Handout ACCIDENTS & INCIDENTS REPORTS H-1.

ACCIDENTS & INCIDENTS REPORTS

1.1 2015, AIRBUS A330-303, KATHMANDU, NEPAL

https://skybrary.aero/accidents-and-incidents/a333-kathmandu-nepal-2015

Description: Airbus A330-300 on a scheduled passenger flight from Istanbul to Kathmandu touched down
at a higher than normal rate of descent at destination in very poor day visibility with the landing gear
partly on the grass before leaving the runway completely. The aircraft was extensively damaged and
subsequently declared a hull loss. Impact damage was caused to lighting and signage.

AIM-related findings and safety recommendations:

 Use of resolution and rounding in publication and calculation of runway threshold coordinates
 Use of AIRAC for publication/cancellation of AIP SUP
 Coordination between aeronautical information services and aerodrome authorities
 Provision of raw aeronautical information/data by the aerodrome authorities in accordance with the
accuracy and integrity requirements

1.2 2006, A321-211, B2290, DAEGU, KOREA

https://skybrary.aero/accidents-and-incidents/a321-daegu-south-korea-2006

Description: An Airbus A321 failed to follow the marked taxiway centerline when taxiing for departure in
normal daylight visibility and a wing tip impacted an adjacent building causing minor damage to both
building and aircraft.

AIM-related analysis and findings:

 The change from the straight taxiway to the curved taxiway was not published as NOTAM, and was
not recorded in the Aeronautical Information Publications, Flight Information Publications and
Jeppesen Chart.
 The flight crew was taxiing without knowing the information on the curved taxiway and obstacles
(PAR building)
 The AIS organization stipulates that aeronautical information should be compiled from available
sources, but did not designate the personnel to be in charge of aeronautical information notification
for each competent aviation facility.
 The Flight Information Office at Daegu Airport recognized the matters on the curved taxiway, but did
not recognize them as the aeronautical information which should have been propagated through
official systems.
1.3 2012, SUKHOI SUPERJET 100, MOUNT SALAK, INDONESIA
Description: A Sukhoi Superjet 100 passenger plane was destroyed when it struck the side of a mountain
during a demonstration flight over Indonesia.

AIM-related analysis and findings:

 The insufficient briefing and available charts on board the aircraft did not contain information
relating to the “Bogor” Area and the nearby terrain.
 The terrain information surrounding Mount Salak had not been inserted into the Jakarta Approach
radar system

1.4 2015, BOMBARDIER DHC-8, ADELAIDE, AUSTRALIA

Description: Bombardier DHC-8, during the approach received an obstacle proximity warning, since their
projected approach path would bring them too close to a tower. In response, the crew conducted a
missed approach. No damage or injuries were sustained.

AIM-related analysis and findings:

 The terrain database installed on the EGPWS unit had the height of the tower as 1,325 ft, which was
the height of 1,316 ft on the approach chart rounded up to the nearest 25 ft. The correct height of
the tower was subsequently found to be 1,365 ft and the chart has since been amended.
 The EGPWS database, however, had not been amended at the time of completion of this report.
 Had the EGPWS unit had the correct tower height (1,365 ft), it still would have generated the same
alert and warning. Airservices Australia advised that the height error was due to corruption of an
obstacle database.

1.5 2018, BOEING B747, HALIFAX-STANFIELD INTERNATIONAL AIRPORT, CANADA

https://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2018/a18a0085/a18a0085.html

Description: Boeing 747-400F, suffered a runway excursion after landing at Halifax International Airport,
Canada.

AIM-related analysis and findings:

 Presentation style and sequence of the NOTAMs available to the crew and flight dispatch: The
ineffective presentation style and sequence of the NOTAMs available to the crew and flight dispatch
led them to interpret that Runway 23 was not available for landing at Halifax/Stanfield International
Airport.
Handout ACCIDENTS & INCIDENTS REPORTS H-3.1

1.6 2019, AIRBUS A321, LONDON STANSTED AIRPORT, UK

https://www.gov.uk/aaib-reports/aaib-investigation-to-airbus-a321-yl-lcq

Description: London Stansted Airport (STN) was operating with a displaced threshold, while repairs were
carried out at the normal threshold. Aircraft was observed to be lower than expected during its
approach, over the works area and touched down close to the displaced threshold.

AIM-related analysis and findings:

 Incorrect work-in-progress active periods on the temporary airfield chart on EFBs: An error in the
temporary airfield chart available to them misled the pilots into thinking that the runway works were
not active on the night of the incident.

1.7 2017, AIRBUS A320-211, SAN FRANCISCO, CALIFORNIA, USA

https://www.ntsb.gov/Pages/dmsredirect.aspx

Description: The flight had been cleared to land on San Francisco's runway 28R, but instead lined up with
parallel taxiway C on which four fully loaded and fuelled passenger airplanes were stopped awaiting
take-off clearance. The incident airplane descended to an altitude of 100 ft above ground level and
overflew the first airplane on the taxiway. The incident flight crew initiated a go-around, and the airplane
reached a minimum altitude of about 60 ft and overflew the second airplane on the taxiway before
starting to climb.

AIM-related analysis and findings:

Presentation of notice to airmen (NOTAM) information in pre-flight briefing: Although the NOTAM about
the runway 28L closure appeared in the flight release and the aircraft communication addressing and
reporting system message that were provided to the flight crew, the presentation of the information did
not effectively convey the importance of the runway closure information and promote flight crew review
and retention.