Eurocypria Airlines LTD Incident EPKT 2009-11-09
 

Another hair rising incident by a Cyprus airline Eurocypria Airlines LTD.
Aircraft reg. 5B-DBV
Boeing 737-800
Date: 2009-11-09, 20:36 LT

Rough translation of the report of the Polish Accident Investigation Board:
http://www.mi.gov.pl/files/0/30675/2009962RW.pdf


Flight from the airport, situated at one of the Canary Islands-Fuerteventura (GCFV) to Katowice (EPKT) was the second flight of the crew landing in Katowice. The crew conducted the approach to runway 27 at epkt by ils system at atmospheric conditions at the airport at 19.30 utc: wind 210 °/2 kt, rvr for runway 27 was 350 m by the presence of fog, and the lower limit of clouds was determined to 100 ft
Minima for airport and crew for the approach in CAT I are: rvr _ 550m and cloud base 200 ft. After touch down to the left of the centre line the aircraft left main and front gear left the runway and then for approximately 373 m remained outside of the runway damaging part of the two edge lamps. The right main landing gear wheel during this time, remained on the asphalt of the runway.
The aircraft returned to the runway and has eventually stooped.
In his submission, the pilot (cpt) stated, that he probably took left edge light for non-existent central line lights. After parking on stand crew did not report any observations. FO of the anding crew provided the information for the crew from Katowice to Warsaw, that he will do the PFI– CPT of amending crew accepted this.
As a result, FO of the previous crew checked only left main landing gear without performing properly throughout the PDI-pre departure inspection.
When doing this FO did not have a flash-light for lighting of aircraft elements contained in the PDI procedure. As a result, he skipped checking the front landing gear, the right main landing gear and other items subject to PDI. In the action FO, has not detected damaged tyres of the front gear, right front wheel rim and headlamp on the protectors of the gears. Undetected remained corruption of the tyres right main landing gear internal wheels.
Each of these faults should have resulted in the inability of the aircraft for further flight until Exchange all damaged items. After returning to the aircraft FO reported to the CPT for the crew to Warsaw, aircraft is OK.
During the push back person monitoring this process on the ground, reported broken landing headlamp to CPT.
CPT asked FO of the previous flight (previous crew was returning to Warsaw on board of the aircraft) if when executing PDI he noted any damaged headlamp, FO reported "negative".
Therefore, the CPT minimum equipment list (MEL) allows him to complete the flight to Warsaw and has no objection to the efficiency of the aircraft. After loading in Warsaw and checking the status and tyres of the front gear, CPT wrote a ASR report entry, has filed it to the logbook, handed over the aircraft to the technical personnel, and then both crews proceeded to the hotel.

:mad::mad::mad:

This is just a preliminary report, I will keep you informed a.s.a. any news emerge.

I wouldn't necessarily pin this on a "Cyprus" outfit. This ignorance and oblioviousness is a systemic tumor that goes waaaayyyyyyy deeper than geographic location.

When you mix recklessness with inexperience, you get a dangerous cocktail.

If people only knew what they're paying for!!!:ugh:

Standards are low and falling. Experience is diminishing. Commercial pressures are ramping up.

These people were fortunate. (Passengers and crew). Expect more such events in 2010 and beyond. And they won't be confined to small carriers.

Just read the original incident report.

The behavior of the inbound crew was plain criminal! If these cats didn't realize that there was something not right with that landing/roll out, they're f:mad:g retarded!
But I suspect the inbound FO volunteering to do the walkaround for the outbound crew, that they knew.

What's criminal is the fact that this pi..ant comes back and with a cool conscience tells the Captain that the a/c is ok?! WTF?
Maybe they are retarded, cause in the end they got on the outbound plane as a deadheading crew....

According to the report, the left main, as well as the nose gears were off the runway. How do you not feel that??

I'm not sure how the euro authorities handle things, but on the other side of the pond, these knuckleheads would have gotten an automatic violation for shooting an approach that was below applicable mins.

Whatever happened to screwing up and taking responsibility for it??

You're right, that's not exactly setting the right example, is it?!

This one is cut-n-dry in my opinion.

1. Continued approach below published minima.

2. Luckily the (blissfully unaware) passengers weren't harmed.

3. In essence the crew conspired to cover up their deed - :mad:

Both should have their licence/rating revoked. No room for cowboys in our work environment - I'm sure there are many more able and consciencious crew out there currently looking for work.

No bleeding heart boo hoos please. These guys are grade one idiots and should be grounded immediately.

A4

I am not sure about the follow up of this event by the Polish authorities,
but Cyprus is in the EU and EASA should react immediately.

If these morons are not to be taken to responsibility, the airline should be.

Put them immediately on the black list!

So is Poland. Duh! :ugh:

Therefore the airline should be hit hard.
Only this can stop this horror.

And regarding investigators, this is under Polish jurisdiction,
and I can assure you, will be handled properly.

What is your problem, cargo-boy?

The report has been published, nobody is hiding anything,
I only wrote, that I don't know what is being undertaken,
which doesn't mean, that nothing is happening.

Normally in such cases any actions are taken on the basis of the final report,
and not preliminary.

I am sure this will be properly taken care of by the Polish authorities (and EASA).

This is just 30 days since the incident happened.

In Cyprus maybe not, may be you are correct. However, the investigating country ought to have a say as well, and even if these loony tunes get off free down there, it sure would set a tone if the airline were to be punished by EASA.

Slightly better translation at: Aviation Herald:
Incident: Eurocypria B738 at Katowice on Nov 9th 2009, runway excursion on landing

Remembering "similar" Air Europe's incident two years ago, I still can't imagine why are these guys hoping to leave the scene undetected? Shame.

If the Polish CAA is to carry out this investigation it will last for at least 3 years. In 3 years the EuroCypria will say that was 3 years ago, today we operate much better.

The most important thing with any incident is that no-one was hurt, regardless of the degree of culpability.
As for Eurcypria as an airline, I had the privilege of flying with them for two years 2006/7. I've flown with several airlines over the years in Europe, SE Asia, Australia and I found the ECA standard to be equal to the best.
No airline is imune to incidents and I certainly hope that Eurocypria as a whole doesn't get unfairly pilliored over this.

So as far as a very Experienced rocket scientist,JUDGE, fighter pilot,AIB investigator etc etc Mr Ptkay has decided that the crew should be fired and the airline put on the black list!!!
So what do you recommend we should do to Air France?They lost two a/c in the last 3 years.What about BA?? They lost one in London last year.
We are all waiting for your judgment.
I'm not sure what exactly happened and what was going through the mind of the crew but until the investigation is over i guess the only thing the airline can do is suspend them.
In my aviation career i learnt to never point a finger at someone. There are those who screwed up and those who will at some point. And that goes from the most minor to the most major incident.
I remind you of the top KLM Captain who many years ago was involved in the biggest aviation accident in Teneriffe. He was the first the airline called so he could help in the investigation only to find out that he was actually involved in it.
What i am trying to say is that it can happen to the best of us and that is something we should all keep in mind.
Safe flying !!

Dear Tcas1,

I appreciate your sense of humour.

But I kindly remind you, that it is not the case "sh#t happens",
bit a cover up story following a landing in breach of all rules.

Those rules were written exactly to avoid such incidents or accidents.
Breaking them is criminal.

In the process of cover up the CPT and FO put their colegues
on the flight EPKT to EPWA at risk, not mentoning the plane
and pax (if there were any on board.)

As others mentioned above it is a mater of the "new culture" in the
aviation, when landing below the minima is becoming a rule,
pilots doing a go around or diverting are being put under pressure
not to do so again...

This time there were just 2 lamps and a few tires.

Do you suggest we should look away again and wait until something
more serious happens???

Many happy landings (below minima)

Truly yours

PTKay

Exactly! Duckbelly and tcas1, the issue is not the incident itself, but the attempt to cover it up. That is criminal.

Never flown for 'lines', but I do my outside check myself, if not avoidable my F/O on duty does it. Can you delegate that to a guy technically not on duty?

If all legal arguments are not worthwhile considering them, the attempt to put the blame in the shoes of the following crew is just...just...unbelievable low morale. As the follow on captain I´d kick the s... out of them for trying to blame me. How low can it get?

Yes dear Ptkay.
You could be right. Breaking those rules might make somebody a criminal, but nothing makes you the prosecutor, the judge, and the executor all at the same time!!!!
I wonder, have you ever done a CRM course? Did anybody ever teach you that specially as a pilot you shouldn't jump into conclusions right away? Did you ever hear the phrase "assumption is the mother of all fu*k-ups?" (probably assumption was a contributing factor into this f*ck-up as well). Please give some credit to the rest of the common mortals!!

Coming back to the subject, I am sure there's more to it than what it seems, as is the case in every serious incident / accident. As far as I can tell, nobody here suggested that we should look away (again??? you mention??) until something more serious happen, so why do you jump immediately into that?
No case is black or white. If the crew mis-behaved in any way, I am sure that there are professional people out there that will do their job properly.

tcas1Are you for real? The Air France accident needs to find data and voice recorders before they can truly state what happened there, in terms of culpability.

But how can you pigeon-hole the BA 777 accident, with this 737 incident? The BA accident, although investigations are not yet complete, was apparently caused by a technical/design problem (fuel-oil heat exchanger), yet you seem content to compare it to this wilfully negligent Eurocypria 737 incident, which is compounded by attempts to cover up what happened. I find that offensive!

