Air Canada A321 landed despite go-around order

[Longtimer]

Air Canada A321 landed despite go-around order

30 August, 2018
SOURCE: Flight Dashboard
BY: David Kaminski-Morrow

Canadian investigators have disclosed that an Air Canada Airbus A321 proceeded to land at Toronto despite being instructed to execute a go-around.

The aircraft had been operating flight AC150 from Calgary on 18 August, states the Transportation Safety Board of Canada.

It had been approaching runway 06L, on short final, when air traffic control ordered it to conduct a go-around owing to a preceding aircraft not having vacated the runway.

“The go-around transmission was not acknowledged by the flight crew of [the A321] and the aircraft proceeded with the landing,” says the safety board.

It landed and exited the runway without further incident, with no injuries among the 196 occupants.

At the time of the incident, given as 21:50, the approach would have been conducted in darkness

[Airbubba]

Let me guess, the CVR tape was not available. ;)

[Skyjob]

Crossed transmittion?

[jack11111]

I believe Air Canada also did this at SFO last year, yes?

Edit:
Yes: October 2017.

Go-around issued because traffic had not cleared runway.

[DaveReidUK]

Air Canada A321 landed despite go-around order

30 August, 2018
SOURCE: Flight Dashboard
BY: David Kaminski-Morrow

Canadian investigators have disclosed that an Air Canada Airbus A321 proceeded to land at Toronto despite being instructed to execute a go-around.

The aircraft had been operating flight AC150 from Calgary on 18 August, states the Transportation Safety Board of Canada.

It had been approaching runway 06L, on short final, when air traffic control ordered it to conduct a go-around owing to a preceding aircraft not having vacated the runway.

“The go-around transmission was not acknowledged by the flight crew of [the A321] and the aircraft proceeded with the landing,” says the safety board.

It landed and exited the runway without further incident, with no injuries among the 196 occupants.

At the time of the incident, given as 21:50, the approach would have been conducted in darkness


Confusingly, the TSB reports the incident as occurring at 21:50 UTC (17:50 local time), though that is presumably wrong as AC150's STA is 21:56 LT.

[RobertS975]

I believe Air Canada also did this at SFO last year, yes?

Edit:
Yes: October 2017.

Go-around issued because traffic had not cleared runway.

I the SFO incident was a landing AC jet lining up to land on the parallel taxiway and did a GA narrowly missing some of the aircraft lined up on the taxiway for the runway.

[jack11111]

Quote:
"I the SFO incident was a landing AC jet lining up to land on the parallel taxiway and did a GA narrowly missing some of the aircraft lined up on the taxiway for the runway."

Yes, that also happened.

[Airbubba]

Here's Air Canada 781 landing at SFO on October 22, 2017 after the tower repeatedly called a go around:

https://youtu.be/g77C0rj_lPs

Air Canada, Oct. 22, 2017

Air Canada flight 781 was cleared to land on Runway 28R about six miles from the airport, which the crew acknowledged, but then radio contact ended with the tower. The air traffic controller, worried another plane had not cleared that runway, ordered the Air Canada plane to abort its landing six times with no response from the flight crew. The tower went as far as shining a light into the cockpit of the approaching plane in an unsuccessful attempt to get the flight crew’s attention.

The other plane had cleared the runway by the time the Air Canada jet touched down and landed safely. The FAA concluded after speaking to the flight crew and probing other data that the “crew inadvertently switched from the SFO tower frequency to the SFO ground frequency after receiving their landing clearance.”

“The FAA deemed this event to be an isolated occurrence and not reflective of any systematic deficiencies at Air Canada,” according to a FAA spokesman.

Aimer said pilots often pre-set their radio channels, knowing that once they land they will switch to the ground frequency to get instructions on where to taxi, but this was too soon.

“The pilot should be wondering, ‘How come we don’t hear the tower any more? Why is there complete silence? Why are we hearing ground traffic?’ ” Aimer said. “I can’t understand how experienced pilots didn’t catch that. We’ve all done stupid things, but that’s why you have two people in the cockpit.”

