Final Report

on

Serious Incident

between

M/s British airways Ltd., B787-9

&

M/s Thai Airways Ltd., B777-300

at

Delhi

on

07.10.2017.

K Ramachandran Dr. Jitender Loura

Assistant Director Deputy Director
Investigator Investigator - in - Charge
 Foreword

In accordance with Annex 13 to the Convention on International Civil

Aviation Organization (ICAO) and Rule 3 of Aircraft (Investigation of
Accidents and Incidents), Rules 2017, the sole objective of the investigation
of an incident shall be the prevention of incidents and not apportion blame or
liability.

This document has been prepared based upon the evidences collected during
the investigation, opinion obtained from the experts and laboratory
examination of various components. Consequently, the use of this report for
any purpose other than for the prevention of future incidents could lead to
erroneous interpretations.

i
 Glossary

AAIB Aircraft Accident Investigation Bureau, India

AGL Above Ground Level
AIP Aeronautical Information Publication
AOP Air Operator Permit
APAC Approach Arrival Radar Controller
APST Approach Final Radar Controller
ATCO Air Traffic Control Officer
ATIS Automatic Terminal Information Service
ATPL Airline Transport Pilot Licence
C of A Certificate of Airworthiness
C of R Certificate of Registration
CPL Commercial Pilot License
DFDR Digital Flight Data Recorder
ICAO International Civil Aviation Organization
IATA International Air Transport Association
IFR Instrument Flight Rule
MHz Mega Hertz
MSN Manufacturer Serial number
MTOW Maximum Take Off Weight
NOTAM Notice to Airmen
PIC Pilot In Command
Pax. Passenger
QFE Query: Field Elevation
QNH Query: Nautical Height
RESA Runway End Safety Area
R/T Radio Telephony
VHF Very High Frequency
UTC Co-ordinated Universal Time

ii
 INDEX

CONTENTS PAGE No.

SYNOPSIS 02

1 FACTUAL INFORMATION 04

1.1 HISTORY OF THE FLIGHT 04

1.2 INJURIES TO PERSONS 07

1.3 DAMAGE TO AIRCRAFT 07

1.4 OTHER DAMAGE 07

1.5 PERSONNEL INFORMATION 07

1.6 AIRCRAFT INFORMATION 07

1.7 METEOROLOGICAL INFORMATION 09

1.8 AIDS TO NAVIGATION 09

1.9 COMMUNICATIONS 09

1.10 AERODROME INFORMATION 10

1.11 FLIGHT RECORDERS 11

1.12 WRECKAGE AND IMPACT INFORMATION 11

1.13 MEDICAL AND PATHOLOGICAL INFORMATION 11

1.14 FIRE 11

1.15 SURVIVAL ASPECTS 11

1.16 TESTS AND RESEARCH 11

1.17 ORGANISATIONAL & MANAGEMENT INFORMATION 11

1.18 ADDITIONAL INFORMATION 12

iii
1.19 USEFUL AND EFFECTIVE TECHNIQUES 13

2 ANALYSIS 14

3 CONCLUSION 18

3.1 FINDINGS 18

3.2 PROBABLE CAUSE 20

3.3 CONTRIBUTORY FACTORS 20

4 SAFETY RECOMMENDATIONS 21

Annexure-I - MATS-1 Speed Control for Arriving aircrafts i.

Annexure II - AIP India AD2.2 page 35 & 36 ii.

Annexure III - ATC tape transcript (Tower & Approach) & iv

DSC transcript,
- Speed Table (provided by ATC Delhi)
- Approach speed of FAA for Boeing (787-9)

iv
Final Report on Serious Incident between M/s British Airways Ltd.
B787-9 & M/s Thai Airways Ltd. B777-300 at Delhi on 07.10.2017.

1. Aircraft

Type : B787-9 (British Airways)/ B777-300 (Thai Airways)

Nationality : British/Thailand

Registration : G-ZBKF (British Airways)/ HSTKC (Thai Airways)

2. Owner/ Operator : M/s British Airways Ltd. / M/s Thai Airways

3. Pilot – in –Command : ATPL Holder for both British Airways and Thai airways

Extent of injuries : Nil

4. First Officer : CPL Holder for both British Airways and Thai Airways

Extent of injuries : Nil

5. Place of Incident : Within 02 NM of IGI Airport’s climb out area.

6. Date & Time of Incident : 07th October 2017, 18:24 UTC

7. Last point of Departure : London for British Airways and New Delhi for Thai Airways

8. Point of intended landing : New Delhi for British Airways and Bangkok for Thai Airways

9. Type of operation : Scheduled Operation for British Airways & Thai Airways

10. Crew on Board : 03+11 (British Airways) and 04+20 (Thai airways)

Extent of injuries : Nil

11. Passengers on Board : 216 (British Airways) and 234 (Thai Airways)

Extent of injuries : Nil

12. Phase of operation : Missed Approach for British Airways & Departure for Thai Airways

13. Type of Occurrence : Air Proximity

(ALL TIMINGS IN THE REPORT ARE IN UTC)

Page 1 of 20
SYNOPSIS

On 07.10.2017, British Airways flight BAW143, aircraft B787-9, from London to New
Delhi was given interception by Approach Radar Controller [APST] and the flight BAW143
established on ILS Rwy 29. The aircraft was changed over to Tower South Controller at frequency
125.85 MHz at approximately 10 NM from touchdown. As per ATC, since interception, BAW143
continued to maintain speed of 2001 kts whereas BAW143 was observed to be reducing speed2
from 205 Kts at 20 Nm from touch down, 194 kts at 12 Nm from touch down, 185 kts at 10 Nm
from touch down,183 Kts 7.5 Nm from touch down and 176 kts at 5 Nm from touch down. The
inter arrival spacing between BAW143 and the preceding arrival, Airbus 321 aircraft flight
AIC014 was observed to 6.5 NM3 with the speed of preceding aircraft (AIC014) as 140 kts and
succeeding aircraft (BAW 143) as 200 kts (with a speed differential of 60 kts)

Figure 1: Showing inter-arrival spacing of BAW143 with speed of 200kts as 6.5 NM with
speed differential of 60 Kts

1
ATC Radar replay and Tabular chart provided by ATC, Delhi
2
FDM data of G-ZBKF (BAW 143)
3
Approach – Arrival Radar Snap Shot at time 18:22:06 UTC

Page 2 of 20
 The inter arrival spacing between arriving flight BAW143 and departing Thai flight
THA316 was 6NM, when THA316 was lining up. This inter arrival spacing was actually further
reduced and was approximately 5.27 NM, taking into consideration the high speed of BAW143,
the displaced threshold of RWY29 by 1460 M and CE2 intersection departure [110 M from
beginning of Rwy 29] by THA316.

The Aerodrome Controller without taking into consideration the speed of arriving BAW
143, the reduced inter arrival spacing and displaced threshold of RWY29 lined up and cleared the
departing THA316 for CE2 intersection takeoff. The departing THA316 also took some time on
the runway before commencing takeoff roll.

In the meantime, the arriving BAW143, which was approaching threshold of RWY29,
initiated missed approach at less than 01 NM from touchdown [ approximately from the beginning
of Rwy 29].

This simultaneous going around of the BAW143 and the departure of THA316 from Rwy
29 resulted in the breach of standard separation. The lateral and vertical separation was reduced to
less than 01 NM and 200 feet respectively. The departing THA316 was restricted in climb to 2600
feet and changed over to approach arrival (APAC) controller at 126.35 MHz. The going around
aircraft, BAW143 was asked to expedite climb to 3600 feet and in coordination with approach
arrival radar controller, given a left heading of 180. BAW143 was changed over to approach arrival
radar (APAC) at 126.35MHz.

Thereafter the flights were uneventful with no injuries to persons on board either aircraft.

Director General, Aircraft Accident Investigation Bureau appointed Investigator –in-

charge vide order number AV-15020/13/2017-AAIB dated 11.10.2017, to investigate the cause of
the Serious Incident under Rule 11 (1) of Aircraft (Investigation of Accidents and Incidents), Rules
2017 comprising of Dr. Jitender Loura, Assistant Director, AAIB as Investigator-in-Charge and
Shri K Ramachandran, Air Safety Officer, AAIB as Investigator.

Page 3 of 20
1. FACTUAL INFORMATION
1.1 History of the flight

On 07.10.2017, British Airways flight BAW143 from London to New Delhi came in
contact with approach [APST] radar controller at frequency 124.2 MHz at 18:10:24 UTC and
was vectored for ILS approach Rwy 29. The flight BAW143 was changed over to Aerodrome
Controller-South at 10 NM from touchdown. The APST radar Controller didn’t ask the British
Airways flight BAW143 to reduce speed4 to the published approach speed to maintain inter
arrival spacing of 7 NM. The Captain of BAW143 recalls that the approach was subject to
radar vectors and speed control from ATC, but due to the time elapsed since the event, cannot
recall the exact speeds requested or flown5.

The Tower South Controller gave line up to Thai Airways flight THA316 for CE2
intersection6 departure at time 18:21:57 when the arriving BAW143 was approximately at 7
NM from touchdown with speed of 2007 kts/1838 Kts.

Tower South Controller cleared THA316 for CE2 intersection takeoff at time 18:23:02
when the arriving BAW143 at 4 NM from touchdown with speed of 160 kts.Crew of THA316
stated that after receiving clearance to line up on runway 29, Pilots carried out standard
operation procedure (SOP) as normal. After received take off clearance from ATC and
checklist had been completed, pilot took off as normal without delay.9 The departing THA316
appears to take some time on the runway before starting takeoff roll. At time 18:24:28,
BAW143 reported going around10.

The minimum lateral and vertical separation reduced to less than 01 NM and 200 feet
respectively. The tower Controller passed traffic information11 to BAW143 about departing
THA316. The Tower Controller restricted the climb of THA31612 to 2600 feet and asked

4
ATC Tape transcript of APST Radar frequency 124.2MHz
5
Statement of Crew of BAW143
6
ATC tape transcript of Tower frequency 125.85 MHz
7
Radar Snap Shots and tabular data of ATC, Delhi
8
FDM data of G-ZBKF (BAW 143)
9
Statement of Crew of THA316.
10
ATC tape transcript of Tower frequency 125.85 MHz
11
ATC tape transcript of Tower frequency 125.85 MHz
12
ibid

Page 4 of 20
 BAW14313 to expeditiously climb to 3600 feet and gave left heading 180 in coordination with
Approach Radar Controller at 126.35 MHz. Thereafter the flights were uneventful.

Figure 2: Tower Controller giving lineup to THA316 when BAW143 at 7NM from touchdown

13
ibid

Page 5 of 20
Figure 3: Simultaneous Go Around of BAW143 and departure of THA 316 from Rwy29

Figure 4: BAW143 going around and THA 316 departing Rwy29 simultaneously.

Page 6 of 20
1.2 Injuries to persons

INJURIES CREW PASSENGERS OTHERS

FATAL Nil Nil Nil
SERIOUS Nil Nil Nil
MINOR/NONE (03+11) British Airways 216 British Airways Nil
(04 +20) Thai Airways 234 Thai Airways

1.3 Damage to aircraft Nil

1.4 Other damage Nil

1.5 Personnel information

Both the flights i.e. BAW143 and THA316 were operated by scheduled airlines and all the
flight crew were appropriately licensed. The crew of both the airlines fulfilled all the requirements
of concerned State for operating the flight.

