Serious incident Boeing 747-87UF N856GT, 24 Sep 2017
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ASN Wikibase Occurrence # 199972
 
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Date:24-SEP-2017
Time:23:45 LT
Type:Silhouette image of generic B748 model; specific model in this crash may look slightly different    
Boeing 747-87UF
Owner/operator:Atlas Air, opf Cathay Pacific
Registration: N856GT
MSN: 37561/1442
Fatalities:Fatalities: 0 / Occupants: 4
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:nr Hong Kong-Chek Lap Kok International Airport (HKG/VHHH) -   Hong Kong
Phase: Initial climb
Nature:Cargo
Departure airport:Hong Kong-Chek Lap Kok International Airport (HKG/VHHH)
Destination airport:Anchorage-Ted Stevens International Airport, AK (ANC/PANC)
Investigating agency: CAD Hong Kong
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Cathay Pacific flight CX86, operated by Atlas Air, overflew mountainous terrain below the Minimum Sector Altitude shortly after takeoff from Hong Kong-Chek Lap Kok International Airport.

The crew consisted of one Plot-in-command (PIC) and two first officers. The PIC was the Pilot Fying (PF). Of the two First Officers (FO), the junior FO was the Pilot Monitoring (PM). The senior FO, who was the Relief First Officer (RFO), sat in the cockpit observer seat during the departure. They all commented that they were well rested and ready for duty. In addition, a company captain not rated on Boeing 747-8 aircraft was in the cockpit as a passenger.
As the crew was preparing the flight deck for departure, the PIC planned for a RNAV 1 SID RASSE 3A and gave a preliminary departure briefing to the PM. The PIC also loaded the expected runway 07R and the RASSE 3A SID in the FMC.
Prior to taxi the crew received cleared for the RASSE 1E, a Radius-to-Fix (RF) SID, with which the crew was unfamiliar. When the PIC selected and programmed RASSE 1E SID in the FMC, waypoint PORPA was overwritten and replaced by waypoint PORSH. Meanwhile, both the PIC and the PM had their respective Navigation Displays (NDs) selected in the Airport Moving Map (AMM) display mode. After execution, neither route verification nor a briefing on the new SID was conducted.
At 23:44 hrs, once the aircraft took off from runway 07R, it commanded a right turn towards the first active waypoint PORSH. Climbing through approximately 1,800 ft AMSL, the PF called for PM to select the Left Autopilot (A/P) to command while the aircraft continued turning right towards the high ground at Lo Fu Tau. At 23:45:14 hrs, ATC informed the flight crew that the aircraft was off track and instructed the crew to turn left to resume the RASSE 1E SID. The PF started making a HDG Select heading change leaving VNAV engaged.
Shortly afterwards, ATC informed the flight crew of terrain to the right of the aircraft and instructed the crew to expedite the climb to 5,000 ft AMSL.
At approximately 2,000 ft AMSL, the Enhanced Ground Proximity Warning System (EGPWS) on board the aircraft was triggered with a Mode 2A visual alert and the aural warning "TERRAIN, TERRAIN; PULL UP" annunciated. In response, the PF immediately disconnected the A/P and increased pitch and thrust. The aircraft passed over the high ground by approximately 670 ft AGL. Subsequently, the aircraft re-established the SID track at approximately 23:46 hrs and continued without further incident.

Causes :
Modification of the RF SID RASSE 1E while programming the SID into the FMC by overwritten waypoint PORPA, making PORSH the first active waypoint.

Contributing Factors
- CRM – assignment of the FOs’ duties and lack of communication amongst the crew.
- The crew accepted the RF SID RASSE 1E with which they were not familiar.
- The SID course and the first active waypoint were not verified.

Sources:

http://www.cad.gov.hk/reports/Prelim%20Report%20on%20CPA86%2020%20October%202017%20English.pdf
http://hk.on.cc/hk/bkn/cnt/news/20170926/bkn-20170926091951134-0926_00822_001.html
https://hk.news.appledaily.com/local/realtime/article/20170926/57255146
http://www.ais.gov.hk/HK_AIP/AIP/AD/HK_AD2-97%20RASSE%20EF.pdf
Incident 4 June 2017: A320 premature departure turn towards terrain, below MSA at Hong Kong

Accident investigation:
cover
  
Investigating agency: CAD Hong Kong
Status: Investigation completed
Duration: 4 years
Download report: Final report


Images:


Revision history:

Date/timeContributorUpdates
26-Sep-2017 18:17 harro Added
26-Sep-2017 18:40 harro Updated [Source]
17-Dec-2017 10:14 harro Updated [Time, Total occupants, Source, Narrative]
29-Sep-2021 09:58 harro Updated [Narrative, Accident report]
29-Sep-2021 19:13 harro Updated [Narrative]

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