EasyJet A319 lands on closed Runway at Pisa 30/12

[Suzeman]

Reported on Aviation Herald

Incident: Easyjet A319 at Pisa on Dec 30th 2015, landed on closed runway (http://avherald.com/h?article=49196d15&opt=0)

Landed on closed R/W 04R instead of 04L.

Related NOTAM:
B6654/15 - RUNWAY 04R/22L AVBL AS TWY ONLY. RUNWAY 04L/22R AVBL AS RWY IN USE. RMK1:TRAFFIC MAY BE SUBJ DLA RMK2:DRG TAX OPS MAY BE NECESSARY TO CROSS ACTIVE RUNWAY IN ORDER TO PREVENT RWY INCURSION FLW STRICTLY ATC INSTRUCTION.REF AIP AD 2 LIRP 2-1. 23 DEC 15:44 2015 UNTIL 31 JAN 23:59 2016 ESTIMATED. CREATED: 23 DEC 15:44 2015

[de facto]

Approach lights ON only for the runway in use if landing following a non precision and max intensity if landing into the sun.
Should be NOTAMed to the ATC! and always requested.

[RAT 5]

I've read the AVH report & comments. I did not notice any publication of ATC landing clearance. Surely it should have been "ez-XYZ cleared to land RW04L." even adding, "be alert RW04R is closed." What did ATC say? They have the tapes. Ref notams: in many companies, at relevant bases, there would be a large wall poster, or some eye catching publication, of such critical operational data. Was/is there such a thing at ez?
The crew were only 1 slice of the cheese.

[737aviator]

Hands up whoever here has landed on 04L in Pisa as I never have, its always 04R (the only runway with an ILS) or 22L after the circle.
And if someone wants to trawl through the piles of pointless NOTAMS for PSA (and most Italian airports) in the past, there would have been an identical NOTAM, except saying that 04R/22L is in use and 04L/22R is in use as a taxiway only as that is what I remember every time I've been there as being in the NOTAMs.
My point is is that while of course the crew 'should' have seen the NOTAM, the amount of clutter, junk, old pointless NOTAMS, etc, that a crew is bombarded with when flying to Italy meant that something being missed like this is inevitable and will happen again unless things change. The crew had probably landed 04R every other time they'd been there...throw in a controller shouting into a microphone held too close to his mouth, with a poor quality radio with associated background hum, clearing them to land and its the perfect combination.

[HeartyMeatballs]

Totally sympathise with the crew. PSA is a nightmare. Not only are the radios poor quality the controllers speak very quickly, they shout, are heavily accented. They will bark orders at you which contradict NOTAMS. They will give you last minute runway changes whilst at the hold for one runway. They will switch runways at a minutes notice yet lie to you regarding tailwinds to avoid changing runways when it suits. Then keep you sat at the hold so that an Air One plane can land on the easterly to get a quick taxi in to the apron.

Throw in some bad weather or poor vis and the place will quickly descend into chaos.

[Hotel Tango]

Surely it should have been "ez-XYZ cleared to land RW04L." even adding, "be alert RW04R is closed."

You are joking of course. You are given a landing clearance for a specific and stated runway. ATC have no time to start adding a caveat with all other runways which you are not clear to land on and should avoid! :ugh::rolleyes:

[Chris Scott]

The remarks from posters above re the plethora of NOTAMs and quality of R/T indicate that nothing has changed in Italy since I retired... But never mind, the bureaucrats' backsides are well and truly covered, the resident operatives will all express astonishment at such an inexplicable error, and the embarrassed airline managers are unlikely to have the moral courage to support the crew concerned.

Hotel Tango, as a retired air-traffic controller you should know it is the responsibility of an air traffic service to assist all crews to the best of its ability. It should be obvious that a foreign crew is less likely to be au-fait with current WIP at a provincial airfield than one that is based there, or which has operated in and out earlier on its shift. RAT 5 is right. An alternative addition to the landing clearance might be: "...caution, runway zero-four right is closed." How busy is ATC at Pisa? And, by the way, there are only two strips at Pisa.

[shaun ryder]

Surely if they flew the VOR they should have realised it was 04L? Have to agree with above, the place is an absolute shambles.

[Hotel Tango]

Chris, in my opinion "cleared to land runway 04L, caution runway 04R is closed" may actually create more of a potential for misunderstanding with say a busy crew as the last verbal reference is 04R. I would stick with a clear and positive landing clearance for the runway concerned. If you really want to add to the clearance then go for "Runway 04L cleared to land runway 04L". I would avoid mentioning any other runway in the same transmission.

[Chris Scott]

Can anyone tell us how many NOTAMs are currently in force at (a) PSA, and (b) Milano FIR/UIR?**

Quote from Hotel Tango:
"Chris, in my opinion "cleared to land runway 04L, caution runway 04R is closed" may actually create more of a potential for misunderstanding with say a busy crew as the last verbal reference is 04R."

Yes, you make a very good point. Perhaps "... I say again, runway zero-four left." would do? Alternatively: "Easy XXX, caution: runway zero-four right is closed. You are cleared to land on runway zero-four left."

I wonder what the crew said in acknowledgment to the landing clearance.

** [EDIT] I should have added: Roma FIR.

[RAT 5]

OK, OK. but what did ATC say? If they said "cleared land 04L" it begs a question.

[DOVES]

Dear Sirs and Madams
Correct me if I'm wrong.
...was cleared to land on Pisa's active runway 04L but touched down on closed runway 04R at 11:11L (10:11Z). ...

LIRP 301015Z 11007KT 9999 FEW030 SCT050 10/08 Q1027 NOSIG
LIRP 300945Z 12007KT 8000 FEW030 SCT050 09/08 Q1027 NOSIG

The sun was almost in the zenith and so was not a factor.

I do not want to sound presumptuous but for me it is not so difficult to distinguish right from left.

By the way let's wait for the conclusions of the investigation.

DOVES

[I-AINC]

Is this a post against Italy or to discuss an incident happened to easyJet?

If you are cleared to land on a certain runway you must comply with it. Discussion on Notams or ATC audio quality is pointless.

So then we should be worried to land in Nice aswell or Gatwick? How about Madrid Barajas?

[rod_1986]

So then we should be worried to land in Nice aswell or Gatwick? How about Madrid Barajas?

NCE has a giant flashing X when the usual landing runway is closed.

LGW swap the lighting system over and have a different approach type when the usual landing runway is closed.

MAD you prepare for one of the four options, and whilst they sometimes spring a different one on you there's a precision approach to all of them.

PSA is a chaotic place at the best of times. The NOTAM was terribly worded and started with the words 'RUNWAY 04R/22L AVBL...' with the word CLOSED not mentioned at all. There is no ATIS, only weather passed by approach in heavily accented English faster than you can write.

Only the tapes will prove which runway they were cleared to land on. I would not be the least bit surprised if the controller issued the clearance for the closed runway.

[Chris Scott]

Quote from I-AINC:
"Is this a post against Italy or to discuss an incident happened to easyJet?"

The latter! This is clearly a human-factors incident that, in only slightly different circumstances, could have cost lives. Only one poster on this thread has suggested that Pisa ATC might have cleared the a/c to land on a closed runway and, as DOVES points out (in the longest post so far), we must await the incident report without assuming the facts of this specific case. However, it appears that a flight crew of this well-respected airline made a serious mistake. We are asking: what human factors might have caused the mistake? And any human factors errors discussion should include ATC and the airport authorities. Feel free to add your theories.

Much as I used to enjoy going to Italy during my pilot career, particularly for night-stops, I'm sorry to say that the comments that posters are making about the performance of ATS generally in Italy are fully justified in my experience. Remember, many of us have flown to scores of countries all over the world. One can understand such deficiencies in third-world countries, but Italy is a leading European country with a proud and pioneering aeronautical tradition.

[cheese bobcat]

I've been out of the loop for many years now, but didn't the French have a great idea of placing a giant no entry sign at the end of an out of use runway. It may not have precluded an embarrasing approach to the runway, but I doubt they would have landed on it.

CB

[Cough]

I last flew into PSA 3 months ago, landing 04L. The NOTAMS left me no doubt leaving the crew room that 04R was closed, I have also circled to 22R in the last year too. No issues...

Out of interest when I first started Shorthaul around Europe a long time ago, Italian ATC was pretty poor. Unintelligible, poorly thought clearances were just 'normal'. I have to say they have certainly improved the quality of transmission and the clearances are more thoughtful. Not saying 'perfect', but certainly a great improvement.

[RAT 5]

Only the tapes will prove which runway they were cleared to land on

Feel free to add your theories.

No need to add theories. There was no accident and all participants are alive & well. The tapes are there to be listened to. There is a simple question with a simple answer. If the a/c was held on the ground for 4 hours the answer could have been obtained within that time.
What occurred during that delay? Did the military & local cop shop hold court? They let the a/c & crew depart so something must have been decided. Were the phones between Pisa & Luton burning hot?

[DOVES]

...No need to add theories...: Is it a promise or a threat?

...There was no accident and all participants are alive & well. ...
Yes! Thanks to God! But!
If a malicious person threatens someone with a weapon, that jams and therefore no one gets hurt, just so there is no wrongful?

Who told "The Aviation Herald" to write: ...was cleared to land on Pisa's active runway 04L...?

Was a briefing made for the runway in use? Length/width, obstacles, maximum landing weight, missed approach procedure, availability of the yellow Runway weight limitation table (Max T.O. Weight, One Engine Out procedure...) for the following departure

I have no answers I have only questions.
Happy New Year
Romano

[HeathrowDictator]

According to the Easyjet flight status page yesterday for the return flight, it was delayed as the "crew for your flight had to be replaced". Apparently a replacement crew were sent from Luton causing a 6.5 hour delay. I would assume this would be fairly standard procedure to ensure that the crew involved didn't have this playing on their mind whilst operating the return sector - human factors?

Having never visited PSA I have no clue on how chaotic it may or may not be, however from an ATC perspective, why didn't the tower controller send the aircraft around when it became apparent they were aligned to the incorrect runway?

Just my 2p...

-HD-

[RAT 5]

Doves: "I do not have answers I have only questions."

What it means is save your energy and wait for the facts that will answer all the questions. What's the rush? Shoot the breeze in the bar.

[u0062]

Having operated in to Pisa for the last eight years, I would concur with the majority here.

The notams we receive these days are not written in plain English often they contradict them selves and important information lost in the depths of confusing clutter.

No Atis available , weather available on base leg given by a controller who has been speaking Italian prior to changing to English therefore becoming virtually impossible to understand, therefore having to read between the lines.

Off set Vor approach which lines up with a field a mile away from the Airfield.

I just don't know how they could of made this mistake!!!

[pattern_is_full]

......why didn't the tower controller send the aircraft around when it became apparent they were aligned to the incorrect runway?

How apparent was it?

Leaving aside questions of Pisa operational quality...

Unlike EGLL, the tower at LIRP is not between the runways, but offset to the side of both. The view of landing aircraft will be "slantwise" across the airport at an angle. So the alignment of a particular aircraft with a particular parallel runway may not be that obvious.

Here's a snap of two aircraft on parallel finals for KSFO 28L/R (or perhaps 19L/R). With roughly the kind of view one would have from the tower at LIRP - neither head-on nor directly from the side.

http://farm6.static.flickr.com/5453/18015812025_efa8efe84b.jpg

With another aircraft for reference as to size and altitude, it is easy to tell which is for the left and which is for the right. But without that reference (cover one or the other with your hand), these two planes lined up for two parallel runways look identical. From this point of view.

It's called "parallax" - at LIRP, an aircraft 0.5 miles out from 4R may look identical, as to position, to an aircraft 0.6 miles out lined up for 4L.

At some point, the discrepancy will become obvious - but then you have "startle factor," which applies to ATC as well as in the cockpit. By the time the controller says "What the heck....!!??" and keys the mic, the wheels may already be on the ground.

I'm just pointing out the eyes can play tricks - on anyone.

Note that in the similar recent situation at KSEA, ATC also did not call a go-around. Aircraft accepted clearance for 16C, they were out there at the correct end of 16C - who noticed they actually were aimed at a taxiway?

[tubby linton]

A few thoughts-
I know of a variety of pilots who have lined up on and even landed on runways that were dug up or blocked with oil cans , but this runway is fully operational.
The question I would be asking is why has this notam been promulgated? The runway is not being dug up , but the ILS is out of service. Doing this in the winter seems to be poor planning. So what is the reason as it deprives the airport of its one ILS runway?
Most airlines will be happy to depart with a slight tailwind if the wind is north easterly to save the extended taxi-ing. Is Pisa really that busy that an aircraft can not wait for a backtrack? Does the main runwway really need to be used as a taxiway?
It all sounds to me as a sop to a noise complaint, from probably somebody who probably objects to take offs in a south westerly direction.
The Jepp approach charts which replicate the AIP do not mention that the FAT is offset to the runway direction . I would imagine that Lido charts as used by Easy are the same. The Italian Aip should really highlight this plus the fact that the runways are very close to each other.
Would anybody else like to add a few layers of swiss cheese?

[CommanderRiker]

Oopsy daisy! End of year blues!

Alaska Air landed on taxiway in SEATAC and Easy jet on closed runway ! Gee, we western pilots must have too much eggnogs! We are so lucky the Asians and third world pilots did not come in droves onto pprune to pillory our skills and discipline.:O:{

[marchino61]

I have read the NOTAM as published on Aviation Herald.

Could someone please explain why they are written in "telegrammese" and ALL CAPS?

Surely these messages are not still sent by telex or Morse code or something, are they?

:confused:

[South Prince]

Yes.........., wx was excellent, why ATC did not tell landing crew to go around ( or at least wake them up ;)) having seen aircraft approaching wrong runway?

[Heathrow Harry]

CommanderT - as you say its a well known cultural problem

Western pilots require help from ATC to identify the correct runway as they can't read the LARGE letters painted on the end of the concrete......

too much game playing when kids.........

[Chris Scott]

Quote from Heathrow Harry:
"CommanderT - as you say its a well known cultural problem
Western pilots require help from ATC to identify the correct runway as they can't read the LARGE letters painted on the end of the concrete......"

If a PPRuNe pundit - under no pressure, and sitting in the comfort of an armchair - can mistake an R for a T, would it be surprising if a very busy crew mistook an R for an L? But that's not the reason for this incident.

[slowjet]

Chris, Ha ! Damn...spilled me coffee again !

[slast]

Nice one, Chris - keep it for the rest of the year please!!
Steve

[Dan Winterland]

Surely these messages are not still sent by telex or Morse code or something, are they?

They are still sent via SITA or AFTN, also available by ACARS which are essentially telex systems, as well as being available on-line.

[BitMoreRightRudder]

Lots of holes in the cheese with this one. Having been to PSA recently and seen the current layout I am not surprised. Someone was going to do this at some point. Who the operator was and who was sat at the front is totally irrelevant.

1. 04R resurfaced and far more visually prominent compared to 04L, yet no visual clue as to its closed state (04R having been the single use runway for many years previously).
2. A NPA that doesn't line up with either runway.
3. Notams that are written in Italian and auto-translated, resulting in confusion.
4. PSA ATC. Italian ATC has, in my opinion improved at many places in recent years. VCE and FCO approach are prominent on that list from recent experience. PSA on the other hand has most certainly not improved. I've been asked to maintain 220kts to 8dme on the VOR approach there by a controller who became quite agitated when we refused.

Any pilot who thinks they are beyond making this sort of mistake is playing a dangerously complacent game with their ego. More to the point, these incidents will keep happening as long as EASA and its political chums keep their focus on inventing ridiculous FTL schemes instead of actual safety issues, like harmonising the way European airports conduct and promulgate major infrastructure change.

[fireflybob]

Some of us are old enough to recall that in the 1960s BALPA nominated certain airfields deficient in landing aids a "Black Star" Rating. Often soon after they did so the relevant airfield took immediate steps to improve matters.

Perhaps BALPA/IFALPA could do similar now to effect beneficial changes.

[portmanteau]

Pilots will have to take the responsibiilty for this but it does look like an accident waiting to happen. two runways separated only by 200m. the grey strip on the left ( 04L) could be (was?) mistaken for the taxiway since there is no separate parallel taxiway. Presumably the approach lighting for both runways was not on.

I think Easyjets statement maintains the finest traditions of PR guff.
"aircraft landed safely and routinely". " at no point was the safety of the aircraft or passengers compromised".

[Heathrow Harry]

Chris

I'm sitting in front of keyboard full of New Year's cheer

They were doing the day job in charge of a large number of people

[Wageslave]

Much as we all want to show sympathy to the crew involved an incident like this can only have one cause. Inattention by the crew to instructions given.

Talk of holes in the cheese strike me as being a bit by the by in this case. Holes require errors elsewhere and I don't see "errors" in the info given elsewhere.

We all know the shortcomings of Italian ATC in general and Pisa's in particular, we are also familiar with the layout of the airport and it's offset approach and if not regular visitors then we should be even more cautious to brief these punctiliously.

Perhaps they were "cleared" to land on a runway notified as closed by NOTAM (surmise at present, but possible) this should have instantly lit up a big red mental light and been queried as befits the extra level of caution and suspicion we should all be exercising in that particular environment. Even so, the standard level of caution we should exercise ought to prevent such an incident. I'm afraid the NOTAM looks perfectly clearly written to me.
Surely anywhere we find parallel runways or mistakeable parallel taxiways we check and doublecheck we are using the right one, and that process begins with punctilious reading of NOTAMS in flight as well as pre flight. Nice stands out as an example, apparently three landing strips visually. (another potential gotcha destination where all our antennae need to be out to spot traps)

Of course there will be factors that led the crew into this event but we are very familiar with all of them and therefore should routinely ensure that we do not fall foul of any of them, and one of the factors that should result in a much higher level of attention than usual is the Pisa factor. Unfortunately it got these guys.

Sure, there are far too many unfiltered NOTAMS, many are far too verbose and sorting the wheat from the chaff is nigh on impossible in a 5 minute briefing. All the more reason to refresh them in flight. Both of us...

We anticipate unintelligible RT and strange clearances at Pisa and should be all too aware of the possibility of a runway closure and ATC not responding correctly to it. And so on. Every clearance and instruction should be analysed for rationality, especially at Pisa as we all know and questioned if necessary. There are two of us up front partly to minimise missing such things. It doesn't look as though the crew queried the runway in use so one can only surmise that they were happy to land on the "usual" one regardless of what they were told to do. Where was the NOTAM in their minds?

We are Professional pilots and this is no more than our job requires. Occasionally - rarely two people simultaneously make the same genuine human error and hit the headlines. It's sad but it happens. I can't see any piece of swiss cheese in this incident apart from the one labeled "inattention" or perhaps "complacency" or "environmental capture" and my feeling is that this event, as far as we can tell at present has all the hallmarks of a tricky destination being treated as routine and of all places, as we know, Pisa is not the best place to do that.

Ultimately, (unless dramatic new info is presented) I can only see one cause for this; had the NOTAM been correctly read and understood this incident would simply not have happened. How else can you put it?

Anyone can say "There but for the Grace of God." but this wasn't just happenstance, we can minimise the risks and eliminate most of them by thorough application of our training and experience.

[Wageslave]

If you are cleared to land on a certain runway you must comply with it. Discussion on Notams or ATC audio quality is pointless.

So then we should be worried to land in Nice aswell or Gatwick? How about Madrid Barajas?

"Must" comply? Discussion is pointless? Are you serious? If a runway is NOTAMed closed and you are "cleared" to land on it you'd do so without querying the instruction? Perhaps this thread is about Italian attitudes after all.

Nice? Barajas? Damn right you take special care as we all know and for most of the same reasons we do at Pisa, they're all out of the same box as far as I'm concerned. Gatwick too, though blessed with much better ATC than either of those has its pitfalls too.

[seen_the_box]

Well, Wageslave has already identified the sole cause of this incident. Why bother even having an investigation?

Holes require errors elsewhere and I don't see "errors" in the info given elsewhere.

An ATIS not being available to the crew is a latent error; a hole in the cheese. Poor communication by ATC is a latent error; another hole. Poorly written/ overly verbose NOTAMs are latent errors; another hole. There's three potential "holes" not related to the crew, without going into any sort of depth whatsoever.

Of course there will be factors that led the crew into this event but we are very familiar with all of them and therefore should routinely ensure that we do not fall foul of any of them

Nobody (intentional acts of destruction aside) sets out routinely to cause an incident or accident. Your comment quoted above is therefore nonsense. Of course we should be (and are) familiar with factors introducing threats into the operation, and of course we routinely do everything we can (TEM, good CRM practice) to avoid falling foul of them. Yet, with all that in mind, incidents and accidents still happen. Taking the absurdly simplistic approach that there's only one cause of any accident or incident flies in the face of years of accepted investigative practice.

[Wageslave]

seen the box, tell me, had they read the NOTAM correctly is it likely they would have landed on the wrong runway, yes or no? The means of obtaining airfield info or quality of RT can have no bearing on that if they hadn't understood the usual runway was closed, can it?

Thank you.

I get the feeling that your insistence on thinking inside the box restricts your judgement in terms rigid acceptance of "years of accepted investigative practice."
If someone lands on the wrong runway having failed to digest the NOTAM how much is accepted invest/// yada yada yada likely to change the verdict?

I know full well that pilots are never wrong according to many here, especially after they have made a grave error. That just cannot be true, and a bit more eyes wide open reality/honesty in these matters may not be a bad thing.

Had the NOTAM been understood (and if seen the box finds it verbose perhaps it behoves him to read it a little more carefully) some of your points might have been relevant, but would then require the crew to accept a clearance in contradiction of their understanding and not question it, surely vanishingly unlikely? Easyjet trains people to be very cautious indeed of anomalies like that - I doubt very much that would have happened. It additionally requires Piza ATC to have instructed them to land on the wrong runway which though feasible is Double Jeopardy and thus usually discounted.

Looks like a duck, walks like a duck, quacks like a duck gets my vote every time.

[Chris Scott]

Well said, seen the box...

Quote from Wageslave:
"Talk of holes in the cheese strike me as being a bit by the by in this case. Holes require errors elsewhere and I don't see "errors" in the info given elsewhere."

In which case, why did you continue to expend several hundred words listing them all? There's a hint of old-school elitism in any implication that the pilots' layer of swiss-cheese should be uniquely impervious. If there are holes in several other layers, as your and others' comments imply, customer airlines need to put pressure on the Italian authorities: not simply admit 100% liability on behalf of a crew.

Quote:
"I know full well that pilots are never wrong according to many here, especially after they have made a grave error. That just cannot be true, and a bit more eyes wide open reality/honesty in these matters may not be a bad thing."

Wrong. The default situation with us is that we accept prime responsibility for any error. I think that all the pilots (and ex-pilots, like myself) posting here so far have been simply pointing out the possible extenuating circumstances. Pilots do not need to have traps set for them: being human they are perfectly capable of making their own mistakes - and learning accordingly.

[Wageslave]

Chris, not much logic in those arguments I fear. I expended words to describe why they are NOT holes in the cheese as was clearly stated, and no mention of the pilots' layers being impervious. How did you infer that?

We accept responsibility as individuals, yes, but again I wasn't referring to that, as clearly stated. I was referring to the extraordinary reluctance on PPRuNe of accepting that accident pilots could have made cardinal error/s and finding a plethora of marginally connected extraneous events that could conceivably have had a minor bearing on the matter and using them to try to exonerate or ameliorate the pilot's actions. Its the elephant in the room syndrome and is present in almost every accident or incident topic on this forum.

[seen_the_box]

I was referring to the extraordinary reluctance on PPRuNe of accepting that accident pilots could have made cardinal error/s and finding a plethora of marginally connected extraneous events that could conceivably have had a minor bearing on the matter and using them to try to exonerate or ameliorate the pilot's actions.

What most sensible people have is a realisation and understanding that 1) Errors and mistakes happen, 2) An accident or incident is never down to just one single factor and 3) Breaking the error chain at any point will prevent the accident or incident. You seem to have some fundamental difficulty accepting that point.

Yes, of course the crew made an error. However, had the NOTAM been presented in a clearer and more easily digestible format, had the airfield information been available earlier, had (making an assumption that they had some bearing on the incident) Pisa's ATC procedures been of a better standard: the error chain would have most likely been broken and the incident would not have occurred.

As I'm sure you're aware, the primary purpose of any investigation in an aviation context is not to apportion blame, but to prevent further accidents and incidents. By your logic displayed here, whenever there's an incident which has a human factors element to it, the investigation should simply conclude that the crew made an error, without bothering to look into the contributory factors. Why then bother having an investigation?

seen the box, tell me, had they read the NOTAM correctly is it likely they would have landed on the wrong runway, yes or no?

I don't know, and neither do you. To repeat what has already been said: if anyone's arrogant enough to think that this couldn't ever happen to them, I hope never to share an aircraft with you in any capacity.

[Count of Monte Bisto]

Wageslave - for what it is worth, my observations of PPRuNe are that pilots go into attack-dog mode very quickly with other pilots and are almost invariably at the 'it would never happen to me' end of the scale. The case in question here will no doubt be investigated meticulously by easyJet, the AAIB the Italian authorities and anyone who can claim an interest in the issue, however small.

It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement. Therefore, when mistakes are made, there will be no one more upset at something going wrong than the individuals involved. Given that we can usually agree that the pilots in any incident wanted to do the right thing, and yet did not do so, it is entirely appropriate to try and understand the procedures and processes in place at the time to ascertain why an event took place that no one every wanted to happen. That means looking at all factors, however innocuous they might appear, to try and understand what led to an error occurring. In most cases somehow a series of errors and coincidences take place which make a particular crew on a particular day at a particular airport do the wrong thing. Leaving no stone unturned to work out why would seem a sensible way forward to me.

[RexBanner]

Count of Monte Bisto you are very right on the subject of pilots claiming that they would never make such mishaps in the event of an incident. There are two types of pilots; those it has happened to and those it will happen to, if not carefully guarded against.