Both the Air Traffic Controllers i.e. the Aerodrome Controller and the Approach Radar
Controller (APST) were authorized to handle R/T in the procedural and Radar environment
respectively. Both the Aerodrome Controller and Approach Radar Controller had undergone the
proficiency checks in the respective ATC units and were found proficient14 to perform ATC duties.

1.6 Aircraft information

M/s British Airways Ltd. B787-9 and M/s Thai Airways Ltd. B777-300

The Boeing 787 Dreamliner is a long-haul, mid-size wide body, twin-

engine manufactured by Boeing Commercial Airplanes. Its variants seat 242 to 335 passengers in
typical three-class seating configurations. It is the first airliner with an airframe constructed

14
Proficiency Check reports as obtained from GM ATC,AAI,IGI Airport.

Page 7 of 20
primarily of composite materials. Boeing 787 was designed to be 20% more fuel-efficient than
the Boeing 767. Boeing 787 Dreamliner’s distinguishing features include mostly electrical flight
systems, raked wingtips and noise-reducing chevrons on its engine nacelles. It shares a
common type rating with the larger Boeing 777 to allow qualified pilots to operate both models.

The Boeing 787-9 Dreamliner which features light-weight construction. Boeing 787-9
flight systems has a key change from traditional airliners in the form of electrical architecture. The
architecture is bleed less and replaces bleed air and hydraulic power sources with electrically
powered compressors and pumps, while completely eliminating pneumatics and hydraulics from
some subsystems.

Boeing 787-9 has a "fly-by-wire" control system similar in architecture to that of

the Boeing 777. The flight deck features multi-function LCDs, which use an industry-
standard graphical user interface widget toolkit (Cockpit Display System Interfaces to User
Systems / ARINC 661).

Boeing 787-9 is the first major commercial airplane to have a composite fuselage,
composite wings, and use composites in most other airframe components.

Boeing 787-9 is powered by two engines; these engines use all-electrical bleed
less systems, eliminating the superheated air conduits normally used for aircraft power, de-icing,
and other functions. The aircraft’s left engine’s serial Number is 10573 and was fitted on
03/11/2017. The right engine’s serial Number is 10376 and never changed since new.

The aircraft B787-9 is certified in Normal (Passenger) category, for day and night operation
under VFR & IFR. The maximum operating altitude is 43100 feet and the maximum Laden weight
(MTOW) is 173000 Kgs. The Aircraft length is 62.8 meters. The distance between main wheels is
9.8 meters. The distance between engines is 19 meters.

Boeing 787-9 aircraft G-ZBKF (MSN 38622) had been manufactured in year 2016. The
aircraft’s Certificate of registration No. is G-ZBKF/R1. The Certificate of Airworthiness Number
068040/001 under "Large Aero plane category" was issued by UK, Civil Aviation Authority At
the time of incident the Certificate of Airworthiness was current.

Page 8 of 20
 Boeing 777 is a family of long-range wide-body twin-engine jet airliners developed and
manufactured by Boeing Commercial Airplanes. It is the world's largest twinjet and has a typical
seating capacity of 314 to 396 passengers, with a range of 5,240 to 8,555 nautical miles (9,704 to
15,844 km). Commonly referred to as the "Triple Seven", its distinguishing features include the
largest-diameter turbofan engines of any aircraft, long raked wings, six wheels on each
main landing gear, fully circular fuselage cross-section and a blade-shaped tail cone. As Boeing's
first fly-by-wire airliner, it has computer-mediated controls.

The Boeing 777-300 of M/s Thai Airways, HSTKC (MSN 29211) had been manufactured
in year 1999. At the time of incident, the Certificate of Airworthiness and Certificate of
Registration was current.

1.7 Meteorological information:

Date: 07th October 2017 and Time of Observation: 18:00 UTC

Wind Visibility Weather Cloud Temperature Dew Point QNH

320° 03Kts 3000 meters HZ (Haze) NSC 23 ° C 13 ° C 1008 hPa

1.8 Aids to navigation

All aids to navigation along with Tower South frequency 125.85 MHz, Approach (APST)
frequency 124.2 MHz and approach arrival (APAC) frequency 126.35 MHz were reported
working normal.

1.9 Communications

During the period of occurrence both the aircraft, B787-9 and B777-300 were in contact
with ATC on approach (APST), Tower –South and Approach arrival frequency at 124.2 MHz,
125.85 MHz and 126.35 MHz respectively. There was always two -way communications between
concerned ATC units and both the aircraft.

Page 9 of 20
1.10 Aerodrome information

Indira Gandhi International Airport (IATA: DEL, ICAO: VIDP) is a Joint venture airport
being managed by Delhi International Airport Limited (DIAL) and Airports Authority of
India. The air traffic services at IGI airport are provided by AAI which includes Aerodrome
Control service (ADC/SMC), Approach Control service (APP), Area Control Service (ACC),
Terminal Approach Radar (TAR) and Route Surveillance Radar Service (RSR). IGI airport houses
three near converging runways in the westerly direction namely Rwy 27, Rwy28 and Rwy29. On
the other hand, it has three diverging runways in the easterly direction i.e. Runway 09, Rwy10 and
Rwy 11. At the time of serious incident, the mode of operation at IGI airport was westerly, with
all the three runways being used as:

I. Runway 29 (runway-in-use) was used for both arrival and departures.

II. Runway 28 was used for departures only.
III. Runway 27 was used for arrivals only.

Two sector plan approach sector (AA+ SA) was operational.

