Incident Overview

Date: Thursday 21 January 2010
Aircraft Type: Boeing 747-4R7F
Owner/operator: Cargolux
Registration Number: LX-OCV
Location: Luxembourg-Findel Airport (LUX) – ÿ Luxembourg
Phase of Flight: Landing
Status: Minor, repaired
Casualties: Fatalities: 0 / Occupants: 3
Component Affected: Boeing 747-400F aircraft (CLX 793) ? specifically, the landing gear and the roofline of the maintenance van (ELE 23).Boeing 747-400F aircraft (CLX 793) ? specifically, the landing gear and the roofline of the maintenance van (ELE 23).
Investigating Agency: ATIATI
Category: Accident
On October 12, 2023, a Boeing 747-400F aircraft, CLX 793, experienced a near-miss incident during a scheduled freight flight from Barcelona to Luxembourg. The flight commenced at 11:13 local time, but encountered issues with low visibility conditions. The approach controller (APP) alerted the aircraft to Low Visibility Procedures (LVP) due to fog, cloud base, and temperature/dew point. The aircraft cleared for ILS approach on runway 24 at 12:49, and the Tower then cleared it to land. During the landing, the aircraft impacted a maintenance van, causing significant damage to the van and the surrounding area. The pilot flying initiated an emergency flare, which resulted in the aircraft impacting the van. The incident was followed by a change in the ILS approach, and the Tower Controller cleared the aircraft to land. The pilot monitoring (PM) reported the landing, and the Tower Controller confirmed the landing was authorized. Following the landing, the Pilot Flying noted a car in the touchdown zone. The PM did not observe the car, indicating a potential oversight in the monitoring system. The aircraft vacated runway 24 at taxiway Echo, and the PF informed the Tower Controller about a car in the touchdown zone. The Tower Controller then confirmed the aircraft’s departure and the landing was confirmed. The incident was characterized by a combination of factors including impaired operational readiness, inadequate coordination between aerodrome control and the maintenance department, and insufficient safety procedures, particularly regarding the maintenance of the ELE department during low visibility conditions.On October 12, 2023, a Boeing 747-400F aircraft, CLX 793, experienced a near-miss incident during a scheduled freight flight from Barcelona to Luxembourg. The flight commenced at 11:13 local time, but encountered issues with low visibility conditions. The approach controller (APP) alerted the aircraft to Low Visibility Procedures (LVP) due to fog, cloud base, and temperature/dew point. The aircraft cleared for ILS approach on runway 24 at 12:49, and the Tower then cleared it to land. During the landing, the aircraft impacted a maintenance van, causing significant damage to the van and the surrounding area. The pilot flying initiated an emergency flare, which resulted in the aircraft impacting the van. The incident was followed by a change in the ILS approach, and the Tower Controller cleared the aircraft to land. The pilot monitoring (PM) reported the landing, and the Tower Controller confirmed the landing was authorized. Following the landing, the Pilot Flying noted a car in the touchdown zone. The PM did not observe the car, indicating a potential oversight in the monitoring system. The aircraft vacated runway 24 at taxiway Echo, and the PF informed the Tower Controller about a car in the touchdown zone. The Tower Controller then confirmed the aircraft’s departure and the landing was confirmed. The incident was characterized by a combination of factors including impaired operational readiness, inadequate coordination between aerodrome control and the maintenance department, and insufficient safety procedures, particularly regarding the maintenance of the ELE department during low visibility conditions.

Description

The aircraft was operating a scheduled freight flight from Barcelona, Spain to Luxembourg. The aircraft’s actual departure time in Barcelona was 11:13 local time. At 12:40, flight CLX 793 contacted Luxembourg Approach (APP) for the first time and was advised by the approach controller that Low Visibility Procedures (LVP) were in operation. Fog prevailed at Luxembourg airport with a cloud base at 100 feet overcast and a visibility of 100 meters, temperature and dew point were at 1øC. The aircraft was cleared for an ILS approach on runway 24 at 12:49. RVR readings were 350/275/375 meters. At 12:50:55, CLX 793 reported established on the localiser for runway 24 and was transferred to Tower. RVR readings had decreased to 350/250/350 meters. CLX 793 contacted Luxembourg Tower (TWR) at 12:51:40 and reported established on the ILS 24. The Tower Controller then cleared them to land. At 12:53:46, reaching decision height at 17 ft, the Pilot Flying called out ‘landing’. During the flare, the airplane impacted a maintenance van ‘ELE 23’ positioned slightly to the right of the centreline of runway 24 and about 340 meters from the threshold, with the front-end pointing into the opposite direction (060ø). The roofline of the van was at a height of 2.54 m (8 ft). The right hand body landing gear of the Boeing 747-400F impacted the roof of ELE 23 with tire no. 12 slightly below the roofline of the van on a backward sloped roof section and rolled over it, damaging the roof on the whole length of the vehicle. The van’s lightbar, as well as its R/T antennas, were ripped off on impact. The maintenance crew working on the centreline lights outside of ELE 23 ran off the side of the runway as soon as they noticed an increasing noise from a landing aircraft. The aircraft landed safely at 12:53:51. After touchdown, at 12:53:59, the Pilot Flying mentioned to the Pilot Monitoring (PM) that there was a car in the touchdown zone. The PM, monitoring the instruments during landing in accordance with company procedures, didn’t notice it. The aircraft vacated runway 24 at taxiway Echo and at 12:56:28, while taxiing to apron P7, the PF informed the Tower controller about a car in the touchdown zone. The controller asked if there was a problem and the PF denied. The aircraft continued to the parking position on apron P7 without further incident. Causal and contributory factors: – The impaired operational readiness of the ELE department due to a manning shortcoming, combined with the lack of provisions to appoint external workforce if necessary, prevented ANA to schedule preventive maintenance work outside of normal operating hours (i.e. during the curfew); – The decision to carry out preventive maintenance work in low visibility conditions without hampering air traffic gave priority to flight operations over safety aspects; – The lack of adequate co-ordination between aerodrome control tower and ELE department with regard to the preventive maintenance work contributed to a reduced situational and organizational awareness of the TWR control staff; – Inadequate procedures for the access of vehicles to the RWY and ILS sensitive area during LVP contributed to the development of an unsafe condition; – Read-back procedures were not adequately applied by aerodrome control tower on ground control frequency, making this procedural safety net ineffective; – Low visibility weather conditions, associated with the lack of supplementary ground traffic control and surveillance equipment, limited the capability of aerodrome control tower to identify and correct a developing unsafe condition; – The use of different frequencies for air traffic and ground traffic on the manoeuvring area reduced the situational awareness of ELE 23 maintenance crew working on the RWY, preventing them to take avoiding action.

Primary Cause

Impaired operational readiness of the ELE department, combined with a lack of adequate coordination between aerodrome control tower and ELE department, contributed to a reduced situational and organizational awareness of the TWR control staff.Impaired operational readiness of the ELE department, combined with a lack of adequate coordination between aerodrome control tower and ELE department, contributed to a reduced situational and organizational awareness of the TWR control staff.

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