFR waypoint BEROW (200606015)

The crew of an Airbus A330 did not comply with the vertical navigation requirement of the STAR to cross BEROW at or below 9,000 feet.  The aircraft crossed BEROW at 10,900 feet.

 

9/10/06 IFR waypoint WOORA (200605955)

An airline BAe146 was cleared on a STAR and assigned a descent to 2,500 feet, the aircraft was observed on radar to descend to 2,000 feet before climbing back to the cleared altitude.

 

9/10/06 Brisbane (200606057)

After discussion with the departures controller, the ADC decided to issued “runway heading” to the crew of an airline Dash 8 after take off from runway 19 (instead of the heading of 195 as per the published procedure).  The ADC incorrectly read the heading back as “heading 015” and the departures controller did not detect the error.  The incorrect heading was passed on to the crew who asked if a right turn to the heading was required.  The ADC realised the error and informed the crew to turn onto 195.

 

11/10/06 Darwin (200605999)

The Boeing 767 returned to the gate due to a fire warning indication in the auxiliary power unit (APU). The aircraft was released for departure, but on arrival at Sydney via Brisbane, evidence of a fire was discovered in the APU.