Close call at Kastrup/Copenhagen

[LN-ATC]

The HCL (Danish AAIB) has recently released a preliminary report (http://www.hcl.dk/graphics/Synkron-Library/hcl/dokumenter/Redegorelser/2006/510-000282-LTH-fore.pdf) (in Danish) on a serious incident at Kastrup on 11 September 2006.

Cimber CRJ lined up while Sterling 737 was on short final. The 737 passed low over the CRJ and landed "long". Minimum distance was 10-15 m and 20 feet...

Scary reading... :eek:

English summary:
-Sterling executes a "hot" visual approach at night
-Cimber reports on taxiway/holding V2, but is actually on taxiway T (Cimber uses 1 min from T to V2)
-ATCO does not confirm Cimber's position report on the A-SGMCS
-ATCO does not use radar to check Sterling's distance from touch down
-ATCO instructs Cimber to line up while Sterling is on ca 2 NM final
-Sterling continues approach, despite not being stabilized according to company policy
-Sterling misses all R/T between ATC and Cimber
-Cimber does not check final approach sector visually before line up
-Sterling does not report short final (as instructed)
-ATCO does not use callsign when he (a bit late) tries to stop Cimber from lining up
-Sterling becomes aware of Cimber while they are passing threshold. Cimber was lining up via intersection 500 m further down the runway
-Sterling lands without landing clearance (they were not sure that they were cleared to land, but did not ask...)
-Single runway operations due to noise regulation...

Looking forward to the complete report...

[luoto]

Rather shocking and it will be interesting, as you state, to see what the final report says in all the detail.

It might have been good that the regulation dark trousers were being worn for those at the sharp end.

[A4]

If it's single runway due noise.... doesn't that exclude the option of a "hot visual"? Presumably it was 22L or 04R in use at night? IF, and I repeat, IF the above "facts" are true..... then some people have some serious questions to answer. :hmm:

This is a piece of cheese with numerous holes - and they very nearly lined up.

A4

[eastern wiseguy]

What is a "hot visual"?:confused:

[LN-ATC]

What is a "hot visual"?:confused:
"Hot visual" was my expression; high speed, "tight" visual circuit, unstabilized approach, etc...

[A4]

Visual ccts. Despite over 10 years of flying commercially (8 years Airbus), I still approach visuals with great caution. A visual is great to save a couple of minutes, do a little hands on flying but it also offers you the opportunity make a complete 8alls up of the whole thing. A visual approach at night also throws up additional factors - particularly over water with no defined horizon (R/W 03 ACE for example.)

This incident (near accident) demonstrates how quickly things can change and how easily items get missed due to concentrating on trying to correct the approach - in this case critical RT calls.

Why didn't they go-around? I don't know. Loss of face? Get-in-itis? Tunnel vision? We've all been there - that slightly uncomfortable feeling as you're watching the other guy start to get a little hot'n'high.

When training, I stress to new FO's that if ever they find themselves in this situation and stability looks highly unlikely - GO AROUND or TELL the Captain to GO AROUND. At the best it's probably tea, no biscuits and trying to think of some good answers as to what on earth you thought you were both doing - at worst ......

To be unstable, BE AWARE OF ANOTHER A/C on or entering the R/W and continue to land over the other aircraft is very worrying. :ugh:

Point of this post? Don't know really - it seems I'm stating the obvious - but if it gets a message across to some of the newer guys - great.

Fly safe,

A4 :ok:

PS I recently witnessed a A320 of a large Spanish carrier fly a visual approach to IBZ 24. He was UNBELIEVEABLY high on the approach - TCAS indicated 2,300 at 3 miles. Now I know TCAS is not particularly accurate in azimuth but in this case it wasn't too far wrong. To our astonisment, the aircraft landed approximately half way down the runway........... Question. How do you get to the position of Captain, responsible for many lives etc and (a) Allow an approach to be flown like that in the first place? (b) Actually LAND off of it? :hmm:

Be careful with visuals!

A4

[FLCH-SPD]

How was an accident avoided?

I don't speak Danish, but thanks to LN-ATC's summary I understand that one aircraft lined up, while another landed on the same runway. How did they avoid each other?

[Carnage Matey!]

I think there is a displaced threshold on that runway.

[Pstatic]

If it's 22R there is a displaced threshold. Good post A4. Always good to know your own limitations and be aware. As long as you're not following the procedures the burden is on your shoulders.
In general the danish ATC and the respective airlines are all very professional though Murphy always seem to play a role:uhoh:

[SIDSTAR]

If this account is only half true, the Sterling crew should get a lot more than tea with or without biscuits - P45 comes to mind.

Scary account of that IBZ approach from A4. I presume you reported it to the airline concerned? His FDAP readout must have been interesting.

Another Spanish carrier did something similar in Shannon a few years back (F/O flying pilot!!) landed on its nose a few times and bent the aircraft big time on a day when everyone else diverted due to crosswinds.

[Horntail]

Hi,

Just to verify some things.
- First of all the runway in use was 22L which does not have a displaced threshold.
- Furthermore, the taxiway V2 from which the CRJ was about to enter the rwy from is located some 450-600 m. from threshold 22L and is not perpendicular to the runway thus only giving the CRJ crew a limited view of the final approach sector.
- From the time the CRJ crew checks in on tower frequency to the time of the incident, there is no communication between the Sterling aircraft and the tower, thereby giving no indication to the CRJ crew that there are other aircrafts on the frequency.
- The tower clears the CRJ to line up twice without considering how far the 737 is.
- The Sterling captain who is PF conducts a very unstabilized approach and disregards several conditions which should have led to a go around:

Above target speed V2 + 20 at 1000' (indicated speed acc. to report is 189 kts. with Vref for landing 142 kts.)
GPW at 200' due to not properly configured (flaps)
They were not cleared to land
They still decide to land even though they see the CRJ is about to enter the runway

Of course there are more factors to be taken in to consideration but to me this is indeed lack of professionalism from the Sterling pilots: The captain continues his very unstabilized approach and the F/O does not correct him and call for a missed approach to be executed.

Just my personal opinion,

Horntail

[DK_FCI]

I agree with Horntail.

How can you decide to land when you see the CRJ begin to enter the runway:confused:

And what about the "lets fly over the CRJ" plan:ugh:

[relaxjet]

Typical example of chain of errors.
And the Sterlings crew, mind set for landing, that`s always dangerous.
It can happen to anybody, but you should be able to wake up, at some point on approach (500, minimums, rwy treshold,...)
It`s definitely the reminder for all of us!

[fox niner]

The dude up front probably did not notice the airplane lining up at V2, because it was nighttime. It always astonishes me how difficult it can be to distinguish a large airplane from behind in the dark. Even when taxiing behind it at, say, 100 meters!

So not spotting an airplane at 600 meters while executing a "hot visual" does not surprise me.
But I agree that the "let's fly over the CRJ" sounds more like Congo than Copenhagen.:ugh:

[Rallye EI-BFP]

Another Spanish carrier did something similar in Shannon a few years back (F/O flying pilot!!) landed on its nose a few times and bent the aircraft big time on a day when everyone else diverted due to crosswinds.

The Futura incident at Shannon in 2000 was not due to a hot approach at night, or another aircraft being on the runway or ATCO misunderstanding. It was not tight, he just kept dropping below ILS

[Payscale]

To sterling....pay peanuts. Get monkeys!
IF it true. Is the guy still flying?

[Ladusvala]

Relaxjet, I don´t agree with you, this doesn´t happend to anybody.
Not stabilized at 200´ due to flaps... that´s just to much.

As for not being able to see the CRJ, should we believe that they just were lucky to land half way down the runway, scary indeed.

[JEP]

Being only an amateur with PPL but having 42 year experience with danish language let me add a few things from the report:

- The Sterling was hot and high due to other traffic behind it.

- When the ATCO cleared the CRJ to line up he/she checked the position of the Sterling B737 visually. (but were probably not aware of its high speed)

- The ATCO had some troubles with the stopbar lights not responding as expected.

