Qatar Airways Miami Accdent, initial report

[Cheesaburger]

Preliminary Occurrence Report QR778 released | Civil Aviation Authority (http://www.caa.gov.qa/en/preliminary-occurrence-report-qr778-released)

[Sqwak7700]

Very poorly written report. I know it is only preliminary, but they add more confusion to the matter instead of answering any questions.

They left so much crucial information out of the report that it makes it impossible to understand. It sounds like the Onboard Perf. Tool gave them data for 9 from T1. But the report mentions a NOTAM and does not go on to say what that NOTAM says.

Hopefully the FAA will release their own report and investigation.

:confused:

[SiClick]

"The OPT offered the crew only one option for Runway 09, which was ‘09#T1’ as displayed by the OPT. This was understood by the crews to mean Runway 09 full length, although the performance data had been pre-modified by a temporary NOTAM."

Seems pretty clear to me, the crew thought they were going for full length, but then saw T1 and mistook it for taxiway T1

[StickMonkey3]

Reasons for Always Choosing Daytime Flights and Good Weather #431 (in a never-ending modern series.)



I make an exception for Icelandair - it's often dark up there - they're used to it. ;)

[Jwscud]

No mention of duty hours or rest on the layover either, which will make interesting reading.

[Sireh]

Quote:
Seems pretty clear to me, the crew thought they were going for full length, but then saw T1 and mistook it for taxiway T1
Jolly good, that's another one fixed, then.

As others have suggested, there may be lots of contributors to this one, some of them classics. If the final report is done well, it could be useful to learn from.

But with the pressure vessel breached and approach lights damaged, I'm puzzled why the NTSB doesn't appear to be investigating or why it doesn't seem to appear in the FAA incident database. Did I see an earlier comment along these lines that has now disappeared, or was it another event?



The airline is the jewel in the Emirate's crown. Their establishment has very deep pockets and very compelling influence in the corridors of power in the so called paragon of democracy!:E

[HEATHROW DIRECTOR]

Does Miami not have ground radar?

[peekay4]

@LookingForAJob

NTSB delegated the investigation to Qatar CAA.

NTSB Identification: DCA15WA198 (http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150923X00156)

14 CFR Part 129: Foreign Qatar Airways
Incident occurred Tuesday, September 15, 2015 in Miami, FL
Aircraft: BOEING 777, registration:
Injuries: 279 Uninjured.

The foreign authority was the source of this information.

The National Transportation Safety Board (NTSB) has delegated the investigation of an incident involving a Qatar Airways Boeing 777-300, that occurred on September 15, 2015, to the Civil Aviation Authority (CAA) of Qatar. The NTSB has appointed a U.S. Accredited Representative to assist the CAA investigation under the provisions of ICAO Annex 13 as the State of Manufacturer and Design of the airplane.

All investigative information will be released by the Qatar CAA.

[EGPFlyer]

Does Miami not have ground radar?

I'm sure they do but it's irrelevant... The controllers knew exactly where they were. I'm assuming that the restriction on not using an intersection on that runway is a company one. T1 is a perfectly legitimate take off point (~2600m remaining) so if a crew says they can accept take off from there then the controllers wouldn't query it.

[M.Mouse]

"The OPT offered the crew only one option for Runway 09, which was ‘09#T1’

On the face of it a bizarre designation for full length when there is an intersection called T1!

[JanetFlight]

I wouldnt imagine at QTR a 773 PIC with 38 years old... :ok:

[Sqwak7700]

Seems pretty clear to me, the crew thought they were going for full length, but then saw T1 and mistook it for taxiway T1


OK, so you are saying that the "#T1" designation stood for temporary NOTAM, not for T1 Intersection. I understand that, and it seems the crew understood that by the statement:

This was understood by the crews to mean Runway 09 full length,

But it still does not explain what the temporary NOTAM was. And it sounds like the relief crew understood this was not full length but did not intervene. Surprised they allowed their concerns to be dismissed with a hand wave.

Takeoff performance procedures are often written in blood or very brown shorts, as they soon found out.

