Ryanair B738 at Palma Mallorca on Jul 19th 2020, rejected takeoff due to ATC error, vehicle on runway

Last Update: July 8, 2021 / 19:40:15 GMT/Zulu time

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Incident Facts

Date of incident
Jul 19, 2020

Classification
Incident

Airline
Ryanair

Flight number
FR-2062

Destination
Madrid, Spain

Aircraft Registration
EI-EFJ

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Ryanair Boeing 737-800, registration EI-EFJ performing flight FR-2062 from Palma Mallorca,SP to Madrid,SP (Spain) with 152 passengers and 6 crew, was cleared for takeoff from Palma's runway 24R and was accelerating for takeoff.

The driver of a maintenance vehicle, who had been cleared to enter the runway to perform maintenance work, was alerted by the radio traffic clearing the Boeing for takeoff, rushed to his vehicle and alerted tower of his presence. Tower cancelled the takeoff clearance, the Boeing crew rejected takeoff and vacated the runway.

The aircraft was able to depart about 20 minutes later.

Spain's CIAIAC reported the minimum distance between aircraft and vehicle was at least 1.6nm. There were no injuries and no damage. The CIAIAC is conducting an investigation. The US NTSB advised they have accredited a representative to join the investigation.

On Jul 8th 2021 the CIAIAC released their final report concluding the probable cause of the incident was:

The investigation has determined the runway incursion was caused by the local controller’s (TWR) failure to adhere to the procedures set out in the unit’s Operating Manual and the provisions of the Air Traffic Regulation in regard to the use of phraseology, active listening and surveillance of the airport manoeuvring area.

Furthermore, the following factors are considered to have contributed:

- The phraseology used by Balizamiento 3 driver when naming the runway he wanted to access, given that it was contrary to the stipulations in the LEPA Operating Manual because he failed to use the runway designator.

- A spatial error made by the Balizamiento 3 vehicle driver in his first communication once established at H5, in that he requested entry to a runway he could not access from H5.

The CIAIAC analysed:

General considerations

On 19 July 2020, the Boeing B737-800 aircraft with registration EI-EFJ, operated by Ryanair, was making a scheduled flight (callsign RYR81SN) from Palma de Mallorca Airport to Madrid-Barajas Adolfo Suárez Airport. Aircraft RYR81SN was instructed to taxi to the 24R holding point and then take off on runway 24R.

The lighting vehicle, Balizamiento 3, was conducting a runway inspection from the threshold of runway 06L towards the threshold of runway 24R, having previously been cleared to do so.

Both the vehicle and the aircraft were on the local controller frequency (TWR) when they found themselves on runway 06L/24R at the same time.

The crew of the aircraft had the required licenses and medical certificates for the flight.

The aircraft’s documentation was in order.

The driver of the lighting vehicle had the required licenses to carry out his work.

The local controller (TWR) and the ground movement controller (GMC) had valid licenses, unit endorsements and medical certificates. Furthermore, their activity prior to the incident flight is considered to be compliant with normal standards.

The meteorology at the time was in no way limiting and did not have any bearing on the incident.

Cause of the conflict

At 20:48:53, preparations began for the integration of the ground movement position (GMC) with the local position (TWR) (the frequency unification and handover would occur at 20:50:12). Therefore, during the period between 20:48:53 and 20:50:12, the ground movement controller (GMC) should have made use of the checklists (according to the LEPA Operating Manual. Annex E: ATC handover checklist and Annex E: New control position checklist) and the electronic strips to prepare to close the ground movement control position (GMC), hand over the clearances, and unify both frequencies in the local position (TWR).

If the handover had taken place according to the established procedures, the local controller (TWR) would have been made aware, at that point, of the location and intentions of the Balizamiento 3 vehicle.

There is no documentary evidence to show that, during the handover, the outgoing ground movement controller (GMC) informed the local controller (TWR) that he had a vehicle circulating on the north taxiway or that he had made an electronic strip for the movement of that vehicle, as established in Annex B, section 5.3 of the LEPA Operating Manual and as recommended as a best practice in Appendix M of the EAPPRI 3.0 Plan. However, based on what happened next and the local controller's (TWR) own statement, it’s clear he was not aware of the exact position and intentions of the Balizamiento 3 vehicle.

At 20:50:00, the driver of the Balizamiento 3 vehicle established initial contact on the local controller frequency (TWR), reported that he was “at H5” and requested clearance to “occupy the south runway”. This communication was mistaken on two counts:

- Firstly, because by not using the runway designator when making the occupancy request, he used a phraseology not in accordance with the provisions of the Basic Manual for the airport manoeuvring area EXA43 of AENA, section 4.1, and

- Secondly, because his position at H5 meant the only runway he could access was the north, not the south. Therefore, the message from the driver of the lighting vehicle was incoherent from a spatial point of view because either the vehicle wasn’t at H5, or it was, and he requested access to the north runway rather than the south. Upon hearing the contradictory message, the local controller (TWR) should have asked for some sort of clarification to ensure he understood the driver's intentions, but he didn’t.

Despite the phrasal and spatial errors in the communication, the local controller (TWR) replied, “approved”. This laconic response also failed to comply with the provisions of the LEPA Operational Manual by not using the designator of the runway for which the occupation permit was granted.
His approval lead to the Balizamiento 3 vehicle entering runway 06L/24R through threshold 06L. Previously, at 20:47:08, the ground movement controller (GMC) had cleared the RYR81SN aircraft to taxi to the 24R holding point.

The local controller (TWR) failed to visually identify the vehicle, as stipulated in section 4.5.1.3 of the RCA, claiming in his statement that he couldn’t because it was night-time. Furthermore, he didn’t use the A-SMGCS display to check its exact position. According to section 4.6.10.2.2.1 of the RCA, the SMR surface radar should be used to enhance the visual observation of traffic in the manoeuvring area and provide traffic surveillance in those parts of the manoeuvring area that cannot be observed visually.

Had he carried out either of these two actions, he would have undoubtedly noticed the position of the Balizamiento 3 vehicle. According to the local controller’s statement (TWR), he didn’t carry out either of the two actions.

At 20:50:10, the driver of the Balizamiento 3 vehicle requested the local controller (TWR), “Can you switch off the stop bars at H5, please?”. The controller responded: “Balizamiento 3 go over the stop bars”, to which the driver of the Balizamiento 3 vehicle responded, “Copied, with permission to pass lit stop bars at H5, north runway occupied by Balizamiento 3, listening on frequency 118.3…. 118.305, sorry.”

There was no reply from the controller.

Once again, this communication was erroneous for several reasons, and a decisive factor in the conflict that later occurred on the runway:

- The driver's request to switch off the stop bars was in accordance with the provisions of the LEPA Operating Manual, which states that illuminated stop bars should not be exceeded. However, the controller instructed the Balizamiento 3 vehicle to pass the illuminated stop bars without any contingency circumstances, in a clear breach of the provisions of the LEPA Operating Manual.

- In his acknowledgement, the driver of the Balizamiento 3 vehicle again failed to use the runway designator for the runway he was requesting permission to enter, although this time he said “north runway”, unlike the previous communication in which he said “south runway”. Now, at least, the driver's message was coherent from a spatial point of view because he stated he was entering the “north runway” from H5. However, the controller did not respond to the driver.

- At this point (and as stated later by the local controller (TWR)), the controller thought the Balizamiento 3 vehicle was on the south runway and that he was authorising entry onto a non-operational runway. Despite the aforementioned spatial discrepancy between the two previous communications from the driver of the vehicle, the controller did not request any clarification. It follows, therefore, that his listening was not as active as it should have been because, although he was clear (mistakenly) that the vehicle was in the south zone, the driver had clearly said he was at H5 (which is in the north zone) and that he was entering the “north runway”.

At 20:50:12, the ground movement controller (GMC) finished his shift and left. The local controller position (TWR) had already assumed the handover and integration of both frequencies, which included management of the surface movements at Palma de Mallorca Airport.

At 20:50:43, the RYR81SN aircraft established initial contact on the Palma de Mallorca control tower local controller frequency (TWR) and indicated that it was ready to depart. The controller at the Palma de Mallorca control tower replied: “RYR81SN good evening, wind 210º, 5 knots, runway 24R, cleared for take-off, traffic on final 8 miles out”. The crew of the aircraft read-back the communication correctly.

Resolution of the conflict

This take-off clearance should not have been issued because the runway was occupied by the Balizamiento 3 vehicle. It led to the inappropriate presence of the aircraft on the runway and the runway incursion that is the subject of this investigation. It should be noted that, at the time the clearance was given, the A-SMGCS screen already showed the Balizamiento 3 vehicle at the opposite end of runway 24R. Again, the controller failed to visually verify that the runway was clear and didn’t use the A-SMGCS screen. If he had done so, he would have noticed the presence of the lighting vehicle on the runway on which he was authorising an aircraft to take off.

The investigation has determined the runway incursion was caused by the local controller’s (TWR) failure to adhere to the procedures set out in the unit’s Operating Manual and the provisions of the Air Traffic Regulation in regard to the use of phraseology, active listening and surveillance of the airport manoeuvring area.

At 20:51:32, the driver of the Balizamiento 3 vehicle, who was listening on the TWR frequency, heard the clearance given to the RYR81SN aircraft and notified the local controller, saying, “I’m on the north runway, you cleared me to enter, exiting immediately”.

At that moment, the Balizamiento 3 vehicle was abeam on level with the N7 taxiway and proceeded to vacate the runway via the H4 taxiway.
At 20:51:37, the local controller (TWR) replied to the driver of the vehicle, “Balizamiento 3, you told me you were on the south runway; vacate the runway immediately. Break, break ”.

This last communication clearly demonstrates that the controller had mistakenly thought the lighting vehicle was on the south runway, under the impression that he had previously cleared it to enter the south runway, and not the north, despite the fact that the vehicle entered from H5, which is in the north zone of the airport.

And at 20:51:39, the local controller (TWR) contacted the aircraft: “RYR81SN hold position, I say again hold position”. The crew of the aircraft acknowledged “Stopping RYR81SN”.

According to section 1.4.12 g) of the RCA, this phraseology was also incorrect. Furthermore, the controller did not comply with the provisions of precept 4.5.5.4 of the aforementioned standard, which indicates that when a controller notifies an aircraft of a runway incursion after clearing it for take-off, they must inform the aircraft involved about the nature of the incursion and the position of the obstacle in relation to the runway. Something the controller failed to do.

Finally, the driver of the Balizamiento 3 vehicle notified runway free via H4, and the controller asked aircraft RYR81SN if it could take off from its position abeam on taxiway N1. The crew responded negatively, advising that they would prefer to carry out some checks and return to holding point H1. Thus, the controller instructed the aircraft to leave the runway via N1 and advise when the runway was clear. Which it subsequently did.

According to the radar data, the minimum distance reached between the aircraft and the vehicle was 1.6 NM at 20:51:49.

Relevant factors in respect of the procedures/regulations

The following factors are considered to have been relevant and decisive in producing the conflict:

On the part of the driver of the Balizamiento 3 vehicle:

- The phraseology he used to name the runway he wanted access to was not the phraseology stipulated in the Basic Manual for the airport manoeuvring area EXA43 of AENA, section 4.1because he did not use the runway designator.

- A spatial error made in his first communication, once at H5, requesting access to the south runway (06R/24L), which he did not have access to from H5.

On the part of the local controller (TWR):

- Not detecting the inconsistency in the communication from the driver of Balizamiento 3 when he requested permission to enter the south runway (06R/24L), which he could not access from H5.

- The phraseology he used to approve access to the requested runway was not the phraseology stipulated in the LEPA Operating Manual because he did not use the runway designator.

- He did not perform a direct visual scanning of the position of the Balizamiento 3 vehicle, nor did he use the A-SMGCS display for the same purpose. Accordingly, he did not comply with the provisions of sections 4.5.1.3 and 4.6.10.2.2.1 of the RCA.

- He should not have instructed the Balizamiento 3 vehicle to pass the illuminated stop bars without any contingency circumstances to justify the action and, therefore, did not comply with the stipulations in the LEPA Operating Manual.

- The phraseology he used with the aircraft after warning it of the runway incursion was incorrect, according to section 1.4.12 g) of the RCA.

- He did not comply with the provisions of precept 4.5.5.4 of the RCA, which indicates that when a controller notifies an aircraft of a runway incursion after clearing it for take-off, they must inform the aircraft involved about the nature of the incursion and the position of the obstacle in relation to the runway.
Incident Facts

Date of incident
Jul 19, 2020

Classification
Incident

Airline
Ryanair

Flight number
FR-2062

Destination
Madrid, Spain

Aircraft Registration
EI-EFJ

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

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