- The Sterling may have called short final, but there were some cross transmissions.

- The Sterling CAPT saw the CRJ stopping and decided to make a long landing touching down just before the 22L/30 intersection still having more than 2000 meters stopping distance.
He passed apprx. 20' above the CRJ


The drawing on page 8 in the AAIB report shows scenario.


RWY 22L is 3300 meters long - this could be a reason to continue the fast approach.

edit: New procedures has been established only allowing visual circuits when parallel runway operations are in use and extending the use of parallel runways.

[DK_FCI]

- The Sterling may have called short final, but there were some cross transmissions.

That is not correct - there was no communication from the Sterling aircraft after they acknowledged the they should report on short final (At time 20:41:17).

There was only one cross transmission mentioned in the report, which occured when the controller attempted to stop the Cimber CRJ from lining up.

- The Sterling CAPT saw the CRJ stopping and decided to make a long landing touching down just before the 22L/30 intersection still having more than 2000 meters stopping distance.
He passed apprx. 20' above the CRJ

The Sterling FC saw the CRJ entering the runway - and thought it was stopping - but did not know this - and in fact the CRJ was still moving at this point.

As for the long landing - I personally think that is was a result of selecting Flap 30 at 200' with a speed of 157 knots - which must result in balooning the aircraft - maybe a 737 driver can comment on that.

[JEP]

DK_CFI - you are right - just checked the report and the timeline.
By the time of the cross transmission the Sterling crew appearantly assumed/concluede they were cleared to land

Right - the Sterling FC thought it was stopping.

Certainly with the high speed (Vref + 15) it should not be that hard to extend the landing.

[the_hawk]

http://www.irlgov.ie/tec/aaiu/2001Reports/2001-010/2001-0010.htm FDR readouts should count as facts IMHO:

At 3.5 miles from touchdown and 1 minute 17 seconds to run, the autopilot was disengaged. The barometric height was 1966 ft, RADALT was 1110 ft, CAS was 162 kt and the heading read 219°magnetic. Manual control was initiated but the autothrottle remained engaged and in speed mode. Ceilings were reported as 1800 ft AGL with good visibility, and the approach was continued visually. From this point to touchdown, the aircraft was below the glideslope, ranging from 0.32ddm (3.6 dots) to twice that amount 2.5 seconds before touchdown.

At 1000 ft AGL, the speed selected was at 155 kt or (V ref+12), and remained at that value until touchdown. The actual approach was flown at an average speed of about 163 kt, but excursions of 150 kt to 173 kt were recorded due to gusts and turbulence. Strong headwinds were indicated on the initial approach and decent, but by the time the aircraft was at 700 ft radio altitude, the headwind component had largely vanished. The gusts, turbulence, and variable crosswinds contributed to continuous oscillations in all parameters, particularly pitch attitude.

At 0.6 miles and 14.4 seconds to go to touchdown the “glideslope” warning sounded. The barometric height was now 1016 ft and the RADALT was 186 ft. The CAS registered 160kt with an aircraft heading of 233° magnetic. The “glideslope” warning was again repeated as the aircraft was still below the glideslope.

[A4]

I don't understand how the barometric heights and the RADALT's can differ so much. The approach to 22L is over water (the sea) so how can there be a difference of 850 feet between the two? Last time I went to EKCH the runway was about 30 feet above sea level and about 500m from the shoreline!

At 0.6D you must be just about still over the water, so 186' RA is probably about 150' above threshold ..... perhaps a tad low := :hmm:

If they then landed at the 30/12 intersection they must have flown level at approx 150 feet for about a mile :eek: :confused: :\

A4

[LN-ATC]

A4, the hawk is refering to a slightly different incident. ;)

[A4]

Ahh. Didn't read the link!!! Dangerous to assume!!!!

I will not delete my post. I admit I made an ar$e of myself :)

A4:O :O :O

[Short Approach?]

[QUOTE=JEP;2911075]Being only an amateur with PPL but having 42 year experience with danish language let me add a few things from the report:
- The Sterling was hot and high due to other traffic behind it.
QUOTE]

Not correct. He was permitted to keep up high speed on the approach. Otherwise he would have had to reduce to 250 kts below FL100.