1.10.1 Declared Distances15

The declared distances concerning Rwy-in-use at the time of serious incident are

Rwy TORA (M) TODA(M) ASDA(M) LDA(M) Threshold Remarks

Designator Displaced

29 4430 4430 4430 2970 1460 RESA = 240*120M

1.10.2 Intersection Departures Specific to Delhi16

The intersection departures concerning the runway-in-use are as:

Runway Taxiway TORA (M)

29 CE1 4417
29 CE2 4320

15
Manual of Air Traffic Services –Part 2 table 6.4 pg 6-5
16
Manual of Air Traffic Services –Part 2 table 6.7 pg 6-6

Page 10 of 20
1.11 Flight recorders

The ATC tape recording of frequency 128.85 MHz (Tower – South), 124.2 (Approach
Final controller) (APST), Direct Speech Circuit, SMGCS recordings and FDM data of G-ZBKF
(BAW 143) were available for analysis.

1.12 Wreckage and impact information

There was no damage to either of the aircraft.

1.13 Medical and pathological Information

There was no reported adverse medical condition of the cockpit crew of both M/s British
Airways and M/s Thai Airways.

1.14 Fire

There was no fire.

1.15 Survival aspects

The incident was survivable.

1.16 Tests and research: Nil

1.17 Organizational and management information

Both the aircraft were operated by the Scheduled International airlines viz. British Airways
and Thai Airways.

Both the procedural and Radar Controllers were under the administrative control of
Airports Authority of India which is responsible for Air Traffic Services at IGI airport including
Route Radar Surveillance, Terminal Approach Radar, Area control Service, Approach Control
Service and Aerodrome Control Service.

Page 11 of 20
1.18 Additional information

1.18.1 The standard provisions vide Para 1.5 and 1.6 of ARRIVAL, DEPARTURE PROCEDURE
AND RUNWAY CAPACITY ENHANCEMENT MEASURES at Section 5.2 (III) (1) of
VIDP AD 2.22 of AIP India at page AD 2 VIDP-34 and 35 are applicable.

Para 1.5 inter alia states that “Pilot shall complete all mandatory pre-departure
checks before entering the active runway for departure so that the aircraft is in a position
to take off immediately upon receipt of take-off clearance.”

Para 1.6 inter alia states that “When the aircraft is issued with a line-up and take-
off clearance at the taxi holding position it shall be in a position to line up and affect an
immediate take- off in one continuous movement.”

1.18.2 The provisions of Para 1.8 of ARRIVAL, DEPARTURE PROCEDURE AND RUNWAY
CAPACITY ENHANCEMENT MEASURES at Section 5.2 (III) (1) of VIDP AD 2.22 of
AIP India at page AD 2 VIDP-35 are applicable.

Para 18 inter-alia states that “If the Controller observes a delay in respect of the
departing aircraft commencing its take off run after issuance of take- off clearance, the
take- off clearance will be cancelled and the aircraft be advised to vacate the runway
immediately at the nearest taxiway to make way for the subsequent arrival or departure.
Necessary entries in this regard shall be recorded in the Log Book.”

1.18.3 The provisions of Para 29.1.3.6.2 and Para 29.1.8.3 of MATS-part 2 Page 29-3 and Page
29-7 are relevant. Para 29.1.3.6.2 inter-alia states that “Approach Arrival controller shall
be responsible for providing desired landing interval between arrivals.”

1.18.4 Para 29.1.8 of MATS-Part2 IGI Airport “Nominal spacing between arrivals” vide table 29-
6 states that for Rwy 29, the nominal spacing between arrivals when there is a departure in
between arrivals, is 7NM. This nominal spacing comes with many riders. One relevant to
this case is vide Para 29.1.8.3.

Page 12 of 20
 Para 29.1.8.3 inter-alia states that “the spacing between two arrivals may be increased
when the speed differential between the preceding and succeeding arrivals is high.”

1.18.5 The required separation standard applicable is Para 7.10.1.1 of MATS-part1 Page 7-15.

Para 7.10.1.1 inter-alia states that “a landing aircraft will not normally be
permitted to cross the runway threshold on its final approach until the preceding
departing aircraft has crossed the end of the runway-in-use, or has started a turn, or
until all preceding landing aircraft are clear of the runway - in-use.” (Figure 4A)

Figure 4 A: Separation between departing and arriving aircraft

1.19 Useful and Effective Techniques Nil

Page 13 of 20
2. ANALYSIS

The analysis of ATC tape recording of frequency 128.85 MHz (Tower – South), 124.2
MHz (Approach Arrival-SA), Direct Speech Circuit and SMGCS recordings, Log books of Tower
and Approach Arrival and Proficiency Check report of AAI and FDM data of G-ZBKF (BAW
143) reveal that:

1. On 07.10.2017, British Airways flight BAW143, B787, from London to New Delhi came
in contact with approach final [APST] radar controller at frequency 124.2 MHz and was
vectored for ILS approach Rwy 29. The aircraft was changed over to Aerodrome
Controller-South at 10 NM from touchdown. At this point of time, BAW143 was number
two in the arrival sequence maintaining speed of 18517 kts. The number one aircraft Airbus
321 flight AIC014 was 3 miles from touchdown with speed of 140 kts. The inter arrival
spacing, with a speed differential of 45 kts between the same type of aircrafts (Heavy/wide
body), was less than 8 NM. This inter arrival spacing was continuously reducing and was
6.5 NM when the preceding aircraft was 0.5 NM from touchdown and the succeeding
BAW143 was 7NM from touchdown, flying with the speed of 183 kts.

2. Approach Radar Controller18 [APST] didn’t apply the speed control restrictions.

3. The crew of BAW143 was observed to be reducing speed 19 from 205 Kts at 20 Nm from
touch down, 194 kts at 12 Nm from touch down, 185 kts at 10 Nm from touch down ,183
Kts 7.5 Nm from touch down and 176 kts at 5 Nm from touch down but this speed was 20
to 25 kts higher as compared to the speed as laid down in SOP20.

4. Tower South Controller gave line up to THA316 for CE2 intersection departure without
confirming for immediate departure at time 18:21:57 when the arriving BAW143 was
approximately at 7 NM from touchdown with speed of 18321 Kts.

5. Tower South Controller cleared THA316 for CE2 intersection takeoff at time 18:23:02
when the arriving BAW143 at 4 NM from touchdown with speed of 160 kts.

17
FDM data of G-ZBKF (BAW 143)
18
Para 29.1.3.6.2 and Para 29.1.8.3 of MATS-part2 pg. 29-3 and pg. 29-7
19
FDM data of G-ZBKF (BAW 143)
20
Table 8-3: Speed Control under Radar Environment for Arriving Aircraft, MATS-Part1 pg. 8-26.
21
FDM data of G-ZBKF (BAW 143)

Page 14 of 20
Figure 5: THA316 Lining up RWY29 via TWY CE2 & AIC014 on Runway 29 at 18:22:59

Figure 6: THA316 Lined up RWY29 via TWY CE2 & AIC014 Vacated Runway 29 Via
TWY Z6 (time 18:23:24). Takeoff Clearance given at time 18:23:02-18:23:09

Page 15 of 20
 Figure 7: THA316 rolling RWY29 position abeam Twy Z2 at time 18:24:02

6. The departing THA316 was observed to be taking some time on the runway before starting
takeoff roll. Though the Crew of THA316 have stated “After received clearance to line up
on runway 29, pilots carried out the standard operation procedure (SOP) as normal. After
received takeoff clearance from ATC and Checklist had been completed, pilot took off as
normal without delay”, yet the crew of THA316 appears to not followed the standard
provisions vide Para 1.5 and 1.6 of ARRIVAL, DEPARTURE PROCEDURE AND
RUNWAY CAPACITY ENHANCEMENT MEASURES at Section 5.2 (III) (1) of VIDP
AD 2.22 of AIP India at Page AD 2 VIDP-34 and 35.

7. The Tower Controller did not take into consideration the developing dynamic situation and
didn’t cancel takeoff clearance Thai Airways.. The Tower Controller did not follow the
provisions of Para 1.8 of ARRIVAL, DEPARTURE PROCEDURE AND RUNWAY

Page 16 of 20
 CAPACITY ENHANCEMENT MEASURES at Section 5.2 (III) (1) of VIDP AD 2.22 of
AIP India at Page AD 2 VIDP-35.

8. The Approach Radar Controller did not follow the provisions of Para 29.1.3.6.2 and Para
29.1.8.3 of MATS-part 2 Page 29-3 and Page 29-7.

9. The speed differential between the preceding and succeeding arrival was high and it was
continuously above 30 kts and sometimes more than 50 kts.

10. The required standard separation as enunciated by Para 7.10.1.1 of MATS-part1 page
7-15 and depicted vide Figure 4 A: Separation between departing and arriving aircraft
was not followed by Tower Controller and crew of BAW 143. In the instant case, the
arriving BAW143 had crossed the threshold of RWY29 when the departing THA316
was still rolling on RWY29 abeam Twy Z4. (Figure 8).

Figure 8: BAW143 at the beginning of RWY29 (Abeam CE1) (0.7 NM from touchdown)

speed 160kts and THA316 rolling (abeam Twy Z4) speed 140 kts at time 18:24:21

Page 17 of 20
 11. At time 18:24:28, BAW143 reported going around. At this time, BAW143 had crossed
threshold of RWY29 (abeam Twy CE2) and the departing/rolling THA316 was still on
Rwy29 (abeam Twy Z4)

12. The minimum lateral and vertical separation reduced to less than 1 NM and 200 feet
respectively.

13. The Tower Controller passed the traffic information to BAW143 about departing THA316.

14. The Tower Controller restricted the climb of flight THA316 to 2600 feet and asked the
flight BAW143 to expeditiously climb to 3600 feet and gave left heading 180 in
coordination with Approach Radar Controller. Thereafter the flights were uneventful.

15. The Coordination between Tower South Controller and the Approach Radar Controller was
affected in non-standard Language.

16. Weather was not a contributory factor.

3. CONCLUSION

3.1 Findings

1. Both the scheduled flights were under the command of an appropriately licensed ATPL
holder and FO being CPL holders.

2. The medical of all cockpit crew members was valid.

3. Traffic density with Approach Arrival Radar and Aerodrome Control South was moderate.

4. All communication facilities including approach (APST) frequency, Tower –South

frequency and Approach arrival (APAC) frequency at 124.2 MHz, 125.85 MHz and 126.35
MHz respectively were reported to be working normal.

Page 18 of 20
 5. The crew of BAW143 was observed to be reducing speed22 from 205 Kts at 20 Nm from
touch down, 194 kts at 12 Nm from touch down, 185 kts at 10 Nm from touch down ,183
Kts 7.5 Nm from touch down and 176 kts at 5 Nm from touch down but this speed was at all
the times 20 to 25 kts higher than the speed laid down in SOP.

6. No efforts were made by the approach radar controller23 (APST) to reduce speed of the
arriving aircraft.

7. The approach arrival radar Controller [APST] failed to provide “desired landing interval
between arrivals.” The nominal interval is 7NM and the spacing can be increased in cases
like this where the speed differential was over 30 NM [from the interception of Localizer by
BAW143 till around 5 NM from touchdown.]

