AIT E145 at Tel Aviv on Sep 14th 2018, runway incursion

Last Update: December 24, 2018 / 15:56:58 GMT/Zulu time

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Incident Facts

Date of incident
Sep 14, 2018

Classification
Incident

Flight number
AYT-623

Destination
Paphos, Cyprus

Aircraft Registration
4X-EMP

Aircraft Type
Embraer ERJ-145

ICAO Type Designator
E145

An AIT Aviation Embraer ERJ-145, registration 4X-EMP performing flight AYT-623 from Tel Aviv Sde Dov (Israel) to Paphos (Cyprus), was taxiing for departure and had been instructed by ground control to taxi to holding point Delta runway 03 ("AIT 623, taxi Delta"). The crew read back "Delta, backtrack 03, confirm?", tower replied "affirm, AIT 623". The aircraft taxied to Delta and without establishing contact to tower crossed the hold short line to line up runway 03.

At the same time a Cessna 172, occupied by a student pilot and an instructor, was on short final to runway 03 already cleared to land on runway 03 when the student pilot noticed the Embraer entering the runway, informed the instructor, the instructur radioed tower and tower instructed the Cessna to go around. The Cessna went around.

The Embraer continued to taxi into position and was cleared for takeoff continuing to their destination without further incident. The Cessna positioned for another approach and landed safely, too.

Israel's AIAI released their final report in Hebrew 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 Hebrew 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, in particular as no reasonable translation software is available and the use of native Hebrew translators is almost needed to make sense of the report. 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 AIAI concluded the probable causes of the serious incident were:

- Deviation from the instruction to contact the tower when approaching the runway holding position and lining up without clearance.

- An unclear query by the ERJ pilot after obtaining clearance to taxi to "D": "DELTA BACK TRACK 03 CONFIRM ?" The pilot considered this query as lineup clearance confirmation, while the ground controller considered it as an informative question about what to expect next.

- The ground controller's reply: "AFFIRM AIT 623" was intended to be an informative reply and not as a lineup clearance. The controller should have stated "hold short delta" or "hold short runway 03", again.

The AIAI analysed that the unclear query "Delta, back track 03, confirm?" by the Embraer crew following the instruction "AIT 623, taxi Delta" contributed to the serious incident. The query was non-standard and could be read in several ways, e.g. as request to subsequently back track runway 03 for a full length departure or an question whether ATC was expecting them to back track runway 03 and subsequently issuing such instructions. The reply by ground control "Affirm, AIT 623" was interpreted as clearance to enter and backtrack runway 03 by the crew however, while ground control had thought the crew was checking with them what to expect. The Embraer crew continued past the hold short line without contacting tower as result and began to line up runway 03 when the Embraer captain noticed the Cessna and stopped the aircraft. The Cessna was already in landing configuration on short final, however, the probability of a collision was rated rather low as the distance between threshold and the Embraer was quite large. Any risk was removed by the Cessna 172 going around.

The AIAI analysed that it would be desireable to clarify instructions by adding "hold short Delta" or "hold short runway 03".

(translation of causes and summary compiled with the help of a native Hebrew speaker)
Incident Facts

Date of incident
Sep 14, 2018

Classification
Incident

Flight number
AYT-623

Destination
Paphos, Cyprus

Aircraft Registration
4X-EMP

Aircraft Type
Embraer ERJ-145

ICAO Type Designator
E145

This article is published under license from Avherald.com. © of text by Avherald.com.
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