[Chris Scott]

Hello Wageslave,

I think seen_the_box and the Count have rebutted your arguments as well or better than I could, so I'll leave it there.

[Wageslave]

Hello Chris Scott. It is very hard to have a fair intellectual battle with an unarmed man but you leave me little choice. The entire post made by seen the box is irrelevant, unsubstantiated personal opinion or just plain wrong. Sorry you wish to align yourself with such inept logic.

Seen the box seems to have so misread my post that he writes that I don't accept that errors happen, or that breaking the error chain "will" (note not "may) break it despite my clearly describing errors, error chains and how to break them. This is the sloppiest and most negligent answer I've seen for a while here - pure unwarranted assumption, or worse.

His second para is also devoid of logic and contains mere surmise; "Had" all sorts of random things happened other results "Might" have occurred. This is an "argument" akin to predicting the football pools by reading tea leaves. The correct position, I say again, is that "had they correctly read the NOTAM" they would have had reason to question an incorrect clearance if one was ever given. If so they apparently did not question it. Further if no incorrect landing runway was given by ATC then ipso facto they just landed on the wrong one. Either way ATC can have had no significant part in determining which runway was landed on unless incorrect readbacks were made. The result was determined by an assumption of the duty runway based, probably, on habit, experience, call it what you will unaffected by NOTAM or ATC. No amount of better quality ATC will remedy that.

His third para is a pastiche of irrationality and misinformation (my logic suggests nothing of what he infers) presented to look as though I had said it, not he. That is dishonest.

To continue by saying that if anyone is arrogant enough....and I emphasise "anyone"- then he would not fly with me is a non sequitur almost beyond belief. Why would he not fly with me if anyone else was arrogant? Or is he just ungrammatically accusing me of some imagined arrogance in taking this stance that he has invented? Because I most certainly did not take or present it. That is not only dishonest, it is a pathetic and weak attempt at slander and merely serves to further discredit his totally worthless "logic". It also describes all too well his staggering arrogance and unprofessionalism at making unwarranted and purely invented assumptions against someone he does not know. I am not impressed.

I have no quarrel with what the count said, it seems almost the same as my position and I agree with it, though I'd like to pay more attention to whys and wherefores of the fundamental error and less to presenting "extenuating circumstances" that played no part in leading to it at all, and are therefore not extenuating circumstances.

If someone is so certain that 07L is the duty runway and not 07R yet still lands on it despite being told 07R the problem is hardly with ATC - is it???

If he believed it was 07R as NOTAMed but was unexpectedly told 07L he would query the deviation from NOTAM rather than just land as previously assumed wouldn't he? How can ATC or ATIS/lack of be responsible for that?

The question is surely how such well trained pilots bamboozle themselves into missing critical NOTAMs relating to fundamental gotchas at well known trap-locations, not mere detail of whether the trap location had an ATIS or spoke the Queen's English. Its much deeper and more fundamental than that. Sure, the detail needs sorting out but it isn't the elephant in the room. Let's address that first?

[tubby linton]

I think that we heard you the first time wageslave!

[flydive1]

Well, but he is an intellectual talking to dumb people, so he has to say twice;)

[portmanteau]

It will be interesting to learn how many times the pilots had been into Pisa.
seeing an airfield on a little chart and simulated on a computer aint the same as looking at it in the raw. and how long do you get to do that on the approach, at low level and with a very slantwise view? not very long.

getting a bit tetchy on here. why not save that for after we know the actual course of events when by the sound of it, a lot of humble pie may be flying around.

[RexBanner]

Flydive1 a real laugh out loud moment, congratulations for the funniest post I've yet seen on pprune.

[portmanteau]

to those commenting on the controllers views of the approach, you should try working in a leaning tower.

[DirtyProp]

:D:D
Good one!

[pattern_is_full]

Without in any way wishing to ally myself with Wageslave's "little moment"...

I am troubled by a piece pf phrasing that pops up in a couple of posts.

s_t_b - "Nobody (intentional acts of destruction aside) sets out routinely to cause an incident or accident."

CoMB - "It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement."That is a low-rent, low-bar, passive standard. A five-year-old can get into a cockpit without "the intention of making an error."

A pilot needs a more assertive attitude: "Today, the world will throw all kinds of $%*# at me - the NOTAMs will be unintelligible, ATC will be obtuse, other pilots will cut corners, the electrons will go haywire, the weather will conspire against me, the bits of cement will be indistinguishable, and I'm not too sure about the guy/gal in the other seat - but I will overcome all obstacles, prevail, and finish the job competently and safely!"

That does not mean one has to be cynical or bitter or scared (skeptical, yes) - one can be a "happy warrior," taking joy in every successful ploy to outwit The Hunter (Fate). And when one arrives safely, and looks back on a flight where, in fact, most things went right, say "Hunh! That was actually a pretty good day!"

[LlamaFarmer]

Without in any way wishing to ally myself with Wageslave's "little moment"...

I am troubled by a piece pf phrasing that pops up in a couple of posts.

Quote:
s_t_b - "Nobody (intentional acts of destruction aside) sets out routinely to cause an incident or accident."

CoMB - "It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement."
That is a low-rent, low-bar, passive standard. A five-year-old can get into a cockpit without "the intention of making an error."

A pilot needs a more assertive attitude: "Today, the world will throw all kinds of $%*# at me - the NOTAMs will be unintelligible, ATC will be obtuse, other pilots will cut corners, the electrons will go haywire, the weather will conspire against me, the bits of cement will be indistinguishable, and I'm not too sure about the guy/gal in the other seat - but I will overcome all obstacles, prevail, and finish the job competently and safely!"

That does not mean one has to be cynical or bitter or scared (skeptical, yes) - one can be a "happy warrior," taking joy in every successful ploy to outwit The Hunter (Fate). And when one arrives safely, and looks back on a flight where, in fact, most things went right, say "Hunh! That was actually a pretty good day!"

Given that it wasn't just this crew, but apparently at least two other crews who also made an approach at the closed runway, albeit without actually touching down on the wrong runway, that strongly points to blame other than the pilots.

If it was an isolated incident it could be apportioned (not completely) to crew error as a result of any number of factors such as complacency or fatigue.
But multiple crews made that same approach, they can't all have made the same mistake by chance, there must have been something like a glaring lack of clarity in the NOTAMS or some such.



People have been saying that crews are routinely landing on that runway in normal ops so have got into the habit of that runway and are used to it... but if the crew could fall into that trap... why not ATC?! They're surely much more used to 04R, so isn't it equally likely, if not more so, that in the briefest moment of complacency or distraction they said 04R instead of 04L?

The number of times I hear crew around the south coast in private aircraft talking to ATC with a company callsign before remembering they're not at work... isn't a brain fart like that equally as possible in Pisa?

[fireflybob]

I see "failures" such as this as a system failure.

If you're playing football and your team loses 30 goals to nil then you wouldn't blame it all on the goalkeeper. (Although you might sack the manager).

A pilot needs a more assertive attitude: "Today, the world will throw all kinds of $%*# at me - the NOTAMs will be unintelligible, ATC will be obtuse, other pilots will cut corners, the electrons will go haywire, the weather will conspire against me, the bits of cement will be indistinguishable, and I'm not too sure about the guy/gal in the other seat - but I will overcome all obstacles, prevail, and finish the job competently and safely!"


I am totally with this "attitude". However therein lies part of the dilemma. As pilots our mindset is (naturally) mission orientated but if we all refused to operate to certain airports you can bet your bottom dollar that matters such as no ATIS, poor ATC, inadequate NOTAMS etc would be sorted at the drop of a hat.

[slowjet]

I tried swallowing the Oxford Dictionary (original version, not the dumbed down one) for breakfast but much prefer me toast 'n' butter. I also had a quick go at the Times criptic but got no further than clue one. I guess I was clueless. I am breaking all me New Year Resolutions which included avoiding social yuckspeak and must use three , commonly used , to illustrate what happened here (at Pisa)............ Look,........ AT THE END OF THE DAY.............HE DID WHAT HE DOES...........AND IT IS WHAT IT IS. Blimey Wageslave, geeeza break. Do you write Notams for a hobby ?

[FlightDetent]

Valid NOTAM: Q) LIMM/QMRXX/IV/NBO /A /000/999/4341N01024E
A) LIRP
B) 16/01/03 09:49 C) 16/01/31 10:00
E) RUNWAY 04R/22L CLSD. AVBL AS TWY ONLY. RUNWAY 04L/22R AVBL AS RWY IN USE. RMK 1: TRAFFIC MAY BE SUBJ DLA. RMK 2: DRG TAX OPS MAY BE NECESSARY TO CROSS ACTIVE RUNWAY IN ORDER TO PREVENT RWY INCURSION FLW STRICTLY ATC INSTRUCTIONS. REF AIP AD 2 LIRP 2-1 In a previous life I took part in reverse engineering :ooh: a NOTAM-highlighting system for an electronic briefing tool. With such solution, it is inevitable that pilots will de-focus from the non-highlighted notams. That left me feeling uneasy as a designer and an operator and we did not stop until a really smart algorithm had been devised.

The original notam does not provide enough clues for software recognition of its importance. B6654/15 - RUNWAY 04R/22L AVBL AS TWY ONLY. RUNWAY 04L/22R AVBL AS RWY IN USE. RMK1:TRAFFIC MAY BE SUBJ DLA RMK2: TAX OPS MAY BE NECESSARY TO CROSS ACTIVE RUNWAY IN ORDER TO PREVENT RWY INCURSION FLW STRICTLY ATC INSTRUCTION. REF AIP AD 2 LIRP 2-1. 23 DEC 15:44 2015 UNTIL 31 JAN 23:59 2016 ESTIMATED. Does EZY use any sort of notam highligting in their EFBs, which I understand are rather elaborate?

[EGPFlyer]

Valid NOTAM: In a previous life I took part in reverse engineering :ooh: a NOTAM-highlighting system for an electronic briefing tool. With such solution, it is inevitable that pilots will de-focus from the non-highlighted notams. That left me feeling uneasy as a designer and an operator and we did not stop until a really smart algorithm had been devised.

The original notam does not provide enough clues for software recognition of its importance. Does EZY use any sort of notam highligting in their EFBs, which I understand are rather elaborate?

Notams are printed as part of the flight plans/weather pack. I think the eventual plan is for it all to be available on the EFB but it's still a way off.

[bar none]

Does Easy get a reduced landing fee for not using the runway? If so, don`t tell Mol.

