ryr Landed In a taxyway by mistake in CAG

[Lord Lucan]

Just for more info, this picture has been taken yeasterday at 2.30 pm on final rwy 32L

Ubotte is it really 32L when there is no parallel runway? Or is the situation still rather confused?

[ubotte]

here the references:

md80.it • Leggi argomento - Velivolo Ryanair atterra su via di rullaggio a Cagliari

[White none please]

Unfortunately in Ryanair, Jepp plates, (printing, checking they are all complete/valid) is another one of the many duties lumped in to a pilots 45min preflight. The trip kit for CAG being used on the day, while all the plates were valid, was missing the plates that pertained to the straight in ILS 32.( I checked them the following morning)
I can only guess that when these kits were printed out a month or two earlier, the person in question did not include them in the kit, as they were not going to come in to effect for some time in the future.
For the crew on the day, having a current trip kit(although missing a few pages!) all pointing to the now out of date side step procedure, did nothing to help the situation.
As usual in Ryanair,while the final responsibility rests with the crew to ensure all of the current plates are included in the trip kit, it is a sad state of affairs that one can not rely on these basic things being looked after, because due to cost cutting, it is not possible , as in most other airlines ,to have this taken care of by an OPS person / department.

[MPH]

I imagine that the CVR and the ATC transcript will give an intresting take on this incident. I know that for the last 6months or more the approach was always and ILS or VOR app. for one of the rwy´s with a side step onto the 14L or32R which is infact the taxiway!! The runway was offficaily opened on the 6th of april and at least the ATC or tower should have pointed this out barring notman´s, etc. One wonders wether the clearance was the above mentioned approach or infact an ILS or VOR onto the then active runway ie 32 or 14? As always we will have to wait for the official report!!!

[bookworm]

RAT 5 and Oleo, this is the standard way to build the NOTAM. One day a doc is issued to inform about the starting of such a kind of work on an apt, later a new doc is issued to inform about the closure of the work. It always happened and it always will happen in that way, no more no less.

I disagree.

(B1003/09 NOTAMR B8396/08
Q)LIRR/QFATT/IV/BO/A/000/999/3914N00903E005
A)LIEE B)0902121555 C)0904222359
E)TRIGGER NOTAM - EFFECTIVENESS OF PERM PROVISIONS PUBLISHED LAST
04 DEC 2008 WITH AIRAC AIP AMDT 13/08 AND CONCERNING FLW ITEMS
POSTPONED TO 09 APR 2009:
- RE-ESTABLISHMENT OF NORMAL OPERATIONS ON RWY 14/32
- NEW AERODROME LAY-OUT
- COMPLETE REVIEW OF INSTRUMENTAL APPROACH PROCEDURES
THEREFORE AIP SUP 20/07 WILL BE IN FORCE UNTIL 08 APR 2009
AIRAC WILL BE POSTED AND AVBL ON WEB SITE WWW.ENAV.IT)

B1003/09 is an accident waiting to happen. OPADD clearly requires the following (my bold):

2.7.4.2 Effective Date: AIP Supplements become effective at the date and time stated in
the Supplement. Information to be published under the AIRAC system does not
always start on an AIRAC cycle date (e.g. major works, large air exercises etc. ...).
Consequently, both the AIP Supplement and the Item B) of the Trigger NOTAM
shall contain the effective date and time of the start of the information.

2.7.5 Notification of changes to AIP SUP
2.7.5.1 Changes: Any change to an AIP Supplement and its associated Trigger NOTAM,
shall be published by the Publishing NOF in a way that the information itself is
always clear and without any ambiguities.
...
2.7.5.3 Notification of a later end date or time: the notification of a later end
date or time of validity of the information published in an AIP Supplement is
announced by replacing the Supplement and announcing this replacement by
the same procedures as the one described in 2.7.5.2.

The NOTAM claims to be a Trigger NOTAM, but fails to meet the criteria for a Trigger NOTAM. The whole point of a Trigger NOTAM is that it first appears in PIBs when the change to the AIP happens. This one has a B) field two months before the change to which it refers.

[bookworm]

For those of you scoring at home, here are the "Trigger NOTAMs" published for LIEE with approximate times.