"Heads down" played a mojor effect on behalf of all parties in this incident.

The approaching aircraft performed a visusal app, using auto-throttle and armed the auto-pilot to intercept ILS 22L. This caused the engines to spool up, and the aircraft commenced a climb as auto-pilot captured the glidepath inside 4 NM. 737-drivers: Is this "how to do it)?

[Payscale]

Doesnt realy matter if there was traffic behind him. There is no excuse other that a few extrem emergencies, that warrant to continue an unstabilized approach and fly over an aircraft that has passed the stop bars, to land long. None.

I am sure this fellow and his willing FO are not flying anymore. Thats reackless endangerment.

[relaxjet]

[QUOTE=Ladusvala;2909258]Relaxjet, I don´t agree with you, this doesn´t happend to anybody.
Not stabilized at 200´ due to flaps... that´s just to much.

Of course, I didn`t mind that to be not stabilized at 200 RA, can happend to anybody. I was talking about mind fixation on landing and the ability to recognise this situation. Pilot is just fellow human, and to fix to some particular aim is natural for man. The point is to be able to recognize this OR to have somebody in the cockpit who will recognize, if you as PF (doing not the right thing) are not able to do so.
Problem is when there are two which are not aware of the situation.
Man, this is quite common in accident reports, isn`t it?
:uhoh:

[ATC Watcher]

Doesnt realy matter if there was traffic behind him. There is no excuse other that a few extrem emergencies, that warrant to continue an unstabilized approach and fly over an aircraft that has passed the stop bars, to land long. None.
I am sure this fellow and his willing FO are not flying anymore. Thats reackless endangerment.

Interesting to see that those poor pilots caught in this mess should fear more from their fellow colleagues than from the authorities.

I was told Denmark has one of the best safety management system in the world and they even have a unique legislation passed that no-one will be prosecuted for reporting incidents.
An this is an incident right ?

If I was in charge of Safyety in Denmark I would spend far more time trying to find out what are the hidden causes that caused this to happen rather that crucifying in public 2 pilots.

For instance, has possibly the recent takeover of Sterling changed some things inside the company ?

That sorts of things would be interesting to investigate.

[DK_FCI]

Interesting to see that those poor pilots caught in this mess should fear more from their fellow colleagues than from the authorities.

I was told Denmark has one of the best safety management system in the world and they even have a unique legislation passed that no-one will be prosecuted for reporting incidents.
An this is an incident right ?

If I was in charge of Safyety in Denmark I would spend far more time trying to find out what are the hidden causes that caused this to happen rather that crucifying in public 2 pilots.

For instance, has possibly the recent takeover of Sterling changed some things inside the company ?

That sorts of things would be interesting to investigate.

Bang on - there has been a great deal of turmoil surrounding Sterling the past few years. Especially the merger of Sterling and Maersk Air has caused a great deal of stress on many of my freinds.

[Short Approach?]

I was told Denmark has one of the best safety management system in the world and they even have a unique legislation passed that no-one will be prosecuted for reporting incidents.
An this is an incident right ?

No-one will be prosecuted for UNDELIBERATE actions. You could still get canned. Not a major role here maybe, as both the Captain and ATCO will shortly be retired (age 63 and 60)

[JEP]

Re #25

I was just quoting the report:

The report states on page 2; the 3rd paragraph - "Due to subsequent traffic inbound EKCH, the pilots on (Sterling Aircraft) were instructed by the approach controller to maintain a high airspeed during descend and approach" (own translation).


I thought it could explain why the crew had their mind set on getting down and out of the way. Of course it does not justify landing without clearance, etc

[unablereqnavperf]

JEP
Only a fool would land from an approach in a jet like the 737 if the approach is still not stable by 200 feet. Most sensible airlines adopt the policy that if the approach is not stable at 500ft then you must go-around. As for landing deep of the approach it is equally as stupid!

These guys should be wearing spurs!