Another thing, the timing does not seem right. It shows Miami being only 6hrs behind Doha. I thought it was 8hrs, making it 0412 time in the morning for the crew.

[framer]

"The OPT offered the crew only one option for Runway 09, which was ‘09#T1’
On the face of it a bizarre designation for full length when there is an intersection called T1!
I think there is quite a threat to operations world wide hidden in what you say there.
The way information is presented to us now days is different. We become more and more accepting of computer generated information as each year passes. A lot of that information is generated by people with computer skills, but no aviation experience.
Personally I feel like basic gross error checks and rules of thumb are becoming more and more important as I get older because of this very fact.
I think there were many contributing factors here but one of them was the use of #T1 on the OPT. One other glaring factor was the Captains choice to not actively investigate ambiguity ( re concerns from other crew members).

[gcal]

'One other glaring factor was the Captains choice to not actively investigate ambiguity ( re concerns from other crew members)'

That for me is the most glaring thing about the incident.
Without reading the thread again I believe there were enough people with doubts on that flight deck and that should, at very least, have caused some concern.

[Hotel Tango]

That for me is the most glaring thing about the incident.
Without reading the thread again I believe there were enough people with doubts on that flight deck and that should, at very least, have caused some concern.

And which shows, alarmingly, that lessons have still not been learned. Was rank and culture once again the enemy?

[gcal]

I know it is always the old ones that are going to get you.
Didn't BA have a narrow squeak in the W. Indies a couple of years ago in vaguely similar circumstances? But in daylight if my memory serves me right.

[DaveReidUK]

Didn't BA have a narrow squeak in the W. Indies a couple of years ago in vaguely similar circumstances? But in daylight if my memory serves me right.

Rather longer ago than that: St Kitts, 26th September 2009. BA 777 crew misidentified the intersection from which they were departing, giving them a TORA some 700m less than anticipated.

[racedo]

NTSB delegated the investigation to Qatar CAA.

Is this standard practice ?

[Smilin_Ed]

To me this a case of gethomeitis combined with loss of situation awareness. "Lets get in the air and on the way home and everything will be OK" :ugh:

And yes, I'm guilty too. It just happened that for me there were no problems as a result.

[PeetD]

Forgive the post from SLF (who may be stating the obvious) but why when entering the runway from the taxiway, where you see the big red sign saying something like "27L/09R" is there not a sign that also says "3000m" or something that tells you what the runway length is from that location? Wouldn't that be useful to help ground navigation and avoid entering at the wrong point?

[RAT 5]

Indeed often there are. I do not know if it is local 'bon ideé' or EASA/FAA thing, but it surely is a great idea. However, if you line up at the end of the runway, universally, you will see TWO BIG numbers in front of you, plus all the landing point white paint indicators. If all you see is black-top and a few centre line stripes then you ain't where you think you are. That's basic.

[pattern_is_full]

@ Rat 5

However, if you line up at the end of the runway, universally, you will see TWO BIG numbers in front of you, plus all the landing point white paint indicators. If all you see is black-top and a few centre line stripes then you ain't where you think you are.You did read the report?

From the AH version:

"As they taxied along S the commander decided that the aircraft could depart from the runway intersection T1. He could not recall why he made that decision, but believed it may have been because the printed information displayed ‘Runway 09#T1’ in a compelling way. The printed information contained no reference to the fact intersection departures were not permissible from this runway (Figure 3), and contained the message ‘No NOTAM data found’. The commander requested the operating first officer to advise ATC that they were able to depart from intersection T1. The first officer glanced at his notes and saw he had written ‘09/(T1)#’, which made him believe that this was an acceptable line-up point for take-off, [therefore] he called ATC advising them that they were able to take T1 for departure from Runway 09..."

They were exactly where they thought they were (intersection T1), and had no reason to expect to see the runway threshold or numbers from that location.

The problem was the TO performance calculations were for full length, but the "typography" of the electronic pad shorthand was - ambiguous.

