A320, vicinity Oslo Norway, 2008

A320, vicinity Oslo Norway, 2008

Summary

On 19 December 2008, an Aeroflot Airbus A320 descended significantly below its cleared and acknowledged altitude after the crew lost situational awareness at night whilst attempting to establish on the ILS at Oslo from an extreme intercept track after a late runway change and an unchallenged incorrect readback. The Investigation concluded that the response to the EGPWS warning which resulted had been “late and slow” but that the risk of CFIT was “present but not imminent”. The context for the event was considered to have been poor communications between ATC and the aircraft in respect of changes of landing runway.

Description

On 19 December 2008, an Airbus A320-200 being operated by Aeroflot on a scheduled passenger flight from Moscow Sheremetyevo to Oslo descended at a high rate and airspeed significantly below its cleared altitude whilst attempting to establish on the Instrument Landing System (ILS) localiser for runway 19R at destination in night Visual Meteorological Conditions (VMC). An Terrain Avoidance and Warning System (TAWS) ‘TERRAIN AHEAD’ activation resulted following which a recovery was made. There were no injuries to the 61 occupants during the excursion and the approach was subsequently discontinued in favour of vectoring to a second approach which was uneventful.

Investigation

An Investigation was carried out by the AIBN. DFDR and ATC radar data was available to support the Investigation. These sources were used to construct the annotated diagram of the approach track shown below.

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