Monarch A321 at Dublin on May 21st 2011, runway incursion forces high speed reject

Last Update: October 24, 2012 / 16:32:26 GMT/Zulu time

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Incident Facts

Date of incident
May 21, 2011

Classification
Report

Flight number
ZB-7526

Aircraft Registration
G-OZBS

Aircraft Type
Airbus A321

ICAO Type Designator
A321

A Monarch Airlines Airbus A321-200, registration G-OZBS performing flight ZB-7526 from Dublin (Ireland) to Las Palmas,CI (Spain) with 152 passengers and 6 crew, could not accept active runway 16 for departure due to performance limitations and therefore had taxied via AT4 and held short of Link 2 as instructed by ground control. The aircraft was subsequently cleared to taxi to the holding point runway 28 via Link 2, taxiway F1 to E1 hold short of runway 28. Instead of turning left onto taxiway F1 the aircraft however continued straight along taxiway A.

At that time a Ryanair Boeing 737-800, registration EI-DPT performing flight FR-7148 from Dublin to Vilnius (Lithunia) with 145 passengers and 6 crew, was accelerating for departure on runway 16, when the A321 went past the hold short line on taxiway and proceeded onto runway 16 about 1800 meters/5900 feet down runway 16. The Ryanair crew rejected takeoff at high speed (maximum speed reached 132 KIAS) and brought their aircraft to a stop about 1455 meters/4770 feet down the runway and about 360 meters/1200 feet ahead of the A321.

The Boeing 737 subsequently returned to the apron for examination of the brakes, a replacement Boeing 737-800 registration EI-DYC performed flight FR-7148 and reached Vilnius with a delay of 5 hours.

The Airbus A321 proceeded for takeoff on runway 28 and reached Las Palmas on schedule.

The Irish Air Accident Investigation Unit AAIU have released their final report releasing following findings into the "Class A Runway Incursion, a serious incident in which a collision was narrowly avoided":

1. G-OZBS requested take-off from RWY 28 when RWY 16 was active, for performance reasons.

2. G-OZBS was subsequently cleared and correctly acknowledged ATC instructions to taxi towards RWY 28 via AT4, Link 2, F1 and E1 to hold short of RWY 28.

3. When the AMC cleared EI-DPT for take-off on RWY 16 the runway was clear.

4. At that time G-OZBS was on a different frequency and its flight crew did not hear the take-off clearance.

5. The flight crew of G-OZBS lost situational awareness after an incorrect assumption regarding the position of another aircraft.

6. They mistakenly taxied from Link 2 onto taxiway A before entering and blocking RWY 16.

7. The wig-wag and runway edge lights at the entrance to RWY 16 from taxiway A were active, but neither they nor the runway signs were observed by the flight crew of G-OZBS.

8. The flight crew of EI-DPT observed that G-OZBS was blocking the runway and carried out a prompt and effective Rejected Take-Off, stopping some 360 metres from G-OZBS on the runway.

9. The flight crew of G-OZBS were possibly distracted by cockpit tasks during a relatively short and busy taxi.

10. G-OZBS was taxied on wet pavement directly towards a bright and low sun. This probably restricted the flight crewÂ’s ability to identify both taxiway markings and signs.

11. The pavement markings in the area of Link 2 are complex but in accordance with ICAO specifications.

12. The stop bar on E2 was illuminated and may have led the flight crew to assume that the runway was still ahead.

13. The stop bar on taxiway A was not active as the procedures did not require it in VFR conditions.

14. Some taxiway nomenclature at EIDW is non-sequential.

15. ASMGCS, which was operating at Level 1 at the time of the occurrence, has been upgraded to Level 2 with associated RIMCAS and SVM warning systems in place.

16. Taxiway Alpha has subsequently been designated an Incursion hot spot.

The AAIU reported the captain (47, ATPL, 9,263 hours total, 1,321 hours on type) was pilot flying for the sector to Las Palmas and was steering the aircraft. After stopping short of Link 2 in compliance with ATC instructions permitting another aircraft to pass on Link 2 and receiving clearance to continue taxi via E1 to runway 28 they thought the other aircraft had been on taxiway F2 (when it was in fact on runway 16), and believing Link 2 was where in fact taxiway A was located they taxied to Link 2. When the runway edge came into sight the first officer (ATPL, no further data known of the first officer), pilot monitoring, queried their position prompting the captain to stop the aircraft short of the runway edge but past the hold short line and within the runway protected strip. The captain said, the surfaces were wet due a recent rainshower and the bright sunshine reflection off the wet surface made poor markings less visible. A bright wig wag at taxiway A could have made them aware of the error. The first officer also said the surfaces were wet, the yellow markings on the taxiway were difficult to see which "was usual in Dublin".

The Ryanair captain (37, ATPL, 6,230 hours total, 2,800 hours on type), was pilot flying, the first officer (ATPL, no further data provided) was pilot monitoring. When they were accelerating for takeoff they both noticed an aircraft encroaching the runway, the captain called "Stop" and rejected takeoff at high speed, the flight data recorder indicated first brake pressure at 123 KIAS (V1 128 KIAS), the aircraft reached a maximum speed of 132 KIAS (118 knots over ground) before decelerating. Immediately after she had called stop, tower instructed them to stop. After coming to a stop, in absence of abnormal indications, the crew taxied back to the apron.

An inspection of Link 2 and taxiway A shortly after the occurrence found the markings and sign were in compliance with regulations by both IAA and ICAO. Wig-Wag lights installed at holding point A were in operation. The stop bar at taxiway A was not illuminated being used only in low visibility procedures.

Two safety recommendations were released as result of the investigation.
Incident Facts

Date of incident
May 21, 2011

Classification
Report

Flight number
ZB-7526

Aircraft Registration
G-OZBS

Aircraft Type
Airbus A321

ICAO Type Designator
A321

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