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-   -   EasyJet A319 lands on closed Runway at Pisa 30/12 (https://www.pprune.org/rumours-news/572511-easyjet-a319-lands-closed-runway-pisa-30-12-a.html)

Suzeman 30th Dec 2015 22:14

EasyJet A319 lands on closed Runway at Pisa 30/12
 
Reported on Aviation Herald

Incident: Easyjet A319 at Pisa on Dec 30th 2015, landed on closed runway

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 31st Dec 2015 08:40

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 31st Dec 2015 09:04

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 31st Dec 2015 10:58

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 31st Dec 2015 11:12

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 31st Dec 2015 13:17


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 31st Dec 2015 14:00

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 31st Dec 2015 14:06

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 31st Dec 2015 14:28

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 31st Dec 2015 14:39

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 31st Dec 2015 14:42

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

DOVES 31st Dec 2015 14:49

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 31st Dec 2015 14:49

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 31st Dec 2015 15:42


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 31st Dec 2015 16:07

Human Factors
 
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 31st Dec 2015 17:09

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 31st Dec 2015 17:32

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 1st Jan 2016 10:10

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 1st Jan 2016 16:09

...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 1st Jan 2016 17:28

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 1st Jan 2016 18:38

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 1st Jan 2016 18:40

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 1st Jan 2016 19:32


......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?

tubby linton 1st Jan 2016 19:53

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 1st Jan 2016 23:28

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 2nd Jan 2016 06:24

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?

:confused:

South Prince 2nd Jan 2016 06:33

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 2nd Jan 2016 09:21

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 2nd Jan 2016 09:36

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 2nd Jan 2016 09:52

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

slast 2nd Jan 2016 11:38

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

Dan Winterland 2nd Jan 2016 12:22


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 2nd Jan 2016 18:55

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 2nd Jan 2016 20:25

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 3rd Jan 2016 12:36

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".

Heathrow Harry 3rd Jan 2016 13:20

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 3rd Jan 2016 13:28

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 3rd Jan 2016 13:48


Originally Posted by I-AINC (Post 9224659)
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 3rd Jan 2016 13:52

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 3rd Jan 2016 15:04

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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