[RAT 5]

I asked this question earlier; no reply, yet. In some of my previous airlines, at those bases which flew to destinations with operationally critical issues, there was a 'notam' board in the crew room kept up to date by the local crew room manager. This was very useful. Does ez employ this type of conspicuous highlight system? I appreciate that ez has a large network, but not all destinations are served from all bases.
If this system is in use this item should have been up there along with e.g. U/S air starters, ILS, CAT 2/3, closed runways with time windows, etc. There is so much buff & trivia in NOTAM's that noticing the critical ones is often tricky. Much also depends on how much time the company allows for flight planning. Some airlines use quite short check-in periods, but yet increase the amount of self-help briefing necessary. The days of 'dispatchers' at this level are over.
Does your airline make it easier for you?

[portmanteau]

A full-stop between " active runway " and " in order to prevent..." is also necessary to make sense.

[Willy Miller]

7 minutes to print, read, understand, brief and leave crew room = not surprised.

[Wageslave]

7 minutes to print, read, understand, brief and leave crew room = not surprised.

Which leaves crew with two options.

1) Remain in the crewroom until briefing is complete.

2) Continue the foreshortened brief in flight.

Both case clearly require a MOR and possibly further action, up to and including declining further flights until this critical failure in the flight safety system is addressed. I can see no other option but to decline the duty.
In no case can a Professional crew defend carrying on regardless and respond with "not surprised" when an incident occurs.

I acknowledge that the above is a difficult path to take, but it is surely the only path that a properly motivated and properly protected employee could take.

I respectfully suggest that a plea of "7 minutes to print, read, understand, brief and leave crew room = not surprised" would cut no ice whatsoever with a law court - indeed it would seal your guilt instantly.

"Not surprised" just won't do.

[Sober Lark]

7 minutes to print, read, understand, brief and leave crew room = not surprised.


Nov 2007, then presidential candidate Barack Obama was heading for Cedar Rapids but his pilot landed the plane about 100 miles west in Des Moines! Easy mistake.

[kick the tires]

Notams
7 minutes to print, read, understand, brief and leave crew room = not surprised.

Where does 7 mins come from?

We have 15 mins to do the above, NOT 7!

[easymxp]

I think he is confusing the 7 minutes for A319 for cabin tidy/security search during turnarounds

[golfyankeesierra]

Aren't we all in the same boat? Whether 7, 15 or 20 minutes, it's still not enough. It's always a case of ETTO..

[kick the tires]

Its enough time and if I havent finished my flight preparation, I simply carry on. I've never had any comeback for not preparing fully and on time, quite the opposite in fact.

What doesnt help on here is trolls taking wild, uneducated guesses at how we conduct our business. Sensational claims of 7 minutes are ridiculous and gives the poster no credibility at all.

[autobrake3]

Actually, it is not being over sensationalised. There is overt pressure to have the aircraft ready for boarding at STD-25. We are expected to conduct our inter crew brief either en route to the aircraft or on board prior to the first flight of the day. If the aircraft departs late and the 3rd party handling agent determines that the crew were not ready on time, you will have to explain yourself. Now I am quite able to defend my actions but have no doubt, heavy commercial pressure is ever present. The rushed collation and digestion of the paperwork prior to flight IS a problem.

[Uplinker]

15 mins is NOT enough time to:

-Sign in and select correct flight plans
-Print off PLOGS, TAFS, METARS, NOTAMS etc (sometimes have to load paper or toner cartridge to the printer. Sometimes have to reboot the computer)
-Assemble paperwork and flight folder
-Sort out and staple up paperwork (sometimes have to mend or refill stapler)
-Sign and annotate same with crew names etc
-Check head/tail wind on wind charts
-Check PLOG uses correct wind component
-Check PLOG for correct aircraft, passenger number and cargo etc.
-Check PLOG for operational notes specific to destination airports
-Read TAFs, METARs to determine which runways in use at departure and destination airports
-Calculate fuel adjustments for track mile differences to opposite runway(s) if
reqd
-Check weather and NOTAMS and agree alternate
-Calculate RTOM if reqd
-Check if tanking sector
-Check aircraft servicability and deferred defects.
-Decide, calculate and agree on fuel figure
-Phone handling agent with fuel figures, check CTOT, stand and cargo.
-Brief crew
-Get in bus

15 minutes is barely enough time to even skim through all this. I will admit that I have missed airspace closures and level restrictions in the FIRs downroute because there isn't time to read all the NOTAMs thoroughly. We got away with that without having to make a tech stop, but we were lucky. In the past we used to carry a healthy amount of extra fuel so we had plenty of contingency, but now it has to be absolute minimum fuel, so a mistake at the briefing stage can be very embarrassing.

I now report well early just to get all this done to maintain OTP. Most others do the same or download everything at home to read before driving to work.

File an MOR? yeah good luck with your career !

[RAT 5]

-Check PLOG for operational notes specific to destination airports

Out if interest; was the status of runways at PSA noted on the Plog? If so then critical data had been highlighted and could have been reviewed en-roue and before approach briefing. We still wait to find out what ATC said in their landing clearance.

[portmanteau]

according to Monarch Blogger in 2012 their cabin crew reported 90 minutes before flight...... and flight crew get 15 mins plus?

[F4USAF]

I noticed that there are fifty NOTAMs for Pisa. Is that par?