The incident prompted the FAA’s Flight Standards Service executive director to meet with his Canadian equivalent, according to the FAA, which led to an immediate safety review of the air carrier’s entire operations, including increased pilot training and a closer look at the airline’s arrivals and departures at SFO.



https://www.mercurynews.com/2018/05/02/wrong-radio-frequency-wrong-runway-faa-releases-findings-of-sfo-close-call-investigations/

[DaveReidUK]

Quote:
"I the SFO incident was a landing AC jet lining up to land on the parallel taxiway and did a GA narrowly missing some of the aircraft lined up on the taxiway for the runway."

Yes, that also happened.

And was extensively discussed in these columns at the time: PPRuNe: Air Canada non go-around at SFO (https://www.pprune.org/rumours-news/601042-air-canada-non-go-around-sfo.html)

[ATC Watcher]

The go-around transmission was not acknowledged by the flight crew ” says the safety board.

which suggest , like the preceding incident in SFO it was a technical issue (e.g. crossed TX, inadvertent chg of FRQ or simply tuned the volume down by error, etc..)..
Good that is is investigated, no so good that such things are thrown up in public before the incident is investigated and explained.

[highflyer40]

I think the title should be amended to “Air Canada A321 landed despite go-around REQUEST”. ATC can’t order you to do anything once airbourne . They can request and you better have a very good reason to refuse, but refuse you can.

[SquintyMagoo]

I have listened to the audio at LiveATC and I don't hear the go around "request." Could that be because they are recording two frequencies?

[Can't Hover]

Interesting incident, fortunately without any injuries. I must wonder if where the problem lies; with the crew or with the system? In Europe and elsewhere a landing clearance is only given when the preceding aircraft has vacated the runway and the runway is ready to accept the next landing aircraft. The policy of giving the landing clearance concurrently to multiple aircraft clearly invites this kind of incident, be it due to stepped on transmissions, radio failure, or, as in this case operator error. Implementing a safer system seems sensible!

[Skyjob]

Interesting incident, fortunately without any injuries. I must wonder if where the problem lies; with the crew or with the system? In Europe and elsewhere a landing clearance is only given when the preceding aircraft has vacated the runway and the runway is ready to accept the next landing aircraft. The policy of giving the landing clearance concurrently to multiple aircraft clearly invites this kind of incident, be it due to stepped on transmissions, radio failure, or, as in this case operator error. Implementing a safer system seems sensible!
LAND AFTER clearances are still given in EU, fortunately, as sometimes it makes the difference between a mandatory missed approach due preceding (rival) aircraft slowly vacating at end of a 3km runway

[gwillie]

.
Longtimer -

It seems that your source neglected to include.......the punch line:
Canada's TSB rated the occurrence an incident reportable involving the risk of a collision, however, did not open an investigation.

Incident: Canada A321 at Toronto on Aug 18th 2018, continued landing despite go around instruction (http://avherald.com/h?article=4bcfd256&opt=0)

That is the unforgivable piece.
.

[EGPFlyer]

Interesting incident, fortunately without any injuries. I must wonder if where the problem lies; with the crew or with the system? In Europe and elsewhere a landing clearance is only given when the preceding aircraft has vacated the runway and the runway is ready to accept the next landing aircraft. The policy of giving the landing clearance concurrently to multiple aircraft clearly invites this kind of incident, be it due to stepped on transmissions, radio failure, or, as in this case operator error. Implementing a safer system seems sensible!

Not so. CDG give landing clearances as soon as you check in with them, despite being possibly number 2 or 3 on approach. I believe it’s only the case if using separate runways for landing and takeoff

[DaveReidUK]

Longtimer -

It seems that your source neglected to include.......the punch line:
Canada's TSB rated the occurrence an incident reportable involving the risk of a collision, however, did not open an investigation.

Incident: Canada A321 at Toronto on Aug 18th 2018, continued landing despite go around instruction (http://avherald.com/h?article=4bcfd256&opt=0)

That is the unforgivable piece.

There are around 20 ongoing investigations listed on the TSB website in respect of aviation accidents/incidents occurring in 2018, with the most recent being an event on 1st August.