[LN-ATC]

10 points to Jack Pot for the summary.
I think we all must agree that there were at least three contributing parts. It will be very interesting to read why they all did such a "lousy job" that night.

[threemiles]

The approaching aircraft performed a visusal app, using auto-throttle and armed the auto-pilot to intercept ILS 22L. This caused the engines to spool up, and the aircraft commenced a climb as auto-pilot captured the glidepath inside 4 NM. 737-drivers: Is this "how to do it)?
from the link above

3.1.9
The 737 Flight Crew Training Manual (FCTM), Reference C, page 2.8, states: “when in manual flight, manual thrust control is recommended”. The approach was flown using autothrottle while in manual flight, contrary to the FCTM recommendation

[Payscale]

Yes ATC Watcher....maybe the poor captain was traumatized in childhood, which 30 years later led him to be afraid of taking command.
In my book (and the FOM) he broke several safety gates, eventually getting 20' from an aircraft. There is no excuse. It was with intent, since the judged his skills to be superior to the average bloke, who would have to G/A.

He took a COMMAND decision to continue. That warrants punishment. :D

[ManaAdaSystem]

63 year old Captain?

[unablereqnavperf]

Pay scale
Spot on I fully agree:D

[qsyenroute]

From the control tower I have seen so many scheduled arrivals make a 8alls up of a visual approach. e.g.

A 747 bouncing after touch-down after a staggeringly incompetent hand flown final approach path.

Captains’ requesting orbits at 4NM final after getting the height wrong, and then treating 200+ passengers to a guided tour of the undershoot area.

Other, equally big boys, lining up on the parallel taxiway and then enquiring in a haughty voice " xxxx Tower are you landing on 34L or 34R this morning”, when there is patently only one runway.

Traffic landing so deep into the runway that they are cordially invited back to the spot landing competition at the weekend.

The list is endless so it’s no surprise to an air traffic controller that this sort of incident can manifest itself. Thank goodness it happened in Denmark where they will investigate the “system” and not the hapless controller/pilot.

[Short Approach?]

It was the Sterling chief pilot flying. Could that have played a part, if the guy next to him was "fresh out of the academy"?

Hmmm :rolleyes:

[A4]

Is that the soon to be ex-Chief Pilot? Great example to set..... :hmm:

A4

[teleport]

politiken.dk reports today that another incident happened on Nov 8. (Apologies if a separate thread is open on this one - tried to find it)
CPH has decided to close V2 onto 22L.
However Danish AAIB not ready yet w. report.

[FlyByHeart]

The incident was actually on 9th of november, and there is a preliminary report on the Danish AAIB homepage here (http://www.hcl.dk/graphics/Synkron-Library/hcl/dokumenter/Redegorelser/2006/510-000282-LTH-fore.pdf) (sorry it's published in Danish only).

[JEP]

I think we are talking of 2 incidents:
one on 11 SEP and one on 08 NOV - link to the latter is here http://www.hcl.dk/graphics/Synkron-Library/hcl/dokumenter/Redegorelser/2006/510-000308-lth-fore.pdf (sorry still in Danish)

AAIB report on an older incident (SEP 2003) is out http://www.hcl.dk/graphics/Synkron-Library/hcl/dokumenter/Redegorelser/2003/47-03-lth-eng.pdf
in english this time

All 3 incidents took place in the same corner of the airport.

[FlyByHeart]

Stand corrected - thank you for the clarification JEP:ooh:

[teleport]

Final Danish AAIB report out:
Overall conclusion:

Runway usage bound by noise limitation reduced safety.
Pilots' and ATC's situational awareness was out of step w. reality leading to less than ideal decision making.
Several deviations from operational correction procedures occurred simultaneously.

In Danish 51 pages:
http://www.hcl.dk/graphics/Synkron-Library/hcl/dokumenter/Redegorelser/2006/510-000282%20endelig.pdf

[danishdynamite]

It doesn't say anything about the action taken against the pilots or atc if any was taken???

[Short Approach?]

None taken against the atc personell.

[A32A]

They do come that age nowadays You know, even older:sad: