Nova E195 and Europa B738 at Madrid on Jan 22nd 2022, first aircraft not clear of runway when the second touched down
Last Update: August 17, 2022 / 20:08:51 GMT/Zulu time
Incident Facts
Date of incident
Jan 22, 2022
Classification
Incident
Airline
Aero Nova
Flight number
UX-6078
Departure
Palma Mallorca, Spain
Destination
Madrid, Spain
Aircraft Registration
EC-LFZ
Aircraft Type
Embraer ERJ-195
ICAO Type Designator
E195
Airport ICAO Code
LEMD
An Air Europa Boeing 737-800, registration EC-MXM performing flight UX-1026 from Paris Orly (France) to Madrid,SP (Spain) with 128 passengers and 6 crew, landed on Madrid's runway 32R at 21:23L (20:23Z) less than a minute after EC-LFZ, when EC-LFZ was still occupying the runway. The aircraft rolled out without further incident and vacated the runway also via taxiway K4.
Spain's CIAIAC reported they opened an investigation into the occurrence with both aircraft occupying the runway at the same time. The Boeing had been trailing the Embraer by 3.1nm horizontally at the time the Embraer touched down.
On Aug 17th 2022 the CIAIAC released their final report in Spanish 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 Spanish 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 final report concludes the probable causes of the incident were:
Lack of adherence to procedures by both crews: The Embraer crew did not leave the runway via taxiway K5 as stipulated by the AIP, the Boeing crew landed without landing clearance. ATC should have prioritized his tasks better, he lacked a certain amount of pro-activity to prevent both situations from occurring: non-adherence to procedures due to not using standard phraseology.
The CIAIAC analysed that after review of the data it became clear that the Embraer had already crossed the hold short line of taxiway K4 when the Boeing touched down, the aircraft thus did not occupy the runway at the same time. It had initially looked like a runway incursion by the Boeing as they landed without having received landing clearance. However, at the time the Embraer passed the taxiway K5 - where it should have vacated the runway - the controller should have been more proactive, instructed the Embraer to hurry up, but did so only 15 seconds later and neither issued a landing clearance nor a go around instruction to the Boeing.
Had the Embraer vacated the runway at K5, the Boeing would not yet have reached the runway approach minima. The controller however, when he instructed the Embraer to hurry up 15 seconds after they had passed K5, immediately appended the instruction to the Boeing to go around without the required "BREAK! BREAK!", the last part of the transmission to the Boeing was unreadable most likely overlaid with the readback by the Embraer. Therefore it is almost certain that the Boeing crew did not hear the go around instruction.
Not hearing the go around instruction however is not a valid argument to continue the landing as no landing clearance had been issued.
The controller should have prioritized his tasks better in preventing the Embraer from rolling past taxiway K5, subsequently ensuring the Boeing crew did receive the go around instruction in addition to using the standard phraseology (Break! Break!).
Metars:
LEMD 222230Z 34005KT CAVOK 01/M02 Q1027 NOSIG=
LEMD 222200Z 35004KT CAVOK 01/M01 Q1027 NOSIG=
LEMD 222130Z 36003KT CAVOK 02/M01 Q1027 NOSIG=
LEMD 222100Z 33003KT CAVOK 01/M02 Q1027 NOSIG=
LEMD 222030Z 34002KT CAVOK 03/M00 Q1027 NOSIG=
LEMD 222000Z VRB01KT CAVOK 03/M01 Q1027 NOSIG=
LEMD 221930Z VRB01KT CAVOK 03/M00 Q1027 NOSIG=
LEMD 221900Z 33002KT CAVOK 04/M01 Q1027 NOSIG=
LEMD 221830Z 36003KT CAVOK 06/00 Q1027 NOSIG=
LEMD 221800Z 35003KT CAVOK 06/00 Q1027 NOSIG=
LEMD 221730Z 33003KT CAVOK 06/01 Q1026 NOSIG=
LEMD 221700Z 36003KT CAVOK 09/01 Q1027 NOSIG=
Incident Facts
Date of incident
Jan 22, 2022
Classification
Incident
Airline
Aero Nova
Flight number
UX-6078
Departure
Palma Mallorca, Spain
Destination
Madrid, Spain
Aircraft Registration
EC-LFZ
Aircraft Type
Embraer ERJ-195
ICAO Type Designator
E195
Airport ICAO Code
LEMD
This article is published under license from Avherald.com. © of text by Avherald.com.
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