So the fact that the 18th August event isn't (yet?) listed doesn't necessarily mean there won't be an investigation, notwithstanding Avherald's jumping to conclusions.

[The Ancient Geek]

It can get very tight at places like LHR with a stream of landing aircraft at 90 second intervals.
It only takes one to miss the intended exit to mess things up, if the following aircraft has to go around it has to be squeezed back into the stream somehow causing knockon delays. Sometimes "please expedite" is not enough to clear the runway.

[Herod]

Was it dark at the time? There seems to be some confusion. In Europe (I know, different continent), "land after" could not be given at night; only during the day. Apologies if this has been changed; retirement was a long time ago.

[Rabski]

Land after, etc. is not the issue. What is, is the possibility of someone switching comms to ground frequency while still on approach. Maybe I've lost the plot over the years, but that takes some effort to mess up. Methinks someone was in a bit of a hurry.

[Austrian Simon]

So the fact that the 18th August event isn't (yet?) listed doesn't necessarily mean there won't be an investigation, notwithstanding Avherald's jumping to conclusions.

It is obvious that you aren't in possession of the details and you are jumping to conclusions. The TSB has already stated the occurrence class: Class 5. No investigation. I recommend you check what occurrence investigation class 5 means at the TSB.

The AVH never jumps to conclusions - opposite to you, who repeatedly sell your conclusions as fact even though they are verifyably completely wrong, and you even started to campaign against AVH with your "facts".

[Rabski]

I dunno.. I've seen it happen. Check in with tower and set ground on stby and force of habit changing a fx then pressing swap over. Just saying it is not beyond the realms of possibility.

Not beyond possibility for sure. But staying on the right freq for where you are is pretty fundamantal really. Why in hell would you change comms while still on approach?

[fab777]

I dunno.. I've seen it happen. Check in with tower and set ground on stby and force of habit changing a fx then pressing swap over. Just saying it is not beyond the realms of possibility.


I heard that happen just today: aircraft on final found on the ground frequency and subsequently cleared to land by the ground controller (after an apology from the crew)

[Rabski]

I heard that happen just today: aircraft on final found on the ground frequency and subsequently cleared to land by the ground controller (after an apology from the crew)

The point is that separation of duties is key. Ground in anywhere I know are usually sitting next to the people in ATC doing inbound and approach, but having ground starting to give landing clearance looks like a perfect way to cause havoc.

[DaveReidUK]

The TSB has already stated the occurrence class: Class 5. No investigation. I recommend you check what occurrence investigation class 5 means at the TSB.

Thank you, but I'm perfectly familiar with TSB classifications.

Class 5 does not preclude an investigation, though it's obviously not used for events that involve damage, injury, etc and require significant resources such as deploying a go-team. Nor indeed does it preclude subsequently upgrading the event to a higher classification should that be deemed appropriate.

Given the media attention that the event has attracted, I suggest we watch this space.

FlightGlobal: Air Canada A321 landed despite go-around order (https://www.flightglobal.com/news/articles/air-canada-a321-landed-despite-go-around-order-451527/)

[F-16GUY]

Why didn't the controller try to call them up on guard frequency? Don't most commercial aircraft have one radio dedicated to listen in on 121.5? And the controller probably have a touch key on his screen to enable him to transmit on guard easily .

[RAC/OPS]

Why didn't the controller try to call them up on guard frequency? Don't most commercial aircraft have one radio dedicated to listen in on 121.5? And the controller probably have a touch key on his screen to enable him to transmit on guard easily.

Not in any tower that I have worked in, or know of! The best we have is a hand held that has to be switched on, changed to 121.5 cos it’s probably set to TWR or Ground freq. We’ll try comm checks on TWR, check with APP if the acft is with them, maybe get Ground to broadcast, and show the signal lamp

[AerocatS2A]

Not beyond possibility for sure. But staying on the right freq for where you are is pretty fundamantal really. Why in hell would you change comms while still on approach?
It’s a mistake, you don’t do it on purpose. Ive seen someone change to Tower when they were supposed to be on Approach. It’s caused by your brain running in auto mode and doing things without conscious thought.

[Sailvi767]

Why didn't the controller try to call them up on guard frequency? Don't most commercial aircraft have one radio dedicated to listen in on 121.5? And the controller probably have a touch key on his screen to enable him to transmit on guard easily .

often in the approach phase the number two radio is tuned to company operations or the ramp to get gate assignments and pass maintenance and other requests. Often does not get switched back to 121.5. I doubt tower has a guard transmitter anyway. Normally enroute sectors have that.

[fab777]

At my Airlines, it is SOP to switch off guard below 10K, so one is not disturbed by the kiddies making animal noises during climbout and landing. Part of the sterile flight deck procedure.

[Rabski]

It’s a mistake, you don’t do it on purpose. Ive seen someone change to Tower when they were supposed to be on Approach. It’s caused by your brain running in auto mode and doing things without conscious thought.

Of course nobody does it on purpose. And of course we've all messed up at one time or another. However, there really are some fundamental errors that nobody at the sharp end should make. Changing comm freq when you are utterly reliant on communications has to come under the 'insane' category surely. That's exactly the time nobody should be on 'auto mode'. It's the one time we do (or used to) earn our living.

There are some things we all (well I do) remember from our very first lessons. The basics, which keep you safe.

[AerocatS2A]

Well, as I say, I’ve been sitting next to someone who has done the very same thing. Normally a very good operator, but his brain just did something automatically without thought. The most dangerous thought a pilot can have is that there is a category of errors so fundamentally basic that he could never make one. I have had an FO select flap to zero instead of the gear up. He never thought it would be an error he could possibly make, and yet he made it.

[Check Airman]

At my Airlines, it is SOP to switch off guard below 10K, so one is not disturbed by the kiddies making animal noises during climbout and landing. Part of the sterile flight deck procedure.

Not unheard of to hear a tower or approach controller needing to use guard to give someone instructions. May want to raise that possibility with your flight operations management.

[Capn Bloggs]

Not unheard of to hear a tower or approach controller needing to use guard to give someone instructions.
Does ATC have the capability to transit on 121.5? RAC/OPS above says no (apart from a handheld) and ATC in my neck of the woods cannot TX on 121.5.

[cossack]

Does ATC have the capability to transit on 121.5? RAC/OPS above says no (apart from a handheld) and ATC in my neck of the woods cannot TX on 121.5.
My tower does but it takes numerous button pushes on a touch screen to get the frequency active or configure a hand-held, which would take longer as its set up as a back up to your frequency.
In the case of a late go around instruction, there would not be time to configure either. We do occasionally inquire on guard for aircraft no longer listening. Sometimes find them there too.

[Intrance]

Regarding ATC (tower/ground) on 121,5... A few weeks ago at Munich airport, a Air Canada (hopefully a coincidence) A330 was holding for 08L with ground and tower trying to reach them with no luck. Ground or tower even tried on 121,5 so at least in Munich they can :ok: . We were holding behind the Air Canada and eventually got cleared to taxi around them. I tried to wave and tap my headset as a signal to check comms, don't know if it they even saw, but shortly after they did check-in with tower. It might have also been the fact that some pesky regional jet got to cut in front of them that made them wonder what was up, or just sheer coincidence.

[mgahan]

In my active ATC days (unfortunately many years past now) grabbing the Guard (121.5/243.0) handset and transmitting to aircraft on the ground or in the circuit was a regular, but infrequent occurrence which usually "saved the day", if not the occasional life. As a result, those towers for which I have raised Operational requirements and technical specs in the past 15 years as a consultant, have easily accessible guard TX/Rx facilities.

Not my spec, but even Bonriki AFIS can by one touch on the screen TX on 121.5 and the RX monitor is always on and when the vendor finally gets around to the installation, Cassidy will have the same capability,

MJG

[Rabski]

Well, as I say, I’ve been sitting next to someone who has done the very same thing. Normally a very good operator, but his brain just did something automatically without thought. The most dangerous thought a pilot can have is that there is a category of errors so fundamentally basic that he could never make one. I have had an FO select flap to zero instead of the gear up. He never thought it would be an error he could possibly make, and yet he made it.