BTW the electronic airport map , as depicted on AH, seems to have a major error. It shows taxiway T as running the full length of 09/27, but T actually dead-ends at the T1 intersection where this flight chose to TO.

@ Smilin_Ed

To me this a case of gethomeitis combined with loss of situation awareness. "Lets get in the air and on the way home and everything will be OK"Not sure whether you mean before, or after, the TO roll, but the report points out that ATC was asking them to expedite their TO:

"The aircraft was then cleared to line-up with another aircraft reported on final approach, requiring an expeditious departure."

Interestingly, there was even an attempt at CRM, that was misinterpreted and thus failed:

"As this was not what relief crew recalled had been briefed, they queried T1. The commander made a hand gesture and said something which he thought was seeking reassurance from the crew that everything was OK. The operating first officer confirmed that he was content with T1, but the relief crew interpreted the commander’s communication as him confirming he was content with a T1 departure so, thinking they had missed the operating pilots recalculating the take-off performance from T1... did not voice any further concerns."

PIC always bears the ultimate responsibility - but this is another of those cases where the universe conspired against him. "Murphy's Law" will sneak through any crack in your defenses, if you let it. Be hyper-vigilant. Excuses don't count if you're dead.

[EMIT]

RAT5,

If you line up full length RW09 at MIA, you are a couple hundred meters in front of the displaced threshold, so the big numbers will be out of sight in front of you. You will still be in the approach light area with barettes, no centreline lights yet, etcetera. (still, of course, enough clues available for correct identification of position)

[twochai]

Qatar Airways Chairman says:

"At no time was the aircraft or the passengers put in any harms way.”

“Such kind of incidents happen quite often, either it is a tail strike on the runway or it is contact with the landing lights,” says Al Baker. “It is nothing out of context.”

Is he kidding? Is not the top man supposed lead the safety culture at any airline?

Count me out - I won't ride QR again!

[mary meagher]

The NTSB delegated the investigation to the Qatar CAA, and the preliminary report appears to be straightforward and to flag up some serious misunderstandings.

First, it makes sense for the Qatar people to make the report as they will understand what was said on the flight deck. The good news is that the relief crew did question the captain, but he carried on regardless and took off from a taxiway intersection, causing a small rip in the 777 fuselage. This was compensated by the aft outflow valve maintaining correct pressure during the flight back to Qatar. A long way to fly with a hole in your aircraft...after an encounter with a light fixture on takeoff!

In a perfect world, the Captain would have listened to the doubts of the relief crew and rejected the marginal takeoff. Seems to me that ATC could have raised some doubts as well, instead of piling on the pressure with traffic on approach.

[Longtimer]

Culture of denial?
https://www.flightglobal.com/news/articles/qatar-chief-points-to-air-traffic-control-in-miami-c-419912/

Qatar chief points to air traffic control in Miami collision 09 December, 2015
| BY: Edward Russell
| New York


Qatar Airways chief Akbar Al Baker says instructions from air traffic controllers resulted in the September runway light collision in Miami, despite evidence of confusion in the cockpit.

“It was an instruction given to our pilot by the air traffic control, which he should have refused to accept,” says Al Baker at a media event in New York today. “However, he had enough runway for getting airborne and it was only an unfortunate incident. At no time was the aircraft or the passengers put in any harms way.”

Al Baker’s comments differ markedly from preliminary findings from the Qatari civil aviation authority on the incident earlier in December.

Investigators found that the captain of the Qatar Boeing 777-300ER chose to depart from the T1 intersection of runway 09 at Miami International airport despite carrying out the calculations for a full-length runway departure and despite a prohibition on intersection take offs from this runway.

Neither the captain nor the three other crew members in the cockpit realised that the T1 intersection was some 1,000m from the beginning of runway 09, leaving the 342t aircraft with only 2,610m available for the departure, the investigation finds.

No where do the initial findings suggest that air traffic controllers told the pilots to take off from the T1 intersection. They do say that the first officer advised air traffic controllers that the intersection was an acceptable line-up point for take off.

