Runway incursion at YYZ (driverless van)

[no expert]

Whoops!:\

Jet ignored order to abort landing after driverless van rolled across Pearson runway | Toronto Star (http://www.thestar.com/news/canada/2013/03/14/jet_ignored_order_to_abort_landing_after_driverless_van_roll ed_across_pearson_runway.html)

[konradeck]

Info from AVHERALD: Incident: Air Canada E190 at Toronto on Mar 11th 2013, did not follow two instructions to go around (http://avherald.com/h?article=45f30c80&opt=0)

[criss]

Proper phraseology anyone?

[dash7fan]

Full callsign, landing clearance cancelled, I say again landing clearance cancelled, (follow standard missed approach)

[clunckdriver]

Flight number with no operator prefix? Dear God, what standards have Nav Canada sunk to? Its not uncomon in North American airspace to have more than one flight with the same flight numbers, thats why SOPs are firm on using the operator prefix, time for some re -training methinks.Maybe if Nav Canada cut out the endless drivel such as " taxi on the ramp is at your own discression" folks might pay more attention to what ATC are saying, fourteen transmissions from ground in CYOW last week just to get to the runway, we were the ONLY aircraft moving! This stuff along with some "Chuck Yeager wanabees" who seem to think that VHF is just another phone system to chatter on are becoming a major problem in North America, they need to spend some time at LHR to see and hear how to do it. {with the exception of snow removal that is!}

[J.O.]

The LiveATC recording is not the full audio - the scanner software often clips the first second of a transmission. ATC tapes are in the hands of the TSB and it's already been stated that the controller did say "Air Canada" both times.

[clunckdriver]

So J.O. are we to understand that CYYZ Tower controler let go of the transmit button {or foot key, if CYYZ tower has such things installed}}between the two "go around" calls, thus causing the "Air Canada" prefix to be dropped twice by ATC Net? If so it again is in conflict with SOPs, reminds me of an RCAF incident way back when after a ground collision between a fighter and a comercial aircraft, all five tower tapes busted at the same time,{wink wink} ah well, they all make for good stories over a beer.

[bubbers44]

If call sign is not used as tapes seem to show pilots did not need to go around unless they saw a conflict in my opinion.

[no expert]

Transportation Safety Board is launching a formal investigation.

“The aircraft and the vehicle were very close, abnormally close,” said Ewan Tasker, a regional senior investigator with the board. “We see a lot of runway incursions where perhaps they were several thousand feet apart or one was further down the runway.“This one, you have an aircraft that is possibly as close 50 feet (about 15 metres), maybe even a little closer,” Tasker told the Star Friday. “It’s quite serious.”

Safety board launches probe of Pearson near-miss | Toronto Star (http://www.thestar.com/news/canada/2013/03/15/safety_board_launches_probe_of_pearson_nearmiss.html)

[ex-EGLL]

clunckdriver, from the AvHerald article

"178, go around" without response and repeated "178, go around", again without response.

This would suggest two separate transmissions from the tower controller. Given the way that web sites collect their audio (i.e. from scanners) it is very likely the first syllable of the transmissions could be clipped.

[J.O.]

So J.O. are we to understand that CYYZ Tower controler let go of the transmit button {or foot key, if CYYZ tower has such things installed}}between the two "go around" calls, thus causing the "Air Canada" prefix to be dropped twice by ATC Net? If so it again is in conflict with SOPs ...

There is a short break between the two go-around calls on ATC Net. This is not unexpected given that it's pretty natural for a controller to assume that a crew is going to hear and follow the go-around instruction the first time.

If call sign is not used as tapes seem to show pilots did not need to go around unless they saw a conflict in my opinion.

The ATC tapes do not show that, they show the controller using the full call sign. Only a second hand scanner recording shows that, but that recording is not official evidence in an investigation.

[DaveReidUK]

ATC tapes are in the hands of the TSB and it's already been stated that the controller did say "Air Canada" both times. Where, and by whom ? Do you have a link ?

Only TSB statement I can find is this one:

Transportation Safety Board of Canada - Transportation Safety Board of Canada deploys investigator to a runway incursion at the Toronto/Lester B. Pearson International Airport (http://www.tsb.gc.ca/eng/medias-media/deploiement-deployment/aviation/2013/a13o0045-20130315.asp)

which, as you would expect from an investigation that is in its initial stages, only gives a broad outline of the event.

[clunckdriver]

I think we have all overlooked the point that a few years back, all ramp equipment not only had to set brakes and all that other good stuff but were required to carry chocks that were mounted on the vehicle and had to be put in place if the driver was not in the cab, such very sound procedures seem to be a thing of the past, this along with outfits such as Sun Wing seem to be a case for going back to such procedures. On listning to other tapes from CYYZ tower the call signs seem to be quite clear, so lets wait for the TSB report, can only hope its not long in coming.

[no expert]

The van was apparently running and in gear (and unattended). We already have laws that make it an offence to leave the keys in the ignition of an unattended vehicle, and presumably in order to remove the keys you need to put the vehicle in "Park".

Of course, if the van had traveled through the perimeter fence it would have been in the City of Toronto, where a bylaw makes it illegal to leave an engine idling even if the driver is inside.:=

[J.O.]

Sorry DaveReidUK, my mistake, I thought it was posted here. I saw a posting by a YYZ controller on another (private) forum where he stated that it's been investigated internally and he said that the controller used the full call sign. I observed at one of NavCan's internal investigations several years ago and that's where I learned that the live ATC sites often clip the beginning of a transmission. When I listened to the recordings of this event, I clearly heard something being clipped at the start of his calls - not only the calls for the go-around but also 3 minutes earlier when he issued the landing clearance.

[WHBM]

There is a short break between the two go-around calls on ATC Net. This is not unexpected given that it's pretty natural for a controller to assume that a crew is going to hear and follow the go-around instruction the first time.
Fortunately here in the UK there are ICAO standards and therefore no such assumptions. It would be, all in one breath :

"Air Canada 123 Go Around I SAY AGAIN Air Canada 123 Go Around".

[clunckdriver]

WHBM, I think you will find that its meant to be said the same way over this side of the pond.

[Married a Canadian]

As I said on avcanada...I cannot believe the amount of people judging this incident AND the controller based on the liveatc recording and NOT the actual tapes themselves. Unbelievable people!!

It is all very well talking about shoddy RT standards..and what NAV Canada do and don't say...and how well they do stuff elsewhere etc etc. NONE of that has any bearing here if the controller issued a go around instruction using the full callsign. As someone who works in YYZ terminal...and hearing about the incident first hand..I would say with 99% confidence that the controller in question used the correct phraseology. The van side of things apart (and there will be a rather uncomfortable driver I think at this point)....we are getting into the rather dangerous territory of pilots either choosing to ignore an ATC instruction...or lacking spacial awareness at a phase of flight in which they couldn't possibly know if the runway is clear or not (just before midnight). People are trying to do the tower guys job for him it seems. Why bother issuing a landing clearance at all?

Maybe if Nav Canada cut out the endless drivel

Perspective of a pilot there Clunck.......ask ATC their opinion on a lot of the stuff pilots say when we are busy and we don't really need to hear it.
Also...it dosen't really matter if the controller didn't use the ICAO standard as the pilot still wouldn't have complied as he thought it wasn't for him....that is the whole point here.

[HS125]

We already have laws that make it an offence to leave the keys in the ignition of an unattended vehicle

That's interesting, I've worked at places where the policy was NOT to remove the keys from an unattended airside vehicle, the theory being that it can be moved in an emergency by anyone without the need to locate the individual with the keys.

in my experience the airport operators we're too busy allowing security/ground ops to shaft people for things like driving without a fastened hi-viz to entertain a reasonable debate about this kind of thing!

[clunckdriver]

"Married a Canuck," you make some good points, but you and I both know that Nav Can, under presure from way too many legal types is becoming a bloody joke, the main requirments to be a Nav Can manager is to have worked for a certain Nothern Airline, you have many good folks, some of who are good friends of mine, but when we, the nation which taught the world to fly, in two World Wars, and the Cold War,have to sub -contract to second rate ,of shore outfits to print our charts, then we both know we have a problem, CYYZ is, without a doubt, one of the worst tower/ground controll/ ATC facilities in the Western World, {there are many even worse, but Im talking about the Western World} you guys "Babble" so much that the normal human reaction is to either ignore you or try to filter out most of it, Im sorry to be so blunt, but Nav Can cost me $3200 last month in airways fees and you were more of a a bloody handicap to safe flight than a help! {Wow! I feel much better now!}Nothing personel, but the privitisation policy just aint working.

[no expert]

HS125, I was referring to laws intended to prevent vehicle theft, and I expect that law does not exempt airports. Nonetheless, I agree that it might make sense to leave keys in a vehicle airside, where there are no criminals.:suspect:

[Married a Canadian]

CYYZ is, without a doubt, one of the worst tower/ground controll/ ATC facilities in the Wetern World, {there are many even worse, but Im talking about the Wetern World} you guys "Babble" so much that the normal human reaction is to either ignore you or try to filter out most of it

Given that I work in said ATC facility I can't really say I agree...AND I have worked in the UK aswell which I know scores highly in a lot of ATC opinion polls worldwide. We work within the parameters set down for us in our manuals, by our training AND also the pilots that frequent through YYZ airspace on a daily basis and also land and depart at Pearson. As an operational controller in some of Canada's busiest airspace I would love to know what is and isn't considered "babble"....remember I am being told to say some of this stuff because some pilot once upon a time did something that requires it to be said. If you really are ignoring or filtering out most of what ATC is saying then you are opening yourself up to this type of incident happening. You tell the safety bods what you do and don't think is important..and I will gladly cut down some of the phraseology I have to use. Your opinions of NAV Canada as an entity should not overide the basic relationship between pilot and controller......and believe me from the other side....you guys are just as culpable as we are.

This incident is being discussed on the online forums with the controller in question being accused of not using proper phraseology..sounding laid back...that this wasn't really an issue as the plane landed safely etc etc.
The controller here did his job.....spotting a prime target on the ASDE at a time of night that some on the internet are saying is a time that "spatial awareness" could be lacking.....and issued the correct instruction to a soon to land aircraft because he couldn't guarantee that the runway was "sterile".

Now from that incident...even as a rough copy before the full investigation...I am not sure how that can rank up there as some of the worst ATC in the western world....especially as the view from the tower at night is not going to give a razor sharp clear view of a tiny van rolling across the threshold of 24R.

I don't normally feel this strongly on PPRUNE Or Avcanada...but tis difficult to keep low when assertions and bold statements are being made on an occasion when even before the official details are released the optics look OK for ATC but bad for the pilots (and the van driver). Criticize based on times when we have ****ed up.....not linking it to this incident when my colleague in the tower did the job that a Western world controller should do.

[SEIFR]

I would like to hear an example of the YYZ ATC "Babble".
I have been the cause of an overshoot :(. And I got to say the controller made everyone on frequency completely aware of what was going on and why the guys in the 737 behind me needed to practice their circuit procedure. Before I pass blame on anyone though I would really like to hear the actual TWR recordings.
The Van driver should get his license suspended...but I could be jumping to a conclusion there too. Maybe it was a vehicle problem.

[clunckdriver]

In the last copy of "P X", the magazine of the "Retired Airline Pilots Of Canada" there is a very well writen and amusing article about what is wrong with ATC at CYYZ, If anyone could post it here it sums up the failings of Nav Canada in a nutshell, I cant copy it as I sent the publication to a friend in Germany {a controller by the way}to illustrate the very points being made here!

[Beefheart]

Total shock you can't cut and paste your spectacular editorial supposedly authored by a bunch of dementia ridden senior citizens clunck. Probably doesn't exist and if it does, it probably holds as much water as the average mainstream media report citing LiveAtc as the primary source. Been CT'd before?

[Annex14]

Total shock on my side of the pond that someone in wonderful Canada seems to believe that the world end at the horizon line of his bush cabin !!
Like to suggest you better check first to whom you send what kind of message.

By the way, I have just made a copy of that mentioned article, though I am almost as old as clunck!!
No hard feelings please !!

[Johnny767]

My view is YZ ATC does a fantastic job, with limited resources.

They are constrained by a very poor runway (airport) layout, brutal Airport Authority (The GTAA,) and possibly a MANOPS that is in desperate need of updating.

As for the individual Controllers, I would match them up with anyone.

[Married a Canadian]

brutal Airport Authority (The GTAA,)

Hear hear....with apologies that anyone that works for them..but they really make the job a lot more difficult for us than it needs to be....and the winter shennanigans this year...in my opinion..have been an embarrassment.

[Annex14]

Sorry, was busy with other tasks. But here the promised copy of the PX article on behalf of clunkdriver

http://i1308.photobucket.com/albums/s610/JoLi40/ATCYYZ041_zps81cf177c.jpg

[Beefheart]

Many thanks Annex14. The author used just enough poetic license to deem this article fictitious.

[a330pilotcanada]

As a suggestion to all, tone down the level of mud throwing and how about this for a novel concept? Wait for the report to be published!!

As one who has used ATC services from South America, Central America, North America, Europe, Asia, Middle East etc my option is this best service is the U.K. Followed in short order Germany and Switzerland.

For YYZ consider this the GTAA and Nav Canada are the guilty parties NOT the controllers who work in the set of regulations set upon them by previous mentioned agencies. In YYZ my most favourite controller was " ROG" now since retired who worked through the hoops but had fun doing so. For the 06:00 curfew he nailed the speed control so well at 400 feet clock went from 05:59 to 06:00 now that was great work.

A message for Beefheart I think you have had 5 posts in 9 years (?) and if you can not contribute in a thoughtful manner please do the community a favour by not posting.

[Beefheart]

a330pilotcanada:

How thoughtful is it to cut and paste an out of date, factually inaccurate and basically irrelevant article? Highlighting the fact that the author misled his readers by offering up "embellished" yet easily verifiable data actually serves this community quite well and I believe it is our collective responsibility to continue to do so.

[Married a Canadian]

Just read the article..bit difficult to take it seriously given how out of date it is. The most amusing part for me was "London Heathrow is 4 times busier than Toronto" which with my rough count would mean Heathrow does something like 1.6 million movements a year...at the current time. Hmmmmm!

Anyway...not much more to add on this subject until said report comes out.
I will also say....having worked in the much loved UK air traffic control system....we had the same complaints over there from the local pilots as I get over here. Just a matter of perspective really. Mr Speedbird told me the other week that it was a pleasure to fly into YYZ (winter ops and all) as opposed to his home base.....I could hear the Air Canada bods snorting on the frequency!
Just ask the London GA community about Heathrow and it's class A zone.

Anyway..safe flying to all...and please answer me by my second transmission.

[clunckdriver]

A330 Pilot, well said, in one thread "Beef" has accused three of us of lying, this in spite of the said "non existant article" now having been cut and pasted to PPrune, {from Germany by the way, where as I stated my copy finished up} I doubt seeing his other posts we will see a retraction of these acusations. As you know, my wife is a retired Air Taffic Contoller, her comment on reading his ramble was, "he reminds me of a very unhappy chap we had in P--- tower who didnt make it beyond the B stand". We may be critical of CYYZ, this may upset "Married a Canadian", but we agree to disagree without spouting such vitriol at each other. and MAC, Speedbird was just happy to hear a "home town voice" methinks, or trying to get you to buy the beer, you know how cheap us pilots are!

[babysitter101]

Can we not all be patient enough to wait for the TSB findings before assuming ATC messed up? As far as i know an Air Canada pilot was instructed twice to go around and did not comply! Why he didn't go around ? Who knows? It's the TSB's job to figure that out. And i'm assuming clunckdriver is probably one of the reasons so many transmissions have to be made between pilots and controllers. He doesn't come across as a very good listener....

[babysitter101]

Sorry, forgot to add...

The proper phraseology is "(callsign eg ACA123), pull up and go around" Nothing more, nothing less!. Usually we'll add a heading and altitude in the initial instruction but some of us don't do that anymore cause it's always missed. A few seconds later we'll give the heading and altitude, although, in this case he never got the chance cause he was still trying to get the guy to go around!

[Beefheart]

Clunck:

I was half wrong. The article does actually exist. I sincerely apologize for doubting that. That said and based on the actual content of said article, I'm absolutely ecstatic it's still out there.

[babysitter101]

What "Married a Canadian" Said!!!!

Wasn't sure what i can say, seeing how i'm new here... ATC was completely and totally spot on in this instance! The mere fact that tower even saw the vehicle on ASDE was incredible! I would like an explanation from someone as to how an instruction to go around was completely ignored?

Aside from that, I understand why some pilots may think YYZ Ground "over controls" or "talks too much". You guys really need to understand that it's one controller vs god knows how many pilots at any given time. How many of the pilots out there have ever had to ask "who's first?" in Toronto? It's a long way from AL to RWY 23, even further to 05. Do you expect the ground controller to have his eyes on you and you alone the whole way there?

[peekay4]

FYI the Canadian Transportation Safety Board official report regarding this incident was recently released:

http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2013/a13o0045/a13o0045.pdf

[hoofie]

A very interesting read that report.

It's interesting to see the "Holes in the Swiss Cheese" line up - van in drive, dim beacon on van, detection systems too slow, electronic delays in radio traffic, crew concentrating on landing - and luckily this time without a bad result. I though the consideration that the last thing the crew would expect at that exact point was a go-around and nothing visible on the ground was interesting.

Speaking as a non-aviator but as an engineer it's very instructive.

[FullWings]

Yes, an interesting factual report. The first go-around instruction was masked by a louder EGPWS standard callout and the second one had the callsign clipped off it, leading the crew to disregard it as they couldn’t see any reason to go-around.

As hoofie says, lots of cheesy holes lining up. The good news is that it was such an unusual alignment of circumstances, it is unlikely to occur very frequently. Where’s the red Very Pistol when you need it? ;)

[phiggsbroadband]

Just a couple of things that I noticed from this side of the pond..


'The tower controller requested an inspection and an unoccupied Sunwing Airlines van was found with the engine running, engaged in gear'....


Which seems to imply that the vehicle had automatic transmission, and an ineffective handbrake. Surely these type of vehicles should not be left unattended with the engine running... EVER...


Also the non-standard ATC Instruction to 'Pull Up' does not seem to be too wise for an aircraft already in a high nose attitude, nearing the flair and stall.


.

[cossack]

"Pull up and go-around" is still the correct phraseology on this side of the pond and until it is officially changed, that's what will be used. Its only been about 5 years or so since we finally got rid of "Taxi to position and hold".:rolleyes:

The influence of the big ATC system to our south is very strong and changes happen at a glacial pace. But at least we can say "Cleared ILS approach".;)

[deptrai]

Emotions are flying high again... nice thread, a lot of drama, but we're still missing conspiracy theories.

[mary meagher]

Interesting report. What is not clear to me is the position of the van at the critical moment....when the aircrew should have seen it. As nobody in the tower or on the ground had a good look at it, due to the dim light on the top of the van and the outdated ground intrustion alert system, it seems to me the van may have rolled across the runway and into the grass by the taxiway by the time the aircraft would have entered the flare.

The aircrew says they didn't see any obstruction on the runway. Alas, the CVR was overwritten...perhaps this hole in the cheese should be nailed shut without delay.

How can emergency ATC transmissions be enhanced so not to be overlooked?
The only time I was given an emergency order - TURN LEFT NOW!!!!! from the glider I was towing, the tone of voice left no doubt. We would have had a midair had he not got my immediate attention, as the other aircraft was not visible from the highwing tug.

[Chu Chu]

Funny to see the "driverless van" thread next to the one on drones . . .

[eppy]

I've never seen 9 slices of Swiss Cheese have their holes lined up before, but this is what we see in this case.

Lots of lessons learned here, but it was way too close. Had the aircraft landed on the piano keys or threshold, we could well have been conducting an autopsy on a major accident.

[J.O.]

Which seems to imply that the vehicle had automatic transmission, and an ineffective handbrake. Surely these type of vehicles should not be left unattended with the engine running... EVER...
.

That is supposed to be what is done. Every airside vehicle operator at YYZ is licensed and they are trained to shut off the engine whenever they are leaving the vehicle.

[India Four Two]

Which seems to imply that the vehicle had automatic transmission, and an ineffective handbrake. Surely these type of vehicles should not be left unattended with the engine running... EVER...phiggsbroadband,

You've probably never lived through a Canadian winter :)

It is quite common on winter mornings, to see cars running, with the doors locked, while the owner waits inside until it warms up. You can even buy remote starters, that allow you to start the car from inside your house!

As far as this incident is concerned, it is clear that after the driver moved the van forward a few feet, he forgot to put it in Park in his haste to get out and take over the shutting of the aircraft door.

The "handbrake" on this van, like most North American vehicles, is a foot-pedal, to the left of the brake pedal, with a ratchet to hold it on. It is referred to as the Emergency Brake, and is hardly ever used in normal driving. Most drivers, including me, rely on the Park setting of the transmission, unless on a steep hill.

[Ancient-Mariner]

Certainly as interesting read.


I am a little puzzled though about the cockpit audio report on page 5.
This seems to have precise timing of each spoken phrase, either crew, radio or EGPWS, which implies from a CVR; yet page 7 relates how there was an hour delay after arriving at Ottawa before the DVDRs power was disconnected as requested by the TSB. Google tells me that the flight time from Toronto to Ottawa is one hour, so with a 2-hour recording capability, does this add up?


Cheers!

[windowjob]

All this discussion about the van, whether it was in park, the engine running etc is all very interesting but for me the important bit was that despite being ordered to go around twice the plane didn't!

Yes there were various factors why the crew didn't but this aspect seems to have been ignored!
The automatic announcements drowned out the first one, the crew didn't see anything (sorry that don't wash, when it's dark and you're concentrating on touchdown point, chances of seeing anything else is small) the crew discussed the second call and decided it wasn't for them - what about "if in doubt ask"
Where are the recommendations regarding all of this?

Next time you send someone round will you really expect them to pull up now?

[DaveReidUK]

Yes there were various factors why the crew didn't but this aspect seems to have been ignored!

Are you saying that having read the investigation report ?

[Ian W]

Certainly as interesting read.


I am a little puzzled though about the cockpit audio report on page 5.
This seems to have precise timing of each spoken phrase, either crew, radio or EGPWS, which implies from a CVR; yet page 7 relates how there was an hour delay after arriving at Ottawa before the DVDRs power was disconnected as requested by the TSB. Google tells me that the flight time from Toronto to Ottawa is one hour, so with a 2-hour recording capability, does this add up?

Incident on landing.
1 hour turnaround (or more)
1 hour flight to Ottawa
Ground crew enter and :mad: for an hour

3 hours from incident - even disconnection immediately may have lost the information.
Yet another reason for shelling out another 50c for a larger SD card.

[SLFguy]

3 hours from incident - even disconnection immediately may have lost the information.

I may have the wrong end of the stick but that's his point.. it wasn't lost and his question is 'why not?'.

[Interested Passenger]

Interesting report. It's unlikely most of the events would be repeated, an empty vehicle left in drive, aimed at a runway, with a dim beacon, passing directly under a landing plane.

However a crew about to land, missing an important audible instruction, due to noise in the cabin, or being 'fixated' on the visual side of the landing is more likely to be repeated.

How about the ATC positions being fitted with big red mushroom emergency stop style buttons, which immediately activate a big red X on both sides of the runway, and transmit on all frequencies, the carefully pronounced "short pause ALL AIRCRAFT ON APPROACH, PULL UP AND GO AROUND" pre recorded message.

That saves the controller having to identify the aircraft, it gives the crew a visual stimulus, and requires technology I have available in my shed.

(Stephen Fry or Joanna Lumley would be ideal for the announcement.)

[Ian W]

I may have the wrong end of the stick but that's his point.. it wasn't lost and his question is 'why not?'.

From the report (my highlighting) :

The aircraft is equipped with 2 digital voice–data recorders (DVDRs), which are capable of recording 2 hours of cockpit audio. At the TSB’s request, the crew of C-FLWH’s subsequent flight from Toronto to Ottawa was instructed by Air Canada Operations to disconnect power to the DVDRs upon arrival in Ottawa. The flight crew was met by company maintenance staff at the gate who informed the flight crew that they would do it. The maintenance crew did not disconnect the power to the DVDRs until an hour later, and the relevant cockpit voice data was overwritten. The TSB’s review of the company maintenance control manual determined that the guidance on how to perform this procedure was unclear.

The information from the CVR was lost. Had the CVR had more capacity then the information would not be lost. There is no reason for the CVR to be limited to 2 hours duration only.

In this case it would have been extremely useful to be able to hear what the go-around calls sounded like from the aircraft viewpoint rather than the transmitting station's viewpoint. Also the discussion in the cockpit - the "was that for us" would have been useful.

[Ancient-Mariner]

The point that I was trying to make; with some uncertainty because I don't know how long the a/c was on the ground at Toronto nor the flight time to Ottawa, was where did the appearingly accurate time-stamps come from for the table on page 5 of the report and indeed the audio, where at the bottom of page 4 it says:
"Once below 500 feet above ground level (agl) on the approach, the following audio occurred in the cockpit" [my emphasis]

The listed sources of message suggest that a CVR (with time stamping) was in fact running, which is contrary to the statement on page 7 that the cockpit voice data was overwritten (due to 2 hour duration of the DVDR memory.

[NigelOnDraft]

DFDR likely records EGPWS callouts - not as audio, but events...

[NigelOnDraft]

The automatic announcements drowned out the first one, the crew didn't see anything (sorry that don't wash, when it's dark and you're concentrating on touchdown point, chances of seeing anything else is small) the crew discussed the second call and decided it wasn't for them - what about "if in doubt ask"
Where are the recommendations regarding all of this?

Next time you send someone round will you really expect them to pull up now? The sounds on a modern flight deck nearing the ground are too many to expect an R/T call, however urgent, to get through.

Between all the EGPWS calls (Rad Alts, Minima), SOP calls, Airbus "Retard" let alone intercom chatter, some of these get missed. I am only subconsciously listening for an ATC call, since "Cleared to Land" is the last call I expect. A strongly worded call like used in the UK, presumably introduced as a result of experience, stands the best chance (repeated, emphasised) of getting through and not getting drowned out.

[netstruggler]

As hoofie says, lots of cheesy holes lining up. The good news is that it was such an unusual alignment of circumstances, it is unlikely to occur very frequently. Where’s the red Very Pistol when you need it?

Possibly interesting to consider this incident alongside this one from 2006, Boeing 737-300, registration OO-TND at Nottingham East Midlands Airport (http://www.aaib.gov.uk/cms_resources.cfm?file=/5-2008%20%20OO-TND.pdf),

... which also involved an ATC call just before landing that failed to produce its intended result, and pilots 'blocking' cues to 'Go Around' while focussed on the landing.

In any case the above report is a good read and has a happy ending.