Code:

 
 2008-12-04 13:44
(B7734/08 NOTAMN
Q)LIRR/QFATT/IV/BO/A/000/999/3914N00903E005
A)LIEE B)0901150000 C)0901282359
E)TRIGGER NOTAM - PERM AIRAC AIP AMDT 13/08 EFFECTIVE DATE
FROM 15 JANUARY 2009
-RE ESTABLISHMENT OF NORMAL OPERATIONS ON RWY 32/14
-NEW AERODROME LAY-OUT
-COMPLETE REVIEW OF INSTRUMENT APPROACH PROCEDURES.
AIRAC WILL BE POSTED AND AVBL ON WEB SITE WWW.ENAV.IT)
 
 2008-12-30 14:02
(B8395/08 NOTAMC B7734/08
Q)LIRR/QFAXX/IV/BO/A/000/999/3914N00903E005
A)LIEE B)0812301357
E)TRIGGER NOTAM EFFECTIVE DATE 15 JAN 2009. NEW NOTAM TO FLW)

 2008-12-30 14:04
(B8396/08 NOTAMN
Q)LIRR/QFATT/IV/BO/A/000/999/3914N00903E005
A)LIEE B)0901150000 C)0903252359
E)TRIGGER NOTAM - EFFECTIVENESS OF PERM PROVISIONS PUBLISHED LAST
04 DEC 2008 WITH AIRAC AIP AMDT 13/08 AND CONCERNING FLW ITEMS IS
POSTPONED TO 12 MAR 2009:
- RE-ESTABLISHMENT OF NORMAL OPERATIONS ON RWY 14/32
- NEW AERODROME LAY-OUT
- COMPLETE REVIEW OF INSTRUMENTAL APPROACH PROCEDURES
THEREFORE AIP SUP 20/07 WILL BE IN FORCE UNTIL 11 MAR 2009
AIRAC WILL BE POSTED AND AVBL ON WEB SITE WWW.ENAV.IT)

 2009-02-12 16:07
(B1003/09 NOTAMR B8396/08
Q)LIRR/QFATT/IV/BO/A/000/999/3914N00903E005
A)LIEE B)0902121555 C)0904222359
E)TRIGGER NOTAM - EFFECTIVENESS OF PERM PROVISIONS PUBLISHED LAST
04 DEC 2008 WITH AIRAC AIP AMDT 13/08 AND CONCERNING FLW ITEMS
POSTPONED TO 09 APR 2009:
- RE-ESTABLISHMENT OF NORMAL OPERATIONS ON RWY 14/32
- NEW AERODROME LAY-OUT
- COMPLETE REVIEW OF INSTRUMENTAL APPROACH PROCEDURES
THEREFORE AIP SUP 20/07 WILL BE IN FORCE UNTIL 08 APR 2009
AIRAC WILL BE POSTED AND AVBL ON WEB SITE WWW.ENAV.IT)

Note the absence of a Trigger NOTAM with B)090409xxxx which would have been the useful one!

The procedures effective 09 APR 2009 appear to be in the AIP AMDT 13/08 effective 15 JAN 09 on the ENAV site. There is no mention of them in the AIP AMDT 03/09 effective 09 APR 09.

Oh, and the info in EAD is out of date -- still the 2007-12-20 versions with the temporary charts, but hey, nothing startling about that, is there?

[fireflybob]

Notwithstanding that crews should be aware of the contents of all relevant NOTAMS, I don't know about you fellows but being a simple soul I find these NOTAMS quite diificult to interpret. Who dreamt this awful format up? It's one thing saying the information is there and available but surely someone can come up with something which is MUCH more user friendly where any VITAL date is readily available. I get fed up with wading through pages of cranes which have been hoisted near an airport not to mention birds in the vicinity etc.

Then somewhere in the middle is something really important like ILS u/s or RW XX closed!

And yes I know some airlines have their own tailored NOTAMS but surely the basic data could be much easier to understand!

[wiggy]

fireflybob

"I don't know about you fellows but being a simple soul I find these NOTAMS quite diificult to interpret. Who dreamt this awful format up?"

I think this has come up before ( ? the relatively recent accident in the States where it seems take off was attempted from a closed runway). In these days of the internet you would think the distribution and presentation of notams could be much more user friendly....instead of which we are stuck with a teleprinter friendly format that seems to date back to WW2.

[737nga320]

attention in case someone lands in LGW early morning

I do not know whether Gatwick is open during 2300 to 0400 but just in case:


NEW TODAY WEF 0904152300 TIL 0904160400
RWY 08R/26L CLOSED 2300-0400. RWY 08L/26R IN USE 2310-0350. LGT
FOR CLOSED RWY AND PARALLEL TWY WILL NOT BE VISIBLE ON APCH. THERE
IS A CHANGEOVER PERIOD OF 10 MIN WHEN NO RWY WILL BE AVBL. LAST DEP
5 MIN BEFORE CHANGEOVER

One can never be to sure!

[GearDown&Locked]

Is a basic ATIS service that expensive for not having one installed?

[blissbak]

Where is the difference between an ATIS system and the RWY in use given at first contact by the ATC unit ?

ATIS or APP freq. they would have get the 32 in both cases , then .....

[tarjet fixated]

Where is the difference between an ATIS system and the RWY in use given at first contact by the ATC unit ?

The difference lays in the fact that in CAG they never give you the WX nor the RWY nor the expected procedure unless you ask for it when already in the final phases of your flight...and when they do then they change the arrival procedure at least 2 times.

Some companies conduct their line checks on flights to CAG to see how their pilots cope with "unfavourable" environments....makes you wonder....

[SID PLATE]

Jeez Bookworm ... you've a well chosen login name there ...
Do you iron your underpants?

[IcePack]

I agree with the lousy notam bit. Just look at the notams for VLC rwy closure times. Something lost in translation methinks.
& in fact how many times have you read a notam and on arrival you find that it was rubish. My sympathies to the crew in this case. Unfortunatly they will get the blame as oh no it can't be the authorities fault!

[saucy jack]

I am a regular into CAG which, as you would probably expect, now has white "Xs" painted on the closed runway/taxyway in question, along with cones/lighting across at various intervals.

Regulars (presumably like this crew) will also know that for the last year prior to 9th April) all ATC approach and landing clearances have had to be read back ackowledging the side step onto Runway 32 Right, and this has been reinforced by ATC to the extent that it becomes routine...and hence susceptible to confirmation bias or however you would wish to refer to it. I am not using this as an excuse for what happened, but I can see why the potential for the mix up is there. I can confirm that the ongoing works have been pretty regularly updated in Jeppesen and Notams (legible or not) and most of us seem to have been aware of the new implementation date for the new runway which has been put back several times already.

I too have received landing clearances from Approach Control. The reason seems to be that a "late landing clearance" by the tower is considered to be anything up to 5 miles out when, in my book, a late landing clearance comes once over the threshhold. Nevertheless I always called visual in these circumstances and was switched to Tower. In this case that did not happen so the chance to contact the pilots was missed.

On finals one night I did witness the converse scenario to this incident, when an A320 was cleared to line up and take-off in front of me. He then proceeded to taxy onto the closed main runway (32L) of which the second half was still a construction site. Fortunately the Tower spotted this before any further drama could unfold.

[bookworm]

Jeez Bookworm ... you've a well chosen login name there ...
Do you iron your underpants?

Every AIRAC cycle, SID.

[M609]

This the view at minima at a offset ILS (due terrain) at Bodø.

Spot the runway? Then guess where SAS planted a Fokker 50 back in 2000

Picture from the AAIB-N report

For some reason the SOP is for TWR to keep high intensity lights and flash going for the runway in use at all times, even in CAVOK/daylight after that case!

[Henry VIII]

I disagree.
B1003/09 is an accident waiting to happen. OPADD clearly requires the following (my bold): etc. ………

Bookworm, I never verified the NOTAMs editing procedure docs as you did.
My statement was simply due to real life observation. As far as I remember I saw that way of act a lot of times, not to say always.
For the above reason I guess that receiving such a Notam any pilot has to highlight the essential practical operational information despite the layout or maquillage.
When a Notam says :

• RE-ESTABLISHMENT OF NORMAL OPERATIONS ON RWY 14/32
• NEW AERODROME LAY-OUT
• COMPLETE REVIEW OF INSTRUMENTAL APPROACH PROCEDURES

IMO it MUST trigger a BIG warning, especially if the on board approach plates and aerodrome map still report the previous scenario only, to be CLARIFIED as soon as possible.
With the company dispatcher in first, in the company where those people are allowed to communicate face by face with pilots, or, as last chance, with atco BEFORE the beginning of the approach.
Other technical editing consideration(s) can be very useful for lawyers, later. But in the meantime the harm has been done.

If the taxiway had been in use for months, don't you think that it would have been better to have a positive instruction via NOTAM i.e. saying something along the lines of 'Runway XYZ is fully serviceable, Taxiway ABC is no longer to be used for landing".

anotherthing, I agree with you. But things do not acts in this way.
What to do ? Land out of RWY everytime ?

[bookworm]

Other technical editing consideration(s) can be very useful for lawyers, later. But in the meantime the harm has been done.

Not quite sure what you mean by "technical editing considerations". Trigger NOTAMs are a very important tool in bringing changes to the attention of pilots -- but only if they are used properly by the originator.

[Dutch250]

With all due respect but if these things are clearly noted in the notams:
RE-ESTABLISHMENT OF NORMAL OPERATIONS ON RWY 14/32
NEW AERODROME LAY-OUT
COMPLETE REVIEW OF INSTRUMENTAL APPROACH PROCEDURES

Then sorry, the only conclusion I can make is that this crew did its homework for the flight badly.

I.e BIG screw up!!