Event Description
On June 5, 2020, at approximately 17:50 UTC, a Boeing 787-9 (registration SP-LSE) operating flight LO7836 from Wuhan (WUH) to Warsaw (EPWA) landed at Warsaw Chopin Airport. After vacating runway 15, the crew received clearance to taxi via taxiways H and A to parking position 65. During taxi, the captain inadvertently turned onto the wrong taxiway. Air traffic control (ATC) dispatched a FOLLOW ME vehicle to guide the aircraft for a turn-around. Subsequently, ATC asked if the crew could turn onto taxiway A7; the captain confirmed. While executing the turn onto A7 and then onto H2, the EICAS displayed a "TIRE PRESS" indication. The captain focused on taxiing, while the first officer and a second captain monitored tire status. After completing the turn, they saw the FOLLOW ME vehicle on H2 before taxiway A, and continued via A8 to position 65. During taxi, the crew consulted the "TIRE PRESS" checklist and the gear synoptic page, observing low pressure indications on wheels 1, 5, and 6 of the left main landing gear. After parking, LOT AMS technical staff found that three tires on the left landing gear (wheels 1, 5, and 6) had lost nitrogen and showed mechanical damage (cuts). The Port Duty Officer was asked to inspect the taxiways used by the aircraft; inspection revealed that the aircraft had damaged two edge lights while taxiing on taxiway A7.
Cause
The cause of the incident was crew error, specifically the execution of an inappropriate procedure during taxi after vacating the runway.
Contributing Factors
The following factors contributed to the incident:
- Coordination between the tower controller and the crew to taxi from A6 to A7 and from A7 to H2 despite the absence of markings permitting such taxiing.
- Coordination of the route A6–A7–H2–A8 with the FOLLOW ME coordinator, who raised no objections.
- Lack of a requirement from the tower controller and the crew for FOLLOW ME assistance during taxiing that did not conform to markings.
Recommendations
The Polish State Commission for Aircraft Accident Investigation accepted the following preventive recommendations:
- From LOT Polish Airlines: The incident was recorded in the SMS database and will be included in safety performance indicators.
- From LOT AMS: Information about the incident was disseminated to maintenance area managers and training departments for use in periodic human factors and type-specific training.
- From Polish Airports State Enterprise: Briefings for tower controllers, LOT crews, FOLLOW ME coordinators, and duty officers; inclusion of the incident in FOLLOW ME coordinator training; consideration for inclusion in pilot and tower controller training.
No additional safety recommendations were formulated.