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EasyJet A319 lands on closed Runway at Pisa 30/12

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EasyJet A319 lands on closed Runway at Pisa 30/12

Old 1st Jan 2016, 18:38
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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.
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Old 1st Jan 2016, 18:40
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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!!!
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Old 1st Jan 2016, 19:32
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......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/...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?
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Old 1st Jan 2016, 19:53
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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?

Last edited by tubby linton; 2nd Jan 2016 at 00:17.
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Old 1st Jan 2016, 23:28
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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.
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Old 2nd Jan 2016, 06:24
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NOTAM format

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?

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Old 2nd Jan 2016, 06:33
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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?
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Old 2nd Jan 2016, 09:21
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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.........
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Old 2nd Jan 2016, 09:36
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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.
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Old 2nd Jan 2016, 09:52
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Chris, Ha ! Damn...spilled me coffee again !
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Old 2nd Jan 2016, 11:38
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Nice one, Chris - keep it for the rest of the year please!!
Steve
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Old 2nd Jan 2016, 12:22
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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.
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Old 2nd Jan 2016, 18:55
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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.
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Old 2nd Jan 2016, 20:25
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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.
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Old 3rd Jan 2016, 12:36
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pisar unways

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".
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Old 3rd Jan 2016, 13:20
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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
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Old 3rd Jan 2016, 13:28
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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.

Last edited by Wageslave; 3rd Jan 2016 at 13:54.
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Old 3rd Jan 2016, 13:48
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Originally Posted by I-AINC
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.
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Old 3rd Jan 2016, 13:52
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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.
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Old 3rd Jan 2016, 15:04
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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.
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