Ryanair B38M and Malta Air B738 at Las Palmas on Oct 12th 2024, loss of separation on runway
Last Update: May 24, 2025 / 09:33:43 GMT/Zulu time
Incident Facts
Date of incident
Oct 12, 2024
Classification
Incident
Airline
Ryanair
Flight number
FR-2296
Departure
Las Palmas, Spain
Destination
Palma de Mallorca, Spain
Aircraft Registration
EI-IFS
Aircraft Type
Boeing 737-800MAX
ICAO Type Designator
B38M
Airport ICAO Code
GCLP
A Malta Air Boeing 737-800 on behalf of Ryanair, registration 9H-QBL performing flight FR-5822 from Rome Fiumicino (Italy) to Las Palmas,CI (Spain) with 171 passengers and 6 crew, was on final approach to runway 03R descending through about 250 feet AGL when the crew initiated a go around, the departing aircraft was still in the departure roll about 1/3 down the runway at that time.
According to ADS-B data transmitted by both aircraft FR-5822 was about 0.98nm behind FR-2296 when FR-2296 climbed through the altitude of FR-5822 at about 500 feet MSL.
Spain's CIAIAC opened an investigation into the occurrence.
On Oct 25th 2024 the CIAIAC reported EI-IFS had been cleared for takeoff, when 9H-QBL was 3nm before the runway threshold. EI-IFS began their takeoff roll when 9H-QBL was descending through 350 feet AGL. The CIAIAC continued: "The crews of both planes tried to contact the control tower, but received no response at first and had to communicate with each other. Both then contacted the approach frequency (124.300 MHz). Approach instructed the crew of the aircraft registered 9H-QLB to climb to 3,000 ft and subsequently gave them vectors to land. At the same time, they authorized the crew of the aircraft registered EI-IFS to continue the climb to 10,000 ft and continue on their planned route. The tower subsequently contacted both aircraft and informed them that there had been a communications failure."
On May 23rd 2025 the CIAIAC released their final report concluding the probable causes of the probable causes of the incident were:
The investigation has determined that the loss of separation occurred as a result of authorising a take-off when there was another aircraft on final with insufficient space between the two aircraft.
The crews of the two aircraft involved not receiving to the instructions given to them from the control tower due to the connection pins of the communications device being incorrectly connected for a certain period of time has been considered as a contributing factor, which made it impossible for the messages issued from the tower to be transmitted outside.
The CIAIAC analysed:
Analysis of ATC management
As far as the action prior to the event was concerned, latent conditions were identified as the fact that they had just started training on that day and, on the other hand, that the instructor had been training a student who was at a more advanced stage of training over the last few weeks and did not take into account that the trainee with whom he was going to work was at a different stage, so this issue was not discussed at the briefing meeting prior to starting work.
The working conditions were those typical of a landing and take-off of two aircraft of the same model in which it must be taken into account that the trajectories will coincide with the same course for a period of time and that the aircraft taking off has to spend more time in positioning itself at a certain altitude and speed than the one on approach, the workload being at normal values.
The trainee had to make several communications with the crew of RYR2296 until they understood that they had to maintain their climb to 3,000 ft.
On the other hand, the trainee authorised RYR2296 to take off without expressly instructing it to do so immediately in the first transmission when the separation between the two aircraft was already compromised, nor did he update the position of RYR5822 on final, when at that moment it was 2.6 NM from the runway contact point.
He did give this information in a second communication, but this could not be heard by the crew because there was a simultaneous transmission from the crew of another aircraft with the call sign VLG15NL.
The authorisations given by control were conflicting and this was what caused the loss of separation between the two aircraft, as one aircraft was authorised to take off when there was another on final, which it finally decided to abort, with both aircraft flying over the runway at the same time.
In addition, the altitudes at which the aircraft were previously instructed caused a closer approach, as the aircraft that was going to land was authorised to maintain a runway heading of 2,000 ft while the aircraft that was taking off had been authorised to climb to 3,000 ft, thus producing a crossover of altitudes.
The barriers that exist in these cases that could have served as mitigation are already set out in the unit's Operations Manual.
On one hand, paragraph 5.2.2.1 states that any aircraft must be asked if it is ready for immediate departure when it is reaching or stopped at the holding point, not when it is authorised to enter and align on the runway in use, but at a distance far away from it.
On the other hand, paragraph 5.2.2.3 already establishes that an approaching aircraft (in this case the one with the call sign RYRY5822) must be informed that another aircraft was about to take off (the one with the call sign RYR2296).
Communication failure study
In regard to the second of the issues noted above, i.e. the failure of transmission, the latent conditions were noted by the the instructor himself, who said that at the start of the work there was an issue because the phone was locked and he managed to unlock it when he pressed the foot button, after several attempts.
He also commented that he was sure that it was his phone that was not plugged in properly and insisted that sometimes the phone would get stuck and that in such cases they would call the maintenance service, who would usually solve the problem by restarting the computer system. It follows from the above that there is probably either a design or manufacturing problem, or perhaps both, as it does not seem logical that there should be periodic failures in communications, when that is the essential task of the control tower workstations.
The fact that the plugs have to be plugged in every time the control station is accessed can lead to connection errors such as the one that occurred in this case. In addition, the connection point is underneath the workbench, which makes it difficult to visually check whether the plugs are connected correctly.
On the other hand, the use of the classic telephone forces you to keep your hands busy to use it, it is not very ergonomic from the point of view of operation.
As it can also be operated using headphones and a footswitch to broadcast, and there is even the possibility of using both systems at the same time, depending on the controller's preference, this makes it more difficult to detect a failure, as in this case, and to think quickly about a single solution.