The Qatar 777, operating flight 778, continued to Doha even after overrunning running 09 and striking the approach lights on departure.

“Such kind of incidents happen quite often, either it is a tail strike on the runway or it is contact with the landing lights,” says Al Baker. “It is nothing out of context.”

[Fuel Dump]

Oh yes... Super normal to overun the runway and take some approach lights with you. Happens every day. Dangerous? Of course not! A perfectly calculated manoeuvre!

Sad to say the least, hearing this from their top man.

[captjns]

Such kind of incidents happen quite often, either it is a tail strike on the runway or it is contact with the landing lights,” says Al Baker. “It is nothing out of context.”

I nominate Al Baker to be the next inductee into the Charles Darwin Hall of Fame. Al Baker, being so stupid, will consider this to me a monumental honor.:ugh:

But wait a minute. Calling Al Baker stupid is an insult to those who are just plane stupid:}

[racedo]

“Such kind of incidents happen quite often, either it is a tail strike on the runway or it is contact with the landing lights,” says Al Baker. “It is nothing out of context.”

This is probably the scariest thing I have seen in Aviation in years.
An admittance that practices are not just poor but dangerous to anybody travelling.
I doubt I will be using.

[CONF iture]

BTW the electronic airport map , as depicted on AH, seems to have a major error. It shows taxiway T as running the full length of 09/27, but T actually dead-ends at the T1 intersection where this flight chose to TO.
There is no error - Figure 2 is a screen shot of airport information chart, as displayed on the commanders EFB - It is not the full chart - At that time it was zoomed in and it is very possible the captain thought using T1 was giving full length or so for runway 09.
Is it a case where using the 'old' conventional paper chart would have saved the situation ... ?

[pattern_is_full]

Upon further review - you are correct, sir.

(What did I say about the universe being out to get us, if we let it? :\ )

[Global_Global]

“Such kind of incidents happen quite often, either it is a tail strike on the runway or it is contact with the landing lights,” says Al Baker. “It is nothing out of context.” Scary if that is the response from the top.... Makes you doubt about the safety culture. Nowadays the PR 101 on accidents for CEO's is simple: apologize for any inconvenience/casualties etc and say that you await the full report... :=

[ShotOne]

The fact that you made that mistake, pattern is full, after looking at the same info available to the Captain, is revealing. Our own aircraft were fitted with on airport nav system a while back. On the face of it, it makes this sort of mix-up impossible. In reality, turn offs and intersections aren't marked very clearly; while the system is valuable in helping prevent runway incursions, it's not so useful at identifying a particular entry/exit point.

[Sqwak7700]

I blame the NTSB for letting the Qatari authorities investigate. There is no way they can be impartial, just look at what their ignoramus CEO thinks of such an event. The man should not be allowed within 50ft of a safety related job after such garbage spewing from his pie-hole.

Unbelievable. The FAA and the NTSB should be fully involved in this investigation. Had this aircraft crashed (and it came about as close as you can without actually crashing), who knows how many people on the ground would have been hurt. Miami is a pretty densely populated area.

A 777 rotates on the grass, and it Qatar's excuse is "it happens all the time".

[peekay4]

CEO of Qatar Airways is not the head of Qatar CAA.

Qatar CAA seems to be doing a good job with the investigation so far. They could've "buried" the initial report if they wanted to -- e.g., delay its production ad infinitum -- but they didn't.

[JammedStab]

Perhaps they have been told in no uncertain terms by the NTSB that they will fully review the report and create a dissenting report if needed. Like was done with the Silk Air report from Indonesia.

[45989]

Staggering to see the innate response.
These guys made a mistake. **** happens.
last thing required is a volley of armchair warriors most of whom have never got further than microsoft flight sim poking their noses in.
As a pilots forum this place has become a joke

[Capn Bloggs]

These guys made a mistake. **** happens.

Says the Head of Safety, Flybynightairlines.com :D

[racedo]

Staggering to see the innate response.
These guys made a mistake. **** happens.
last thing required is a volley of armchair warriors most of whom have never got further than microsoft flight sim poking their noses in.
As a pilots forum this place has become a joke

Its not the mistake that people get upset or annoyed about its the cover up and white washing of it that grates.

[framer]

The fact that you made that mistake, pattern is full, after looking at the same info available to the Captain, is revealing.
Bingo.
and it came about as close as you can without actually crashing), That award goes to EK407 in YMML, The structure they hit was below the height of the runway. ie if they were on a runway that didn't have terrain that falls away beneath the aircraft they would have gone in.
As for the CEO's statement....... Tosser.

[DaveReidUK]

That award goes to EK407 in YMML, The structure they hit was below the height of the runway. ie if they were on a runway that didn't have terrain that falls away beneath the aircraft they would have gone in.

Worth a read:

https://www.atsb.gov.au/media/2229778/ar2009052.pdf - "Take-off performance calculation and entry errors: A global perspective", study carried out by the ATSB following the Emirates incident at Melbourne.

https://www.atsb.gov.au/media/3531728/ao2009012_full%20report.pdf - Final report on the incident itself

[slowjet]

For the first time , ever, I think, at last , this CEO seems to be supporting his pilots. Gotta be a first.

[HeavyMetallist]

It does nobody any favours, least of all his pilots, for the CEO to be in denial about the safety implications of a very near miss.

[Capn Bloggs]

For the first time , ever, I think, at last , this CEO seems to be supporting his pilots. Gotta be a first.
Is that so? I don't see "his pilots" waving this away as just one of those things that happen...

[No Fly Zone]

Yup! Stuff happens.
My question is why tablecloth Al Baker's claims are about 180 degrees at odds with the DFDR and DCVR? Does Akbar really believe that anyone believes his 'spin?' I cannot believe that he is that ill-informed. The the pilots were unfortunate enough to be expat contractors of some kind, I'd guess that they were escorted out of Qatar months ago, never to return. If they are U.S. certificated, I'd hope that they have made themselves known to NTSB. Again, yes, stuff happens, but burying it in the sand is not the way to improve anything. (Qatar has more than enough sand for Akbar's head.) If even one of these fellows was a U.S. licensed pilot, he owes it to the safety record to discuss the event with FAA and NTSB.
As for the flight itself, continuing without a thorough inspection was stupid. Everyone aboard likely knew that a collision had occurred. If only to please Akbar, they took the airplane home and probably hid it. If there is no damaged airplane to view, Akbar can (try to) sell almost anything he wishes. What a bad joke.:=

[slowjet]

Yes Bloggsie; That IS so. Not talking about the pilots or the incident but about the CEO who, in the past, would never stand up and legitimise for ANYTHING done by pilots for whom he has profound disrespect. In THAT context, it IS a first. Not saying it was right either. Just a first for this fella. Need more help ?

[Capn Bloggs]

Nah, thanks SJ. I think I now know where you're coming from...

[peekay4]

Seems to me the CEO is saying that (his) pilots are such unprofessional idiots that these kinds of incidents happen all the time.

Hard to characterize that as being "supportive"...

[Gordomac]

Peek ; you are missing it too. I am with Bloggsie in seeing where SJ is coming from.

[Stone_cold]

SJ . I see nothing where he is supporting anything the pilots do/did .

This was an accident and his statements appear to be neutral , probably carefully advised , so as not to point a finger at the airline and at the same time deflect attention away from a very public event in a failed attempt at being facetious . He actually said that the pilots SHOULD have refused ATC . Doesn't seem like he is defending their actions . At this point he cannot publicly throw the crew under the bus as it would have implications for "his" airline .

[BANANASBANANAS]

slowjet

Join Date: Jun 2007
Location: London
Posts: 263
For the first time , ever, I think, at last , this CEO seems to be supporting his pilots. Gotta be a first.

Its got nothing whatsoever to do with supporting the pilots.

It has everything to do with damage limitation to the brand.

[Phantom Driver]

Back to main points----

It does appear that QR 778 and the tower both thought they were taxiing on S, not T from the radio transmissions. A landing aircraft was instructed to taxi behind QR on S as well.

This from the ever wise (i.e good analysis!) Airbubba (post #127 in original thread). Surprised there has been very little comment on this, either on this forum or in the report itself. (Yes I know, it is only preliminary, and they cannot speculate).

However, we all know it is VERY EASY to end up on the wrong taxiway, especially at unfamiliar airports with confusing signage and poor lighting (not saying this was the case at MIA though); happened many times before and will continue to happen.

Take another look at the airport chart; (sorry, not checked out on how to paste in here—so, go to Jepps)

Taxiing along T (thinking you are on S), you come to the end, with a left turn onto the runway. As somebody else has previously pointed out, it is easy to believe you are at the full length of the runway. Add the unfortunate nomenclature confusion of OPT "#T1" versus runway intersection "T1" and the holes start to line up. No heavy jet Captain would knowingly take off from such an intersection on a 12 hour long haul.

The EFB airport moving map is a great tool, but there are also traps; often, you need to "zoom in" to see detail, which means losing peripheral stuff, the Big Picture. Which is why it was my habit to have the hard copy 10-9 paper chart out on the clipboard as a backup, (even though that chart was available on the EFB and normally would be displayed by the other guy on his screen, and it was easy to switch back and forth between the two).

However, Sods Law says the EFB map will pack up just when you need it, (not a rare event). It also kept the old brain tuned in to basic chart reading while navigating around big airports, rather than relying solely on all that great electronic stuff.

Bottom line; we all make mistakes, and I do feel sorry for the guys .S—t does happen. But with 4 of you on the flight deck, there really are no excuses....

[zone]

https://www.faa.gov/airports/engineering/engineering_briefs/media/EB-89.pdf

See para e sub para 2.

This requires the suffix to be 1 from one end of the runway to the other. The picture here is more confused having parallel taxiways. It does lead you to think that you could be at full length when you are not.

If you look at the Chicago airport diagram, the suffix 1 is used well for 14R but not for 09L. There is not a lot of consistency applied.

Perhaps the stub taxiways (not at a runway end) should be numbered with suffix starting at 2 if they are not the full length.

[peekay4]

No heavy jet Captain would knowingly take off from such an intersection on a 12 hour long haul.

If you read the ATC transcript (in the original thread), it's pretty clear that the pilots knew they were at intersection T1 and would be conducting an intersection take off. The preliminary report also made this very clear, with the relief pilots questioning the intersection takeoff.

So whether they were originally on S or T is kinda a moot point.

[CONF iture]

If you read the ATC transcript (in the original thread), it's pretty clear that the pilots knew they were at intersection T1 and would be conducting an intersection take off.
Except that in the mind of the captain (due to the setting for his own chart), that T1 intersection was costing him only at most 200 feet of the full length. Do we know how many times before that captain used rwy 09 for take off in MIA ... ?

The report mentions a few times they were using S taxiway - Is it really the case ... ?

[jmmoric]

Could be time to go back to the "always use full runway"... That'll be "better safe than sorry".

Are there any reports out there, when it comes to overruns during departure, that actually mentions that as a recommendation?

Sure, I'll find it dumb having to taxi a few kilometres in a Piper 28 just to get the whole 2810 metres available on an airport I know quite well. But I do see quite a lot of pilots not familiar doing it though...

[wanabee777]

The three most useless things to a pilot:

1. Altitude above you

2. Runway behind you

3. Sondy on Sunday

[Capn Bloggs]

3. Sondy on Sunday

add the real third:

3. Air in the fuel tanks. :ok:

[PDR1]

4. Finance Director on the flight deck

5. The Daily Mail in...well, anywhere actually.

PDR

[fullforward]

the third one is actually:

3. Fuel in the fuel truck...

[Redlands]

A simple set of light boards alongside runway, showing distance available.

[wanabee777]

I'm pretty sure they have those on runway 9 at MIA.

[Chris2303]

I was always told that #3 was "a tenth of a second ago"