To remove the 'high and mighty' hat for a moment, I have to confess my darkest sins. Which include the fact that I once did exactly the same thing. Therefore, I get where you are coming from. (mea culpa, etc.). No harm done, but I got some choice words aimed at me for that one. Very choice words.

[AerocatS2A]

Yeah. The guy who swapped the radios with me was the Capt and he wasn't happy with himself.

We actually had a company policy at the time to have both radios tuned to the appropriate frequency when in the terminal area (starting with Approach or Ground). En route we'd have the second one on 121.5 or company if required. So he managed to switch both radios automatically without thinking about it.

[Sailvi767]

The Airbus radio panel is far more capable than the Boeing panel. It’s also far easier to screw up!

[Guy D'ageradar]

Does ATC have the capability to transit on 121.5? RAC/OPS above says no (apart from a handheld) and ATC in my neck of the woods cannot TX on 121.5.

Yes - everywhere that I have worked in the last 20+yrs

I think the title should be amended to “Air Canada A321 landed despite go-around REQUEST”. ATC can’t order you to do anything once airbourne . They can request and you better have a very good reason to refuse, but refuse you can.

Depends on what part of the world and what type of airspace. At most international airports, it’s an instruction, not a request. Yes, you have the authority to decide otherwise, but you had better be ready to explain yourself. In many cases, it’s because of something that you are blissfully unaware of. Do you really want to second-guess the guy who knows what all the other aircraft are doing - not just yours?

[hans brinker]

I think the title should be amended to “Air Canada A321 landed despite go-around REQUEST”. ATC can’t order you to do anything once airbourne . They can request and you better have a very good reason to refuse, but refuse you can.

I think ATC issues instructions and clearances, not orders and requests. If they cancel a landing clearance and later instruct you to make a GA, you are not allowed to land anymore. If you need to land and/or are unable to make a GA you can use your emergency authority to do what you have to. If you do, you have to declare that beforehand or be able to explain later why you didn’t declare your emergency.
This thread isn’t so much about request vs order, it is about AC once again being somewhat confused what they are supposed to be doing in the last minute of their flights.

[Ian W]

There were times when the RAF Runway Controller with a red flare was far more attention getting than any radio call.

[Rabski]

Yeah. The guy who swapped the radios with me was the Capt and he wasn't happy with himself.

We actually had a company policy at the time to have both radios tuned to the appropriate frequency when in the terminal area (starting with Approach or Ground). En route we'd have the second one on 121.5 or company if required. So he managed to switch both radios automatically without thinking about it.

We all like to think we are faultless, but if I'm honest, the few (thankfully) f**kups we make are usually the dumbest ones. I did the 'flaps to zero instead of gear up', which did not go down well at the time. Fortunately, I never did it the other way round... I'm a bit fussy about comms though, because my very first ever instructor thought that comm settings and altimeter settings were 99% of keeping it in one piece. Actually, I think now that he was pretty well spot on. Being in communication with people on the ground and knowing how far away from it you are equate to probably the two most vital things, even if everything else has gone to bits.

[ATC Watcher]

Well is a "Go Around:" spoken on the R/T by a Controller an ATC instruction ? Yes it is..
Most national AIPs follow Doc 4444 where it says that in IFR all ATC instructions have to be followed by the crews . I guess it is the same in Canada or in the US.
PIC can of course always decide not to follow an ATC instruction , but he/she will have to explain why afterwards., and if it endangered someone or other aircraft you will be in real trouble.
The reply "unable" comes to mind of course but not really applicable to a Go around I would say.

[Guy D'ageradar]

Well is a "Go Around:" spoken on the R/T by a Controller an ATC instruction ? Yes it is..
Most national AIPs follow Doc 4444 where it says that in IFR all ATC instructions have to be followed by the crews . I guess it is the same in Canada or in the US.
PIC can of course always decide not to follow an ATC instruction , but he/she will have to explain why afterwards., and if it endangered someone or other aircraft you will be in real trouble.
The reply "unable" comes to mind of course but not really applicable to a Go around I would say.

unless, of course, you forget to add the go-around power 😬 but that would never happen, would it?!!!