The Eurocypria crew should be suspended immediately, and once their actions have been investigated (and right now they appear to be very serious allegations of endangering the aircraft and occupants, and covering up afterwards), they should face the appropriate punishment. Whatever that punishment is, it is likely to be heavy.

I think a lot of you are missing the point!

This is not, or at least it shouldn't be a pi:mad:ing contest about judging others and solving accidents.

tcas1, after reading your comment, which to me completely misses the point, I would just like to know, if you've learnt in your aviation career to accept responsibility for your screw ups?

Maybe I'm just way off here, but I don't know how the hell you drive an a/c-or half of it- through the grass/dirt and not have an incline that something was "off"; to at least get you to go out and "investigate" a little?!

His dudeness,
I don't think an FO's capability to do a walk around is at debate.
What seems interesting, at the very least, is that one of the players involved in a booboo volunteers to go do it.

Ethics, unlike procedures, cannot be taught.

OK. Let me make myself clear.
By reference to the AF, BA and KLM accidents what i am trying to point out is that accidents can occur to the best airlines and pilots.
Nobody had the right to judge until all facts are analysed. Never rush into assumptions and buring someone or the airline involved. The point is to learn from peoples mistakes and procedures improved to avoid the same thing happening again.
As for taking responsibility for what I,or anyone does it is not a matter of only punishing the person involved but obviously so others can learn from our mistakes.
Finally something for everyone to think about and again not trying to take the part of the crew's lawyer. Do you really think that the crew involved realised the severity of the incident and then stayed on board and deadheaded to WAW after doing a PDI themselves? I would like to think they didn't.
And as far as the minima involved ,flying into poland myself time and time again we get info for airports where vis given is 1500m and rvr 350.Not that it cannot happen but a bit confusing and misleading.
Finally something else for everyone to think about is that by doing some furhter research into the incident you find out that a LOT a/c landed only few mins before the incident.

It would be interesting to find out then what, if any, RVR reading was given by the tower to the LOT aircraft. :E

Having spent most of yesterday trudling around Europe which involved 3 Autolands down to 300m, it IS inconcievable that the crew would not have realised that they had left the "hard stuff".

An RVR of 350m is nothing like an RVR of 75m - that may sound like a stupid statement, but the point is IT WOULD HAVE BEEN PLAINLY OBVIOUS to the crew concerned that the event hadn't gone quite to plan!!

On the information given so far this would appear to be an act of wilful negligence in carrying out the approach in the first place and perhaps criminal in not entering it in the Techlog and actively trying to cover it up. Did they seriously think they would get away with it?

Perhaps the more serious question is why do crews, on occasion, go completely against the rule book? I was told many years ago that if ever I was facing a scenario which was "pushing the envelope" of acceptable practice, I should picture, in my head, me with my best "courtroom voice" justifying why I did what I did to the management or even a Jury.

The usual pressure is time. Does it really matter that much? Is it so important that you are prepared to put your passengers, aircraft, licence at risk? Being late/diverting is a pain in the ar$e - but it's a lot more palatable than the other options which WILL eventually catch up with you. If you got away with it once you're likely to "push" again...may be a bit more this time. And then you push.... and push.... and push..... and you end up sticking the mains off the side doing an illegal autoland...... and then you try to cover it up. :ugh:

Fly safe everyone.

A4

tcas1,
Fair enough-but, wouldn't the prudent thing to do, be to abandon the approach at the bottom? Surely, we've all come down the slope only to have to go around, after arriving at DH?!
And yes, I did call you Shirley!!:E

Again, I don't think anyone is "judging" the crew on starting or flying the approach; at least I see no problem there.
What is at debate is how they dealt with the aftermath.

Tcas1,

Now you become nasty.

Here are the METARS:

EPKT 092130Z VRB01KT 0400 R27/0500N FG VV001 07/07 Q1010
EPKT 092100Z 24002KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 092030Z 28002KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 092000Z 00000KT 0100 R27/0350N FG VV001 07/07 Q1010
EPKT 091930Z 21002KT 130V250 0050 R27/0350N FG VV001 07/07 Q1010
EPKT 091900Z 23003KT 180V260 0050 R27/0300N FG VV001 07/07 Q1009
EPKT 091830Z 13001KT 0050 R27/0300N FG VV001 08/08 Q1009
EPKT 091800Z 13002KT 0100 R27/0350N FG VV001 08/08 Q1009
EPKT 091730Z 13004KT 0100 R27/0300N FG VV001 08/08 Q1009
EPKT 091700Z 12004KT 0300 R27/0350D FG VV001 08/08 Q1009

What is it, that makes you think that is specially "Polish" in them.???

You have steady and continuous RVR of 350m for over 4 hours,
with fog and 100ft ceiling.


And this is exactly why such incident should be treated with all available severity.

The LOT guys went away with it (maybe).
(You don't know their aircraft equipment and crew skills.) ;)

Nevertheless Polish CAA has insisted on ATC to report any and all landings
below minima at Polish airports since the incidents become more and more
frequent. (See the former one in EPKT.)

Also recently Just Culture committee was established by the CAA allowing
pilots or any other person involved to report anonymously about the incidents
they witnessed.

This is the "old boys" culture of cover ups and
"don't puke into your own nest" that makes the fight with
such reckless flying practices so difficult.
And also gives the management of the airlines an argument to put pressure
on the crews to fly below minima, because they can always say,
"Look, you will get away with it, everybody does".

And the incident we discuss here is a perfect example of such cover up mentality.

[QUOTE]You don't know their aircraft equipment and crew skills/QUOTE]

Do you know? Can you please explain to all of the non judgemental members?

Last time I've checked, Katowice had CAT I ILS. Lack of centerline lights indicates no significant change since then. Shooting CAT I ILS with RVR below 550m is illegal, for reasons that have once more become painfully obvious.

So the crew made high speed runway excursion and went dead-heading on the same aeroplane, without maintenance checking the aeroplane.

Never mind the legal consequences, they'll have hard time explaining the occurrence at next medical renewal.

Wouldn't the airport have to be certified for anything more than CAT1, besides aircrew and aircraft?
In which case the LOT plane would be "discovered" (if it did land as said), ironically not b/c of their own doing!

It's all good, unless we're talking safety of flight stuff.

Just to confirm: KTW is CAT I., minimum is RVR 550. They do not even have an LVP (actually they have one prepared since months but it's not signed by one of their 2000 authority, agency or bureau) therefore even the take-off minima is 400m.
Poland does not have a single CAT III runway for 10+ airports with considerable traffic and population approx. 40 million. But at least their weather is s...ty every autumn/winter. :)

So if i was ptkay and rushed into conclusions, the LOT a/c landed below minima and then covered up their wrong doing by not reporting it!!! Thats criminal... lets suck the crew and blacklist the airline!!!!

(You don't know their aircraft equipment and crew skills.)

I love your comment ptkay.Its actually the most ammusing thing i read on this thread. So let me get it right. The LOT crew are extremely skilled and experienced in landing below minima and have equipment that allows them to do that!!!???!!! AMAZING!!!!

No tcas1, it's probably one of LOT's old boys that the Polish CAA is trying put some sense to!

[QUOTE]Poland does not have a single CAT III runway for 10+ airports with considerable traffic and population approx. 40 million/QUOTE]

And to add: The only CAT II runway at EPWA was downgraded to CAT I for 3 weeks in November!
Where do all these guys land when foggy weather comes in? In BERLIN???

Does KTW have ATIS??

If not, do you know what the RVRs passed to the crews of either aircraft were? Are you sure that they were the ones shown in the metars above?

No, they don't.

But I would be very surprised if TWR would pass anything else than
listed in the quoted METARS, by such constat conditions.

lventes,

no, I don't know either, and this comment was meant "tongue in cheek".
(I edited it with some emoticon to make it clear.)

;)

Tcas1,

I am happy I was able to amuse you.

As I mentioned above, the remark was meant "tongue in cheek",
which obviously didn't come through.

Tcas1, I fully agree with you.

Please, kindly read the whole of my post, where I express my concern
about rising frequency of such breaches of rules and suggest
introducing Just Culture.

I will quote myself for your comfort:

So why wouldn't you, anonymously, report the LOT crew to the Polish CAA,
to do the matter just.

Or you rather wouldn't, just to stick together with your chaps???

Levantes,

you are right, the situation in Poland is really critical regarding CAT.
And you are right, the only choice is sometimes Berlin, although
usually POZ has much better weather than KK, KT, or WA.

Regarding the LOT old boys, if not tcas1, then maybe you will
report the violation through the Just Culture scheme to Polish CAA,
to finally stop this "accident waiting to happen".

BTW: on DEC07 32th meeting of the Provisional Council ( PC) of the EUROCONTROL took place in Brussels.
Among others the Safety Regulation Commission reported on introduction
of "Just Culture" and once again stressed the importance of this tool
to improve flight safety.

[QUOTE]But I would be very surprised if TWR would pass anything else than
listed in the quoted METARS, by such constat conditions./QUOTE]

My friend ptkay you are again assuming and jumping to conclusions!
As you see the METAR's you uploaded are 30 min apart!
I would be a very unhappy man if I was in holding pattern over KTW waiting for the weather to improve and TWR gave me weather updates every 30min!:ugh:
I ASSUME (I'm stating it!!!!) that there is RVR indicator in the TWR giving readings to aircraft!;)
Its easy to judge the weather conditions constant NOW but at real time nothing is constant at these conditions.