Swiss Cheese Day
By: James Mcbride
Tags: Aviation, Airlines, Travel

“ALITALIA XXX! WHICH SID are you flying?” The voice of the radar controller on the VHF sounded more than a little concerned, he was mighty hacked off, you could tell.

…he was watching the radar display and could barely believe what he was seeing.

In our own flightdeck we looked across at each other with raised eyebrows — this sounded serious. We had taken off from runway 26 at Catania and were climbing through Flight Level 90 on the PEKOD 5B route, the Alitalia Airbus behind us should have been following our track…

The reply we then heard from the A320 was, “We are flying the PEKOD 5 Bravo departure, Alitalia XXX…” I noted that the tone of his transmission was confident, yes he really did believe his aircraft was flying that SID, but the Air Trafficker was having none of it. Clearly he was watching the radar display and could barely believe what he was seeing. “NEGATIVE ALITALIA XXX, you are 2 miles north of the airport and have turned 180 degrees towards the East — this is NOT like any of our standard routings!”

The Italian Captain then replied somewhat hesitantly, “Roger Sir… but we think we are on the PEKOD 5 Bravo SID… We shall file a report Sir…” to which the controller stated, “I WILL FILE A REPORT ALITALIA, turn right radar heading 110 degrees and climb Flight Level 240!”

…during preflight briefings from Catania, Mount Etna always gets a mention.

There was then more discussion on the R/T, but we missed the rest of it as we were handed off to Rome Control on the next frequency in our climb to the North. Bear in mind that SIDs* are designed to keep IFR departing aircraft separate from both terrain and other air traffic. Even a slight track deviation from the published SID is a potentially serious matter, but to completely diverge from the intended track is almost unheard of. We were puzzled as to how it could have happened. You see the East/West runway at Catania airport in Sicily is located in a rather special place. Just 15 nautical miles north of the airport there is high ground rising steeply to over 10,000 feet above sea level — the actual Minimum Safe Altitude (MSA) is 13,300 feet. Mount Etna has the distinction of being listed as the tallest, active volcano in Europe. Certainly when “considering the threats” during preflight briefings from Catania, Mount Etna always gets a mention.

Mount Etna — the most active volcano in Europe and 10,702' above Sea Level.

All the more worrying then, that the errant Alitalia flight turned to the north, towards the highest terrain closest to the runway, but why would they do that? Clearly it was not the fault of ATC (according to what we heard on the radio) and these days most unlikely to have been a technical malfunction, so it was most likely to have been a Human Factors error. Once we were up at Flight Level 380 in the cruise we had time to discuss the event properly. We ran through the sequence of events leading up to our departure, taking off only two minutes ahead of the Alitalia.

I recalled that it had started as one of those classic Swiss Cheese Days. The sort when you realise there are a multitude of possible ‘Gotchas’, waiting for you as you report for duty on a busy 4 sector day. In the crewroom, our preflight briefing was interrupted when the First Officer informed me that the fourth of our flightplans was missing from the computer system so valuable minutes were taken up chasing it with the remote Flight planning Department. Almost simultaneously the cabin crew informed me that our Senior Cabin Crew Member (the Number One) had not reported for duty yet, but had phoned from the carpark saying she was waiting for the shuttle bus. She would arrive a few minutes after official report time. In the interests of good crew relations, (modern CRM) I try not to overreact when I hear things like this, although it is an irritation. Finally we got the briefing done; the crew altogether; legal documentation all present and headed out for the jet, only 5 or 6 minutes behind the drag curve.

Of course the crewbus which had been ready to take us to the remotely parked aircraft, had just left to do another job so we have a further wait for another bus… While we stand idle, I talk with the First Officer and we discuss the fact that Mount Etna has been more active recently. These days of course we aviators are very conscious of the danger of volcanic ash clouds and it was only in December 2015 when Mount Etna last erupted with consequent disruption for air traffic in and out of Catania airport. Of course there are contingency plans to permit flight operations to continue in the case of major volcanic activity, but it does add another layer of complication for the Flypro.

We arrive at the aircraft to find that the previous crew had sealed it all up, so it takes a little more time than normal to unlock it all and get the AC electrics established. Thankfully the refueller is there ready for us, so I take the opportunity to get the dispatcher to call for the passengers to board the buses. While the FO starts preparing the cockpit for his departure (he is Pilot Flying for this sector) I carry out the walkround and ensure the refuelling is happening. Now the cabin crew are well into prepping the aircraft and call my attention to look at a defect in the cabin, “Captain, can you look at this please, is this okay for our flight?” One of the aft lavatories will not flush and it is not in the aircraft Techlog… What to do? “Yes, no problem, lock it off please, we are not full with passengers and it is only a short flight”. I reason that there are two other lavs also, but it all takes time… Why is a toilet flush problem important to us? Well you only have to look back at the Air Canada DC9 accident (Cincinnati 1983) when a malfunctioning toilet flush motor started an inflight fire which resulted in terrible loss of life. In our case if nobody can use the lav, the problem is solved. As an extra precaution I ask the engineers to disable the lav and we can get it fixed later — it is an acceptable deferred defect.

Fuelling is now complete and passengers are boarding. The dispatcher is looking at his watch and I am also conscious of the Alitalia Airbus on an adjacent stand. They are boarding pax also, so they might delay our pushback. I ask the cabin crew to expedite the boarding process as much as they can, but I am aware there is a limit to how fast you can get people to sit down with their baggage stowed away. Some smart cabin crew actually ask the pilots to keep the cabin cool in winter as the passengers come aboard — then the people will sit down quicker as they keep their coats on, rather than obstruct the single aisle while taking off their coats, scarves and hats etc to stow them away. Another problem occurs now when the Ground Power Unit disconnects without warning and the aircraft lighting swaps to the standby electrical system. In the flightdeck we switch on the APU, but it does take a minute or two come online… “Yes it’s one of those days” I say to myself.

“The wind…. Ahh, she is a fickle mistress…”

Now we are focussed on the final preparations for flight, the fuelling is complete, the techlog is signed off, and we are running through the preflight checklist. We discuss the threats and are conscious that there is a tailwind for takeoff — we are planned for the PEKOD 5A departure for runway 08. As the old sailing masters used to say, “The wind…. Ahh, she is a fickle mistress…” Air Traffic Control are still using runway 08 for departure with a 6 or 7 knot tailwind from the west. We know from experience that this is more convenient for ATC traffic flow and is the preferential runway. In fact it is relatively safer in some ways, even with a tailwind, because the takeoff run is straight towards the sea — the Departure End of Runway 08 (DER) is nearly on the beach — so there is no problem with terrain obstruction in the event of an engine failure on takeoff. The last few moments of our leaving from the terminal come in a real rush. The pushback team arrive with the tug and hook up the towbar to the nosegear, the Senior Cabin Crew confirms all pax onboard, the dispatcher rushes out with his signed copy of the loadsheet, the cargo holds are closed and the front steps are retracted. I do a quick PA to the cabin, then the FO obtains clearance for push and start and we complete the last of the prestart checklist…

Phew! Only a few minutes late AND we are pushing back before the neighbouring Alitalia… very pleasing. As we are starting the engines however, ATC try to give us our departure clearance on the R/T, but I ask the FO to reply “Standby” — we must keep the priorities in order. It would be a shame to ‘cook a motor’** while we were distracted copying down the SID, stop altitude, transponder code, airborne frequency etc. Similarly, these are important items to ensure that we get right, so it is vital that BOTH of us LISTEN and AGREE with the ATC clearance and are not distracted by simultaneously monitoring the engine start process. Finished with engine starting and now we are stationary, waiting for the groundcrew to disconnect all from down below, “Go ahead with the clearance” is the transmission from the right-hand seat and ATC reveals that they have changed runways! Now… it will be RUNWAY 26 for takeoff and the PEKOD 5B SID. We spend a couple of minutes making all the required reprogramming changes in the FMC, plus resetting all the Navaids then we call for taxi. Our company is quite prescriptive about what to do in the event of a late notice runway change and for this we should be grateful.

Thinking about it later on, that was probably where the Alitalia guys got it wrong. Pushing back only a couple of minutes after us, they will have been faced with a similar situation, but we would bet money on it they forgot to change the SID routing in the flight computer. As soon as they were airborne and the autopilot was engaged, it simply turned the shortest way towards the PEKOD 5A magenta track — with a wind from the north, the aircraft heading would have been slightly northwest after airborne.

The big takeaway for us was that when you get a Fastball thrown at you through the cockpit window… slow right down and assess the impact and implication on the operation. As mentioned above, when we are given a late change of runway it is Standard Operating Procedure to stop everything and replan/rebrief as necessary to ensure the operation stays safe.

© James McBride

*SID — Standard Instrument Departure. “It strikes a balance between terrain and obstacle avoidance, noise abatement (if necessary), and airspace management considerations” (Wikipedia Reference)

* ‘Cook a motor’ — slang term meaning to allow an engine to overheat during start-up.

Note that the Catania Airport SIDs have been changed since the time of this event — they are now PEKOD 6A and 7B Standard Instrument Departure routings.

Capt James McBride — author of 4 books available on Amazon.com (and Amazon.co.uk etc) He is an experienced commercial aviator with a passionate interest in Flight Safety and Training.