8. The inter arrival spacing between arriving flight BAW143 and departing Thai flight THA316
was 6NM, when THA316 was lining up. This inter arrival spacing was actually further
reduced and was approximately 5.27 NM, taking into consideration the high speed of
BAW143, the displaced threshold of RWY29 by 1460 M and CE2 intersection departure
[110 M from beginning of Rwy 29] by THA316.

9. Tower South controller failed to take into consideration the high speed of the arriving aircraft
BAW143 and the continuously reducing inter arrival spacing which reduced to 5.27 NM,
before giving intersection line up to the departing THA316.

10. Tower South controller also failed to reassess the dynamic situation and didn’t cancel the
take-off clearance given to the departing THA316 flight.

11. Departing THA316 flight appears to have taken some time before rolling which is not in
accordance to the laid down SOPs of the Airport.

12. The Coordination between Tower South Controller and the Approach Radar Controller was
also affected in non-standard Language.

13. Weather was not a contributory factor.

22
FDM data of G-ZBKF (BAW 143)
23
Para 29.1.3.6.2 and Para 29.1.8.3 of MATS-part2 pg. 29-3 and pg. 29-7

Page 19 of 20
 VHF Tape Transcript

DATE : 07-10-2017
FREQUENCY : 124.2 MHz
CALL SIGN : BAW143, THA316
UNIT : Approach Arrival (SA) / Radar

TIME UNIT TRANSMISSIONS

(HHMMSS)
181023-181033 BAW143 Radar, Hello BAW143, descend flight level 100, heading 100
Radar BAW143 Radar, descend to flight level 90
BAW143 Level 90 BAW143
181113-181118 Radar BAW143 Radar, descend to flight level 70
BAW143 Descend Level 70 BAW143
181307-181312 Radar BAW143 turn left heading 015
BAW143 Left 015 BAW143
181352-181400 Radar BAW143 turn left heading 315 to intercept localizer RWY29
BAW143 Left 315 intercept localizer RWY29, BAW143
181502-181510 Radar BAW143 Radar, descend to 4000 feet QNH 1008
BAW143 Cleared 4000 feet 1008, BAW143
181549-181600 Radar BAW143 descend to 2600 feet QNH 1008 cleared for ILS approach
RWY29
BAW143 Descend 2600 feet cleared ILS approach RWY29, BAW143
182111-182120 Radar BAW143 Radar 10 miles from touchdown 118.. 125.85
BAW143 12585 BAW183, Goodbye

The above transcript is specific to VHF communication between Approach Arrival (SA)
and BAW143 only on 124.2 MHz from time 1810 to 1822 UTC.

Tape Transcript prepared by:

Tushar Anand,
Manager (ATM)
The tabular presentation of ground speeds of AlCOl-4 and BAW143 and approximate spacing between
these two arrivals.

Sno. Position of AlC014 Ground speed of Ground speed of Approx. Spacing

(approx. Distance to Atc014 BAW143 between AlC014 &
touchdown in NM) ( Kts) (Kts) BAW143
(NM)
t 5 170 200 9
IREF SnoDshot -BAW143 21

2 4 160 200 8.1

[REF Snopshot -BAW143 4]
3 3 140 200 8

4'' -2 1.40 200 7.4

IREF Snopsllot -BAW143 5l
5 1.5 140 200 7
IREF Snapshot -BAW743 6l
6 L 1.40 200 6.6
[REF Snopshot -BAW74j 7]
7 0.5 140 200 6.5
IREF Snopshot -BAW14j 8l
 FAA Reference Code and Approach Speeds for Boeing Aircraft 30 March 2016
Max Max
FAA Approach
MTW MTW MLW MLW Wingspan Wingspan Length Length Tail Tail
Aircraft Reference Speed
(lb.) (kg) (lb.) (kg) (ft.) (m) (ft.) (m) Height Height
Code (knots)
(ft.) (m)
707-320/-420 C-IV 125 316,000 143,500 207,000 94,000 142.42 43.40 152.92 46.61 42.17 12.85
707-320B C-IV 128 333,600 152,500 215,000 97,500 145.75 44.42 152.92 46.61 42.08 12.83
707-320C C-IV 137 336,000 152,500 247,000 112,100 145.75 44.42 152.92 46.61 42.00 12.80
717-200 C-III 133 119,000 55,338 102,000 46,269 93.33 28.40 124.00 37.80 29.67 9.00
717-200HGW C-III 139 122,000 54,884 110,000 49,898 93.33 28.40 124.00 37.80 29.67 9.00
727-100 C-III 126 170,000 77,200 142,500 64,700 108.00 32.92 133.17 40.59 34.25 10.44
727-200 C-III 136 210,000 95,300 161,000 73,100 108.00 23.92 153.17 46.68 34.92 10.65
737 BBJ C-III 135 171,500 77,791 134,000 60,781 117.42 35.79 110.33 33.63 41.58 12.67
737 BBJ 2 D-III 142 174,700 79,245 146,300 66,360 117.42 35.79 129.50 39.47 41.42 12.62
737 BBJ 3 D-III 144 187,700 85,139 157,300 71,350 117.83 35.90 138.17 42.10 40.75 12.42
737-100 C-III 128 111,000 50,349 99,000 44,906 93.00 28.35 94.00 28.65 37.17 11.33
737-200 C-III 130 116,000 52,617 103,000 46,720 93.00 28.35 100.17 30.53 37.25 11.35
737-200ADV/C/QC C-III 133 128,600 58,332 107,000 48,534 93.00 28.35 100.17 30.53 37.25 11.35
737-300 C-III 135 140,000 63,503 116,600 52,889 94.75 28.88 109.58 33.40 36.58 11.15
737-300W C-III 135 140,000 63,503 116,600 52,889 102.42 31.22 109.58 33.40 36.58 11.15
737-400 C-III 139 150,500 68,266 124,000 56,245 94.75 28.88 119.58 36.40 36.58 11.15
737-500 C-III 127 136,500 61,915 110,000 49,895 94.75 28.88 101.75 31.01 36.58 11.15
737-600 C-III 126 145,000 65,771 121,500 55,111 112.58 34.32 102.50 31.24 41.67 12.70
737-600W C-III 126 145,000 65,771 121,500 55,111 117.42 35.79 102.50 31.24 41.67 12.70
737-700/C C-III 132 155,000 70,307 129,200 58,604 112.58 34.32 110.33 33.63 41.58 12.67
737-700W C-III 132 155,000 70,307 129,200 58,604 117.42 35.79 110.33 33.63 41.58 12.67
737-8 n/a-III n/a 181,700 82,417 152,800 69,308 117.83 35.90 129.50 39.47 40.75 12.42
737-800 D-III 142 174,900 79,333 146,300 66,361 112.58 34.32 129.50 39.47 41.42 12.62
737-800W D-III 142 174,900 79,333 146,300 66,361 117.42 35.79 129.50 39.47 41.42 12.62
737-900 D-III 141 174,700 79,243 147,300 66,814 112.58 34.32 138.17 42.11 41.42 12.62

