B738, en-route, east of Asahikawa Japan, 2010

B738, en-route, east of Asahikawa Japan, 2010

Summary

On 26 October 2010, an All Nippon Boeing 737-800 was radar vectored towards mountainous terrain and simultaneously given descent clearance to an altitude which was 5000 feet below the applicable MVA whilst in IMC without full flight crew awareness. Two TAWS  PULL UP hard warnings occurred in quick succession as a result. The flight crew responses were as prescribed and the subsequent investigation found that the closest recorded proximity to terrain had been 655 feet. It was established that the controller had  forgotten about MVA.

Description

On 26 October 2010, a Boeing 737-800 being operated by All Nippon AW on a scheduled passenger flight from Chubu Centrair to Asahikawa in day Instrument Meteorological Conditions (IMC) was being radar vectored towards an eventual ILS approach at destination when two GPWS/TAWS PULL UP Warnings were activated in quick succession and a recovery climb made. None of the 57 occupants were injured during the occurrence and the aircraft was subsequently vectored to the destination ILS without further event.

Investigation

An Investigation was carried out by the Japan Transport Safety Board (JTSB)Cockpit Voice Recorder (CVR) data had been overwritten but DFDR and ATC R/T recordings were available and a successful download from the non volatile memory (NVM) in the TAWS unit was achieved. It was noted that although thirteen “busier” Japanese airports had been provided with Minimum Safe Altitude Warning (MSAW) prior to the investigated event, this system was not installed at Asahikawa.

It was established that the aircraft commander had been PF. It was noted that the PF had only recently qualified as a commander on the aircraft type but had some prior experience as a First Officer on the type. By contrast, the First Officer was considerably older than the PF and had accumulated a great deal more total and type flying experience.

The full content of this page is available to registered users only.
Please Log in or Register

SKYbrary Partners:

Safety knowledge contributed by: