Vliegtuigongeval op 22 DEC 2013 met Boeing 747-436 G-BNLL - Johannesburg-O.R. Tambo International Airport (JNB)

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Status:	Accident investigation report completed and information captured
Datum:	zondag 22 december 2013
Tijd:	22:43
Type:	Boeing 747-436
Luchtvaartmaatschappij:	British Airways
Registratie:	G-BNLL
Constructienummer:	24054/794
Bouwjaar:	1990-05-30 (23 years 7 months)
Aantal vlieguren:	110578
Aantal vluchten:	12832
Motoren:	4 Rolls-Royce RB211-524G
Bemanning:	slachtoffers: 0 / inzittenden: 17
Passagiers:	slachtoffers: 0 / inzittenden: 185
Totaal:	slachtoffers: 0 / inzittenden: 202
Schade:	Groot
Gevolgen:	Written off (damaged beyond repair)
Plaats:	Johannesburg-O.R. Tambo International Airport (JNB) ( Zuid-Afrika)
Fase:	Taxi (TXI)
Soort vlucht:	Internationale lijnvlucht
Vliegveld van vertrek:	Johannesburg-O.R. Tambo International Airport (JNB/FAOR), Zuid-Afrika
Vliegveld van aankomst:	London-Heathrow Airport (LHR/EGLL), Verenigd Koninkrijk
Vluchtnummer:	BA034

Beschrijving:
The Boeing 747-436 operating British Airways Flight BA34 to London-Heathrow sustained substantial damage in a taxi accident at Johannesburg-O.R. Tambo International Airport, South Africa.
The flight crew prepared for a departure from runway 03L and expected a taxi clearance for taxiway Alpha, which ran parallel to runway 03L. After pushback the flight was cleared by the Tower controller via a different route: "Speedbird 34, taxi Bravo to Cat 2 holding point, Runway 03L". The flight crew did not re-brief for this new route and instead the copilot, who was Pilot Flying, began taxiing towards taxiway B. "Straight down all the way isnt it? It is, yeah makes it nice and easy doesnt it? And Bravo will take us all the way to the threshold. Im following this line jinking slightly to the right and then straight ahead. Perfect", the copilot stated.
Taxiway Bravo ran parallel to taxiway Alpha. But at some point the taxiway curved left where it merged with Alpha. At that point a smaller taxiway Mike proceeded straight ahead to an apron.
In night time conditions the pilots missed the curve to the left because the two green lead in centreline lights were inoperative. The taxiway information sign lighting was also inoperative. The flight continued onto Mike and the copilot noticed that the taxiway seemed smaller. The Tower controller noticed the crew's mistake on his ground radar and instructed the crew to stop: "Speedbird 34, hold your position". At that time the right hand wing impacted a building to the right of the taxiway. The wing sliced through the second storey, injuring four workers inside.
The aircraft was immobilized and passengers deplaned through the rear exit on the left hand side after a fuel leak was contained.

Probable Cause:

PROBABLE CAUSE: The loss of situational awareness caused the crew to taxi straight ahead on the wrong path, crossing the intersection/junction of Bravo and Mike instead of following Bravo where it turns off to the right and leads to the Category 2 holding point. Following aircraft stand taxilane Mike; they collided with a building on the righthand side of Mike.
Contributory Factors: The crew did not conduct a briefing to discuss the cleared route, nor did they refer to the correct taxiway information in chart 10-6. In combination with the ground movement visual aids, this created confusion and loss of situational awareness when taxiing on taxiway Bravo.

Accident investigation:

Investigating agency:	CAA SouthAfrica
Status:	Investigation completed
Duration:	1 year and 6 months
Accident number:	CA18/2/3/9257
Download report:	Final report

Bronnen:

» Map
» FAOR aerodrome chart
» SKYbrary

Veiligheidsmaatregelen

CAA S.A. issued 10 Safety Recommendations

Issued: 19-JUN-2015	To: AAIB	G-BNLL (1)
It is recommended that the AAIB enter into consultations with the operator (British Airways) about the crews non-adherence to applicable briefing and taxi policies, procedures and requirements. The AAIB to communicate to AIID what the appropriate corrective action shall be to prevent recurrence.
Issued: 19-JUN-2015	To: SACAA	G-BNLL (10)
It is recommended that the SACAA should consult with ATNS about their plans to fully commission the A-SMGCS system. This will ensure that the identified radar system is integrated completely with ATNSs quality control process to effectively and efficiently carry out surveillance over ground movement areas. The aim is to contribute to the safety and efficiency of aerodrome surface movement control during low visibility operations (LVOs), e.g. at night, especially to provide active alerts to controllers as a means of early warning of potential incursions and/or taxiing into unsafe locations.
Issued: 19-JUN-2015	To: SACAA	G-BNLL (2)
It is recommended that the SACAA should intensify the ramp inspections on all foreign operators to South Africa to ensure that they comply with international air operation standards, recommended practices and regulatory requirements in terms of the matters raised (i.e. availability and validity of aircraft documentation) wherever their destination in South Africa. The SACAA should also ensure that they put in place a proper, effective and efficiently system of traceability in this regard.
Issued: 19-JUN-2015	To: AAIB	G-BNLL (3)
It is recommended that the AAIB look into or address the matter of the revision status of the aeronautical data issued by the third party service provider referencing the issues raised of Navtech. It should be noted that the South African AIP is a legal document prepared in accordance with the Standards and Recommended Practices (SARPs) of ICAO Annex 15 of which the charts contained in it are produced in accordance with ICAO Annex 4. Its purpose is to provide appropriate safety information (i.e. aeronautical data) to the aviation industry; therefore operators are to ensure that the aeronautical data they use, irrespective of the source, complies with the information published in the South African AIP
Issued: 19-JUN-2015	To: SACAA	G-BNLL (4)
It is recommended that the SACAA should finalise the commitments made to ICAO concerning the SACAA aeronautical information service (AIS) safety oversight responsibility over service providers, so that situations similar to the one of Navtech will not recur in South Africa.
Issued: 19-JUN-2015	To: SACAA	G-BNLL (5)
It is recommended that the SACAA should consult with ACSA about the inadequacies of the ground movement infrastructure issue (e.g. taxiway centreline green lights and signage) identified on Bravo, which may include other taxiways and/or runways at FAOR. It is important to point out that the infrastructure inadequacies identified there caused confusion which could have been prevented with proper maintenance and/or infrastructure development.
Issued: 19-JUN-2015	To: SACAA	G-BNLL (6)
It is recommended that the SACAA should intensify the safety oversight inspections over ACSA operations relevant to the integrity of the airport infrastructure (e.g. lights and signs) with the aim to completely prevent the recurrence of non-compliance by ACSA with quality processes.
Issued: 19-JUN-2015	To: ACSA	G-BNLL (7)
It is recommended that ACSA should consider complete removal of the building into which the British Airways aircraft collided, as in future it will continue to pose a safety risk to crews taxiing on taxiway Bravo en route to the Cat 2 holding point. This recommendation is made based on the evidence of the ASR Ref:24674 incident during April 2005 when the aircraft stopped short of colliding with the building, followed by this accident Ref:CA18/2/3/9257 on the day in question.
Issued: 19-JUN-2015	To: SACAA	G-BNLL (8)
It is recommended that the SACAA should consult with AAIB about the British Airways flight crews non-compliance with the clear and unambiguous taxi instructions, which were to push back facing south using Bravo to Category 2 holding point for take-off from Runway 03L and not what they actually did, which was to taxi full length to end of the taxiway.
Issued: 19-JUN-2015	To: SACAA	G-BNLL (9)
It is recommended that the SACAA should consult with the AIIB about the British Airways flight crews action in that they did not comply with the SOP requirement that they should immediately have stopped when in doubt about the conditions on taxiway Bravo during the taxi phase.

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Foto's

accident date: 22-12-2013
type: Boeing 747-436
registration: G-BNLL

Video, social media

BA plane crash. J burg pic.twitter.com/djTNGHLODL
Harriet Tolputt (@HarrietTolputt) December 22, 2013

Kaart

Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Johannesburg-O.R. Tambo International Airport en London-Heathrow Airport bedraagt 9046 km (5654 miles).
Accident location: Exact; deduced from official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

languages:

Boeing 747

1551+ built
58^e ongeval

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Zuid-Afrika

37^e zwaarste ongeval (toen het plaatsvond)
41^e zwaarste ongeval (op dit moment)

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