ASN Wikibase Occurrence # 297062
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| Date: | Tuesday 27 September 2022 |
| Time: | 20:49 LT |
| Type: |  Airbus A320-214 |
| Owner/operator: | Ultra Air |
| Registration: | HK-5413 |
| MSN: | 3240 |
| Year of manufacture: | 2007 |
| Total airframe hrs: | 43073 hours |
| Cycles: | 26430 flights |
| Engine model: | CFMI CFM56-5B4/P |
| Fatalities: | Fatalities: 0 / Occupants: 177 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | 18 nm WSW of Cali Airport (CLO/SKCL) -
 Colombia
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | San Andres Island-Gustavo Rojas Pinilla Airport (ADZ/SKSP) |
| Cali-Alfonso Bonilla Aragón Airport (CLO/SKCL) | |
| Investigating agency: | Aerocivil |
| Confidence Rating: |  Accident investigation report completed and information captured |
Ultra Air flight U05389, an Airbus A320-214, was involved in a serious incident on approach to Cali Airport (SKCL), Colombia.
During the execution of the RNAV approach ASIKO1C to SKCL, the crew had to perform an evasive maneuver in response to a GPWS alert while flying over the mountainous terrain of the Los Farallones de Cali Natural Park, reaching a minimum altitude of 1,528 feet (465 meters) above the terrain. The executed maneuver was successful, and the crew subsequently landed at SKCL without further incident. There were no injuries or damage to the aircraft.
The investigation determined that the contributing factors to the near-collision with the mountainous terrain, followed by the EGPWS alert evasive maneuver during the RNAV arrival, were as follows:
- Omission by the crew of the strict execution of the published ASIKO1C Standard Arrival Procedure, and instead, continuing navigation directly to point CL807 without verifying the minimum altitudes for the sector to be flown over.
- Weaknesses in Crew Resource Management (CRM) assertiveness, as the PF (Pilot Flying) did not inform the PM (Pilot Monitoring) of their navigation intentions, which contributed to the underutilization of available cabin resources to detect the deviation and determine that they would be flying over elevated terrain.
- Overconfidence of the PF, who, because they had visual reference with the mountainous area and the city of Cali, biased their judgment and did not consider that the flight was in dangerous conditions due to the unsafe separation between the terrain and the aircraft.
- Inappropriate ATC (Air Traffic Control) action, as they authorized the aircraft to fly directly to point CL807 of the ASIKO1C arrival without verifying and evaluating its position and altitude in relation to the minimum sector altitudes.
- Disabling of the MSAW (Minimum Safe Altitude Warning) system by the ATS (Air Traffic Service) in Cali, despite the tool being in good condition, and the lack of implementation of alternative safeguards to compensate for the disconnection of this key device for CFIT (Controlled Flight Into Terrain) prevention.
- Failure to use radar control resources and alerts to detect that the aircraft was flying outside the established RNAV approach procedures and below minimum sector altitudes.
Accident investigation:
 |
|
Sources:
https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-airbus-a320-registered-hk5413-operated-by-ultra-air-on-28-09-2022-near-cali/
https://flightaware.com/live/flight/ULS5389/history/20220928/0023Z/tracklog
https://www.aerocivil.gov.co/autoridad-de-la-aviacion-civil/investigacion/Incidentes%20Historicos/Preliminar%20Inc%20Gr%20HK5413%20TMA%20Cali%2027-sep-22.pdf
History of this aircraft
Other occurrences involving this aircraft
| 11 June 2012 | PR-MHN | TAM Airlines | 0 | Brasília-Presidente Juscelino Kubitschek International Airport, DF (BS |  |
non |
Location
Images:
ASIKO 1C procedure (AIP Colombia)
Flight track of flight 5389 (Flightaware)
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 14-Oct-2022 13:57 | harro | Added |
| 14-Oct-2022 14:12 | harro | Updated [Location, Source, Narrative, Photo] |
| 14-Oct-2022 14:53 | harro | Updated [Narrative, Photo] |
| 14-Oct-2022 14:56 | harro | Updated [Photo] |
| 30-Sep-2023 16:33 | harro | Updated [[Photo]] |
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