1 737-8 Preliminary Information

Airport Compatibility Engineering
Boeing Commercial Airplanes
 FAA Reference Code and Approach Speeds for Boeing Aircraft 30 March 2016
Max Max
FAA Approach
MTW MTW MLW MLW Wingspan Wingspan Length Length Tail Tail
Aircraft Reference Speed
(lb.) (kg) (lb.) (kg) (ft.) (m) (ft.) (m) Height Height
Code (knots)
(ft.) (m)
737-900ER D-III 144 188,200 85,366 157,300 71,350 112.58 34.32 138.17 42.11 41.42 12.62
737-900ERW D-III 144 188,200 85,366 157,300 71,350 117.42 35.79 138.17 42.11 41.42 12.62
737-900W D-III 141 174,700 79,243 147,300 66,814 117.42 35.79 138.17 42.11 41.42 12.62
747-100B D-V 145 753,000 341,500 585,000 265,300 195.67 59.64 231.83 70.40 64.25 19.58
747-200B D-V 152 836,000 379,100 630,000 285,700 195.67 59.64 231.83 70.40 64.25 19.58
747-200F D-V 152 836,000 379,100 630,000 285,700 195.67 59.64 231.83 70.40 64.67 19.71
747-300 D-V 142 753,000 341,500 564,000 255,800 195.67 59.64 231.83 70.40 64.25 19.58
747-400 D-V 153 877,000 397,801 630,000 285,764 213.00 64.92 231.85 70.67 64.00 19.51
747-400 Domestic D-V 146 613,500 278,279 574,000 260,362 195.67 59.63 231.85 70.67 64.25 19.59
747-400ER D-V 157 913,000 414,130 652,000 295,743 213.00 64.92 231.85 70.67 64.25 19.59
747-400ERF D-V 158 913,000 414,130 666,000 302,093 213.00 64.92 231.85 70.67 64.08 19.54
747-400F D-V 158 877,000 397,801 666,000 302,093 213.00 64.92 231.85 70.67 64.08 19.54
747-8 D-VI 153 990,000 449,056 688,000 312,072 224.42 68.40 250.17 76.25 64.00 19.51
747-8F D-VI 161 990,000 449,056 763,000 346,091 224.42 68.40 250.17 76.25 64.17 19.56
747SP C-V 126 703,000 318,800 450,000 204,100 195.67 59.64 184.75 56.31 65.83 20.06
757-200/PF C-IV 137 256,000 116,100 210,000 95,250 124.83 38.05 155.25 47.32 45.08 13.74
757-300 D-IV 142 271,000 122,930 224,000 101,610 124.83 38.05 178.58 54.43 44.75 13.64
767-200 C-IV 133 317,000 143,789 272,000 123,377 156.08 47.57 159.17 48.51 52.92 16.13
767-200ER C-IV 140 396,000 179,623 300,000 136,078 156.08 47.57 159.17 48.51 52.92 16.13
767-300 C-IV 140 352,000 159,665 300,000 136,078 156.08 47.57 180.25 54.94 52.58 16.03
767-300ER D-IV 145 413,000 187,334 320,000 145,150 156.08 47.57 180.25 54.94 52.58 16.03
767-300F D-IV 147 413,000 187,334 326,000 147,871 156.08 47.57 180.25 54.94 52.92 16.13
767-400ER D-IV 150 451,000 204,570 350,000 158,757 170.33 51.92 201.33 61.37 55.83 17.01
777-200 C-V 139 634,500 287,800 460,000 208,700 199.92 60.93 209.08 63.73 61.50 18.75
777-200LR C-V 138 768,000 348,358 492,000 223,168 212.58 64.80 209.08 63.73 61.50 18.75

