Ryanair B738 and EAT A306 at Barcelona on Jun 4th 2022, near collision between takeoff and go around

Last Update: March 3, 2023 / 14:19:38 GMT/Zulu time

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Incident Facts

Date of incident
Jun 4, 2022

Classification
Incident

Airline
Ryanair

Flight number
FR-6353

Aircraft Registration
EI-GJS

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Ryanair Boeing 737-800, registration EI-GJS performing flight FR-6353 from Barcelona,SP (Spain) to Milano Bergamo (Italy) with 187 passengers and 6 crew, was in the initial climb out of Barcelona's runway 24L.

At the same time an EAT Leipzig Airbus A300-600, registration D-AEAO performing flight QY-1685 from Leipzig (Germany) to Barcelona,SP (Spain) with 5 crew, was climbing out following a go around from about 1000 feet AGL on final approach to runway 24L.

Spain's CIAIAC reported: "Both planes maneuvered apart, in accordance with the instructions received from their corresponding on-board traffic alert and anti-collision avoidance systems, and continued their flights normally." The CIAIAC opened an investigation into the occurrence.

On Mar 3rd 2023 the CIAIAC released their final report concluding the probable causes of the incident were:

The investigation has found that the cause of the incident was the non-compliance of procedures on the part of the control services, together with the fact that the AIRBUS A – 300-600 crew failed to immediately notify their intention to execute a missed approach.

The CIAIAC analysed:

This event requires an analysis of whether the crews of the two aircraft and the control services acted in accordance with the established procedures.

Having analysed the performance of the BOEING 737-800 aircraft crew, it appears they complied at all times with the requirements of the control services and carried out a normal take-off in accordance with the procedures.

They were cleared for take-off at 6:31:33 h and started the run at 6:31:47 h, i.e. 14 s later, a time interval that complies with procedures.

They executed the actions stipulated by the TCAS RA warning correctly, aided by the fact that the RA told them to climb, which meant they weren’t required to do anything other than continue as they were.

Their decision not to inform the control services that they had received a resolution advisory warning from the TCAS system because it only lasted for 9 seconds and, as inferred in RYANAIR’s internal report, because they didn’t want to interfere with the controller’s workload, seems to have been the correct judgement.

The aforementioned internal investigation by the operator also detected that, given that an event of this nature would have required it, the crew failed to follow procedure by not disconnecting the cockpit voice recorder circuit breaker (CVR CB) on landing. Furthermore, it established that as the recording time was 1:28 h, the cockpit communications during the event could have been recovered.

With regard to the performance of the AIRBUS A – 300-600 crew, it should be noted that on deciding to execute a missed approach, they followed the procedures set out in the AIP for the runway configuration in force, maintaining an altitude of 1,500 ft. Moreover, when they received the TCAS warning, they descended to 1,200 ft, thus separating themselves from the other aircraft.

Instead of expressly contacting control to advise them of their decision to execute a missed approach, they did so on the back of another communication from the control services, informing them that they would receive a late clearance to land.

They received the warning that they had a problem with the secondary flight control configuration at 6:30:53 h, and control’s late-clearance message (during which they took the opportunity to report the missed approach) came at 6:31:47 h. This means that 54 s elapsed, which should have been sufficient time for them to take the initiative and inform control that they would be executing a missed approach. They should have been the ones to inform the control services at the earliest opportunity.

Between the AIRBUS A - 300-600 crew receiving the secondary flight control configuration warning and the BOEING 737-800 crew being cleared for take-off, 40 s passed. As a result, if the AIRBUS crew had notified the missed approach immediately, the controller could have held the BOEING 737-800 aircraft and not cleared it to take off.

Regarding the performance of the control services, the controller authorised the BOEING aircraft to take off when the AIRBUS aircraft was at a distance of 2.8 NM on final.

When he detected the conflict, he made the decision to resolve it by increasing the vertical separation between the aircraft, the only other possible option being to stop the take-off of the BOEING aircraft, which was still taxiing at low speed.

This was a decision that was not his to make because it falls within the scope of the APP LECB approach controller rather than the local controller. Having authorised the BOEING 737-800 to take off, he should have transferred both aircraft as soon as possible so that APP LECB could separate them as it saw fit.

When he assumed the control of the aircraft to try to ensure their separation, his resolution of the conflict was flawed because he stopped the climb of the BOEING 737-800 aircraft immediately after take-off and instructed the crew to remain at 2,000 ft, thinking that the AIRBUS aircraft would climb to 3,000 ft and not taking into account that the procedure for that runway configuration stipulates that they should remain at 1,500 ft when executing a missed approach. Therefore, there was insufficient understanding of the visual information received, and the processing of the available information was delayed.

ENAIRE reacted proactively, accepting the fact that the training planning may be inadequate and that overly complex procedures or flawed operating procedures could have led to information not being remembered (or being misremembered) and initiating an in-depth analysis of the incident to study whether the 6 NM separation between arrivals, which has historically been considered sufficient, should be changed.
Aircraft Registration Data
Registration mark
EI-GJS
Country of Registration
Ireland
Date of Registration
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Manufacturer
THE BOEING COMPANY
Aircraft Model / Type
BOEING 737-800
ICAO Aircraft Type
B738
Year of Manufacture
Serial Number
Maximum Take off Mass (MTOM) [kg]
Engine Count
Engine
Lpplqgmked eng Subscribe to unlock
Main Owner
PkllqljdklAcggjgpflpijnhcjgnmebcinkAplA c libflhf eqmAfklmdfbfimb Subscribe to unlock
Incident Facts

Date of incident
Jun 4, 2022

Classification
Incident

Airline
Ryanair

Flight number
FR-6353

Aircraft Registration
EI-GJS

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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