What happened
On June 5, 2020, a Boeing 787-9, registration SP-LSE, arrived at Warsaw Chopin Airport (EPWA) on flight LO7836. After exiting runway 15L, the crew received taxi instructions to proceed via taxiways H and A to stand 65. During the taxi sequence, the captain inadvertently turned onto an incorrect taxiway. Air Traffic Control (ATC) responded by dispatching a FOLLOW ME vehicle to guide the aircraft through a turnaround maneuver.
During the subsequent maneuver to rejoin taxiway A7 and proceed to H2, an "EICAS" alert for "TIRE PRESS" appeared on the cockpit display. While the crew monitored the tire pressure levels, the aircraft continued to taxi via A8 to stand 65. Upon arrival at the parking stand, maintenance personnel discovered that three wheels on the left landing gear—specifically wheels 1, 5, and 6—had lost nitrogen pressure and showed visible mechanical damage, including cuts to the tires.
An inspection of the airfield by the airport duty officer revealed that the aircraft had struck and damaged two edge lights on taxiway A7 during the unauthorized maneuver.
The investigation
The PKBWL examined the flight data, cockpit voice recorder (CVR), and digital video recorder (DVR) footage. The investigation focused on the sequence of taxiing maneuvers and the coordination between the flight crew, ATC, and the FOLLOW ME service. The investigation also reviewed the maintenance actions taken, which included inspecting the axles and replacing all wheels on the left landing gear.
Findings
- The primary cause of the event was crew error involving the execution of improper procedures while taxiing after leaving the runway.
- The crew and ATC coordinated a taxi route (A6–A7–H2–A8) that lacked proper markings to support such a maneuver.
- The FOLLOW ME coordinator did not raise concerns regarding the proposed route.
- There was a lack of specific instructions from ATC or the crew regarding the necessity of FOLLOW ME assistance specifically for navigating non-signaled taxiway segments.