2 737-8 Preliminary Information

Airport Compatibility Engineering
Boeing Commercial Airplanes
 FAA Reference Code and Approach Speeds for Boeing Aircraft 30 March 2016
Max Max
FAA Approach
MTW MTW MLW MLW Wingspan Wingspan Length Length Tail Tail
Aircraft Reference Speed
(lb.) (kg) (lb.) (kg) (ft.) (m) (ft.) (m) Height Height
Code (knots)
(ft.) (m)
777-300 D-V 150 662,000 300,280 524,000 237,680 199.92 60.93 242.33 73.86 61.50 18.75
777-300ER D-V 150 777,000 352,442 554,000 251,290 212.58 64.80 242.33 73.86 61.83 18.85
777F D-V 149 768,800 348,722 575,000 260,816 212.58 64.80 209.08 63.73 62.33 18.99
787-8 D-V 145 503,500 228,384 380,000 172,365 197.25 60.12 186.08 56.72 56.08 17.09
787-9 D-V 153 561,500 254,692 425,000 192,777 197.25 60.12 206.08 62.81 56.08 17.09
DC-10-10 D-IV 138 433,000 196,406 363,500 164,881 155.33 47.35 182.26 55.55 58.42 17.81
DC-10-10CF D-IV 138 443,000 200,942 363,500 164,881 155.33 47.35 182.26 55.55 58.42 17.81
DC-10-30 D-IV 149 558,000 253,105 403,000 182,798 165.33 50.39 181.60 55.35 58.58 17.86
DC-10-30CF D-IV 149 558,000 253,105 411,000 186,427 165.33 50.39 181.60 55.35 58.58 17.86
DC-10-40 D-IV 149 558,000 253,105 403,000 182,798 165.33 50.39 182.22 55.54 58.58 17.86
DC-10-40CF D-IV 149 558,000 253,105 411,000 186,427 165.33 50.39 182.22 55.54 58.58 17.86
DC-3 A-III 74 25,200 11,431 24,400 11,068 95.00 28.96 64.50 19.66 23.50 7.16
DC-4 B-III 94 73,000 33,112 58,200 26,399 117.50 35.81 93.90 28.62 27.60 8.41
DC-6A/B B-III 108 107,000 48,534 88,200 40,007 117.50 35.81 105.60 32.19 28.70 8.75
DC-7C B-IV 110 143,000 64,864 111,000 50,349 127.50 38.86 112.30 34.23 30.80 9.39
DC-8-43 C-IV 133 318,000 144,245 207,000 93,895 142.40 43.40 150.70 45.93 43.43 13.24
DC-8-55 C-IV 137 328,000 148,781 217,000 98,431 142.40 43.40 150.70 45.93 43.56 13.28
DC-8-55F D-IV 144 328,000 148,781 240,000 108,864 142.40 43.40 150.70 45.93 43.74 13.33
DC-8-61 D-IV 144 328,000 148,781 240,000 108,864 142.40 43.40 187.40 57.12 43.23 13.17
DC-8-61F D-IV 144 331,000 150,142 258,000 117,029 142.40 43.40 187.40 57.12 43.19 13.16
DC-8-62 C-IV 138 353,000 160,121 240,000 108,864 148.40 45.23 157.50 48.01 43.25 13.18
DC-8-62F C-IV 138 353,000 160,121 250,000 113,400 148.40 45.23 157.50 48.01 43.32 13.20
DC-8-63 D-IV 143 358,000 162,389 258,000 117,029 148.40 45.23 187.40 57.12 43.00 13.11
DC-8-63F D-IV 143 358,000 162,389 275,000 124,740 148.40 45.23 187.40 57.12 43.13 13.14
DC-9-15/F C-III 132 91,500 41,504 81,700 37,059 89.40 27.25 104.40 31.82 27.58 8.40

3 737-8 Preliminary Information

Airport Compatibility Engineering
Boeing Commercial Airplanes
 FAA Reference Code and Approach Speeds for Boeing Aircraft 30 March 2016
Max Max
FAA Approach
MTW MTW MLW MLW Wingspan Wingspan Length Length Tail Tail
Aircraft Reference Speed
(lb.) (kg) (lb.) (kg) (ft.) (m) (ft.) (m) Height Height
Code (knots)
(ft.) (m)
DC-9-21 C-III 126 101,000 45,813 95,300 43,227 93.30 28.44 104.40 31.82 27.42 8.40
DC-9-32/-33F C-III 133 109,000 49,442 99,000 44,906 93.30 28.44 119.30 36.36 27.75 8.50
DC-9-41 C-III 131 115,000 52,163 102,000 46,266 93.30 28.44 125.60 38.28 28.42 8.70
DC-9-51 C-III 135 122,000 55,338 110,000 49,895 93.35 28.45 133.58 40.72 28.75 8.80
MD-11 D-IV 152 605,500 274,655 430,000 195,048 170.50 51.97 202.17 61.20 58.83 17.93
MD-11 Combi D-IV 153 605,500 274,655 458,000 273,294 170.50 51.97 202.17 61.20 58.83 17.93
MD-11ER D-IV 152 633,000 287,122 430,000 195,048 170.50 51.97 202.17 61.20 58.83 17.93
MD-11F D-IV 155 605,500 274,655 471,500 213,872 170.50 51.97 202.17 61.20 58.83 17.93
MD-81 C-III 131 141,000 63,958 128,000 58,061 107.85 32.85 147.83 45.02 30.17 9.20
MD-82/-88 C-III 132 150,500 68,266 130,000 58,967 107.85 32.85 147.83 45.02 30.17 9.20
MD-83 C-III 137 161,000 73,028 139,500 63,276 107.85 32.85 147.83 45.02 30.17 9.20
MD-87 C-III 131 150,500 68,266 130,000 58,967 107.85 32.85 130.42 39.75 31.17 9.50
MD-90-30 C-III 138 157,000 71,214 142,000 64,410 107.83 32.87 152.58 46.50 31.17 9.50
MD-90-30ER C-III 138 168,500 76,430 142,000 64,410 107.83 32.87 152.58 46.50 31.17 9.50

For more information, please contact us at:

Airport Compatibility Engineering

2201 Seal Beach Blvd. M/C: 110-SB02
Seal Beach, CA 90740-1515

Phone: 562-797-1172
Fax: 206-766-5520
e-mail: AirportCompatibility@boeing.com

4 737-8 Preliminary Information

Airport Compatibility Engineering
Boeing Commercial Airplanes