Portugalia E190 at Nice on Nov 6th 2017, takeoff from taxiway rejected on ATC instruction

Last Update: March 26, 2020 / 20:01:29 GMT/Zulu time

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Photo of PGA Portugalia Airlines CS-TPV, Embraer ERJ-190 — PGA Portugalia Airlines CS-TPV, Embraer ERJ-190 (Photo credit: spotter-cgn.de / Flickr / License: CC by-nd)

Incident Facts

Date of incident
Nov 6, 2017

Classification
Incident

Airline
PGA Portugalia Airlines

Flight number
NI-487

Departure
Nice, France

Destination
Lisbon, Portugal

Aircraft Registration
CS-TPV

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

Airport
Nice-Côte d'Azur Airport, Nice

Airport ICAO Code
LFMN

A PGA Portugalia Embraer ERJ-190 on behalf of TAP Portugal, registration CS-TPV performing flight NI-487/TP-487 from Nice (France) to Lisbon (Portugal) with 61 passengers and 5 crew, was cleared to line up and was cleared to take off from runway 04L in night conditions. The aircraft however lined up taxiway U parallel to runway 04L and commenced takeoff. Tower noticed the error a few seconds later and instructed the crew to reject takeoff. The crew rejected takeoff at high speed (about 92 KIAS) and brought the aircraft to a stop about 960 meters down the taxiway. The aircraft returned to the holding point and departed.

The French BEA rated the occurrence a serious incident and opened an investigation.

On Mar 26th 2020 the BEA released their final report in French only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a French only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).

The report concludes the probable cause of the serious incident was:

The push back facing west led the ground controller to routinely choose the taxi route via taxiway T. The crew however was used to use taxiway U to taxi to the threshold of runways 04. They therefore found themselves in an unusual situation, probably without realizing it, even though the crew read the taxi instructions correctly back to ground control.

The crew taxied out without ensuring sufficient outside surveillance (markup, signage, indications) and without verification with the charts available at their disposal. The number of actions to be performed, in particular the start of the #2 engine during taxi, and the short time since push back likely contributed to the limited availability of the crew to monitor, verify and confirm the position of the aircraft during taxi.

Arriving at the end of taxiway T the pilot flying confused the indication panel of taxiway A with the duty sign at the holding point A1. He subsequently thought runway 04L in service was the next lane to his left as usual when they taxi along taxiway U.

Busy with other tasks neither ground now tower controller checked the position of the aircraft and thus did not detect the positioning error by the crew. The tower controller want to squeeze the departure in between two arrivals to save time. He cleared the flight to line up and cleared the flight for takeoff even before the aircraft reached the holding point A1.

This practise, even though it is permitted by the operating manual, leaves the possibility for a routing error by the crew which is difficult to be detected by the controller.

The change of the markup from a blue side marker to a vertical axis marker could have misled the crew to assume, they were entering a runway. During line up the crew did not detect the different colours of the taxiway to lighting of a runway. Finally, the crew was not alerted to the taxiway due to the dimensions of the taxiway which is as wide as a runway without any sign at the beginning of taxiway U to indicate the taxiway.

Nonetheless, the pilot flying had his doubts and queried with the pilot monitoring to verify their position. The latter confirmed they were on the runway. The crew did not call tower to clarify the doubt although reminded by the operator's procedures.

The different taxi route and early clearances by the tower, likely to ensure smooth traffic flow, probably increased the time pressure already linked to the delay of the aircraft, which led the crew to accelerate the actions before takeoff at the expense of verifying the position with tower.

Finally, the pre-takeoff checks included a warning asking to verify they were on the correct runway. The crew was aware of the warning but did not verify they saw the runway label 04L in front of them. This number verification is not part of the checklist.

The ground controller detected the takeoff roll at his surface movement radar, which prompted the rejected takeoff.

The following factors can explain the takeoff from the taxiway:

- high workload by the pilot monitoring during the short taxi due to the start of the second engine and other actions to be performed
- insufficient position monitoring, verification and confirmation while taxiing, possibly due to the habits at the aerodrome which may have led them to assume a different aircraft position
- a confirmation bias, which in the absence of clear indications signalling they were on a taxiway, led the crew to favour clues supporting their misrepresentation of the situation: change of lights, width of taxiway similiar to runway. The difference between arriving on a taxiway and arriving on a runway include panels, markings on the ground before the A1 holding point, runway protection lights, beaconing ... It is more difficult to detect something expected to be missing than to detect something unusual.
- a partial removal of doubt during line up due to the confusion of the colours of lights and the pressure to takeoff quickly
- the focus of tower controller on the flow of traffic in flight rather than the position of the departing aircraft, probably due to trust into the crew's position message
- the use of approximate phraseology which could have led the controller to assume the aircraft was on the A1 waiting point rather than aligned with taxiway U.

The captain (54, ATPL, 12,003 hours total, 555 hours on type as captain) was pilot flying, the first officer (62, ATPL, 14,530 hours total, 739 hours on type as first officer) was pilot monitoring.

Metars:
LFMN 041900Z 01004KT 320V090 9999 FEW033 BKN055 BKN120 18/12 Q1014 NOSIG=
LFMN 041830Z 07009KT 9999 FEW033 BKN055 BKN110 19/13 Q1015 NOSIG=
LFMN 041800Z 07012KT 9999 FEW033 BKN060 BKN110 19/13 Q1015 NOSIG=
LFMN 041730Z 06012KT 9999 FEW033 BKN060 BKN130 19/13 Q1015 NOSIG=
LFMN 041700Z 06013KT 9999 FEW033 BKN060 BKN130 19/14 Q1015 NOSIG=
LFMN 041630Z 08016KT 9999 FEW033 BKN060 BKN130 19/14 Q1015 NOSIG=
LFMN 041600Z 09014KT 9999 FEW033 BKN060 BKN130 19/13 Q1015 NOSIG=
LFMN 041530Z 08014KT 9999 FEW033 SCT065 BKN130 19/13 Q1015 NOSIG=
LFMN 041500Z 08015KT 9999 FEW033 SCT070 BKN130 19/13 Q1015 NOSIG=