Date: 25th October 2024
Location: Ljubljana Jože Pučnik Airport, Slovenia
Aircraft: Embraer ERJ-195, registration SP-LNL
Operator: LOT Polish Airlines
Flight Number: LO-615
Route: Warsaw (Poland) to Ljubljana (Slovenia)
Occupants: Unknown
Injuries: None reported
Summary of Events
On 25th October 2024, LOT Polish Airlines flight LO-615, an Embraer ERJ-195, encountered a critical situation during its ILS approach to runway 30 at Ljubljana Airport. The aircraft failed to intercept the ILS glide path and descended below the prescribed altitude, triggering an Enhanced Ground Proximity Warning System (EGPWS) alert. The warnings included “Terrain! Terrain!” and “Pull Up! Pull Up!” The crew promptly executed the EGPWS escape manoeuvre and initiated a go-around. The aircraft subsequently landed safely on its second approach, approximately 12 minutes later.
Slovenia’s Aviation and Investigation Board (AIB) has classified the occurrence as a serious incident and has launched a formal investigation.
Sequence of Events
1. Final Approach:
• The aircraft was on final approach to Ljubljana’s runway 30 but failed to capture the Instrument Landing System (ILS) glide path.
2. Descent Below Glide Path:
• As the aircraft descended below the prescribed glide path, the EGPWS was triggered, issuing “Terrain!” and “Pull Up!” warnings.
3. Escape Manoeuvre:
• The flight crew immediately performed the prescribed EGPWS escape manoeuvre, applying maximum thrust and pitching the aircraft to avoid terrain.
4. Go-Around and Second Approach:
• The aircraft climbed to a safe altitude, repositioned for another approach, and landed without further incident.
Aircraft Information
The Embraer ERJ-195 is a twin-engine regional jet equipped with advanced avionics, including an Enhanced Ground Proximity Warning System (EGPWS). The system is designed to alert crews of imminent terrain collisions and guide evasive action to prevent Controlled Flight Into Terrain (CFIT).
Initial Findings
Contributing Factors to Glide Path Deviation
1. Flight Crew Error:
• Potential errors during ILS capture or monitoring of descent.
2. Instrument Malfunction:
• Possible misalignment or technical issue with the aircraft’s ILS receiver or autopilot systems.
3. Environmental Conditions:
• Weather conditions, such as turbulence or wind shear, may have disrupted the aircraft’s approach stability.
4. Pilot Workload:
• High workload during approach could have impacted situational awareness.
Safety Risks
1. Controlled Flight Into Terrain (CFIT):
• Failure to respond promptly to the EGPWS warning could have resulted in a catastrophic accident.
2. Operational Disruption:
• A go-around increases the crew’s workload and delays operations.
3. Passenger Safety:
• Abrupt manoeuvres during the EGPWS escape manoeuvre can lead to passenger discomfort or injuries.
Recommendations
1. Crew Training:
• Enhance simulator training scenarios to include unexpected ILS deviations and high-stress EGPWS warning responses.
2. ILS System Check:
• Perform a thorough inspection of the ILS system at Ljubljana Airport to rule out misalignment or interference.
3. Flight Data Review:
• Analyse the flight data recorder (FDR) to determine the exact sequence of events and potential causes of the deviation.
4. Operational Procedures:
• Reinforce standard operating procedures (SOPs) for monitoring glide path alignment during approach.
5. Communication with ATC:
• Ensure timely coordination between the flight crew and air traffic control to address deviations during approach.
Safety Lessons
This incident underscores the critical role of EGPWS in preventing Controlled Flight Into Terrain. The crew’s immediate and correct response to the warnings ensured a safe outcome. It also highlights the importance of rigorous monitoring and adherence to approach procedures during critical phases of flight.
Disclaimer
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Our investigation reports are based on all the evidence and facts available at the time of writing and posting. We apologise if any details are missed or are not fully accurate.