The instructor himself acknowledged that he may have been influenced by the fact that there was a communications failure at the beginning and trying to fix it may have taken him out of his routine and that may have been the reason why he omitted the headset test as he always does.
In its internal investigation, ENAIRE recommended that Tower Management analyse the advantages and disadvantages of using the telephone as a transmission channel, especially during training and when there is heavy traffic, given that the telephone has an omnidirectional microphone that picks up background noise, which can make the reception of communications more complicated, precisely at times when there is already more noise in the cockpit, which is during take-off and landing.
It also recommended that the condition of these phones be checked, as it had been noticed that some had more background noise than others.
However, beyond these two measures, it seems reasonable to think that ENAIRE should study whether the design of the communication elements used in airport towers and the way they are operated could favour the commission of errors.
In regard to what the working situation was, i.e. the conditions that could lead to errors or noncompliance The instructor thought that the transmission failure had lasted about 1:30 minutes, when in fact it was more than twice as long.
He was aware that a loss of separation could occur and therefore took the communications late, but he was not aware of the transmission error at any time. That is why he did not try to transmit from the position of the instructor and missed the indication on the CVS screen.
The supervisor also failed to detect the problem as he was busy with other tasks.
On the other hand, the trainee trusted the instructor and at no time thought that the transmissions were failing.
One of the preventive barriers is that the instructor should have checked the connections when the session started. This action is not included in any ENAIRE document.
For this reason, a recommendation will be issued to study the possibility of including in the controller's relief checklist, in all control units, a section which includes the obligation to check whether the communications equipment is working properly.
As a mitigation barrier after the event has occurred, in the article of the SERA Regulation, on the "Use of relay communication technique", provides guidelines to be followed in cases where communications cannot be established with an aircraft. This issue is also addressed in Annex A of the unit's Operational Manual, but none of the above measures were implemented because neither the instructor, nor the trainee, nor the supervisor were aware that communications were failing.
To mitigate the transmission failure in case they had noticed it, there were several possibilities:
1. Plug and unplug each telephone,
2. Look at the console to see if both positions are transmitting, a green light signal lights up, which means that the transmission is successful.
3. Press the floor pedal.
4. Press the button on the console.
5. Select the frequency 118.3 MHz on the multi-channel selector.
6. Have called on the emergency frequency 121.5 MHz to each of the aircraft
7. Radio check each aircraft on 118.3 MHz and 121.5 MHz from both the instructor's phone, the trainee's phone and the ITPC3 where the supervisor was placed.
On the part of the crews, none of them were initially aware that there might be a communications failure even though the tower did not respond to them and so they did not call on the emergency frequency before the loss of separation occurred.
The crews of the aircraft involved did not apply this mitigation barrier, as they did not contact on the emergency frequency. However, what they did do was to contact the respective frequencies of their assigned approach sector and in this way they managed to regain separation.
Finally, the crew of a third aircraft, not involved in the incident, the one with the call sign VLG15NL, was the one that did apply the procedure and called the tower on the emergency frequency, which alerted the controllers that there was a failure in the transmission of their communications.
Conflict resolution
The crews of the two aircraft involved adequately managed a solution to the conflict, which, being carried out without communication with the tower, occurred without the involvement of control.
The aircraft that aborted, which had the call sign RYR5822, changed course to avoid a closer approach and reported on the tower frequency the action it was taking, subsequently contacting the GCS Approach Sector, which instructed it to make a new approach.
And the aircraft with call sign RYR2296 that was taking off, also reported its intentions on the tower frequency. It then contacted Approach Sector F03 for instructions regarding the climb and continuation of the flight.
For its part, the Approach sector reacted quickly, both by giving instructions to the aircraft and also by contacting the tower supervisor by telephone to report what had happened and to coordinate the transfer of the two aircraft.
Metars:
GCLP 121000Z 15006KT 080V220 9999 FEW020 25/21 Q1017 NOSIG=
GCLP 120930Z 13003KT 060V170 9999 FEW018 25/20 Q1017 NOSIG=
GCLP 120900Z VRB02KT 9999 FEW018 24/19 Q1017 NOSIG=
GCLP 120830Z VRB02KT 9999 FEW018 23/19 Q1017 NOSIG=
GCLP 120800Z VRB01KT 9999 FEW020 22/19 Q1016 NOSIG=
GCLP 120730Z 23004KT 9999 FEW020 21/19 Q1016 NOSIG=
GCLP 120700Z 23004KT 9999 FEW020 22/19 Q1016 NOSIG=
GCLP 120630Z 25004KT 9999 FEW020 22/20 Q1016 NOSIG=
GCLP 120600Z 25008KT 9999 FEW020 22/20 Q1015 NOSIG=
GCLP 120530Z 23007KT 9999 FEW020 22/19 Q1015 NOSIG=
GCLP 120500Z 24007KT 9999 FEW020 22/20 Q1015 NOSIG=
GCLP 120430Z 23008KT 9999 FEW020 22/20 Q1015 NOSIG=
GCLP 120400Z 23006KT 9999 FEW020 22/21 Q1015 NOSIG=
Aircraft Registration Data
Incident Facts
Date of incident
Oct 12, 2024
Classification
Incident
Airline
Ryanair
Flight number
FR-2296
Departure
Las Palmas, Spain
Destination
Palma de Mallorca, Spain
Aircraft Registration
EI-IFS
Aircraft Type
Boeing 737-800MAX
ICAO Type Designator
B38M
Airport ICAO Code
GCLP
This article is published under license from Avherald.com. © of text by Avherald.com.
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