Ryanair B738 and Jet2.com B738 at Malaga on Sep 17th 2014, loss of separation on runway and near collision after go around
Last Update: February 24, 2017 / 18:21:22 GMT/Zulu time
Incident Facts
Date of incident
Sep 17, 2014
Classification
Incident
Airline
Ryanair
Flight number
FR-2446
Departure
Leeds, United Kingdom
Destination
Malaga, Spain
Aircraft Registration
EI-EBC
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
A Jet2.com Boeing 737-800, registration G-GDFR performing flight LS-134 from Malaga,SP (Spain) to Glasgow,SC (UK) with 184 passengers and 6 crew, was departing runway 13 and was still in the departure roll when the Ryanair had almost reached the threshold of the runway prompting the crew to go around climbing out on runway heading, while the Jet2.com became airborne and also climbed out on runway heading.
Spain's CIAIAC reported on Oct 3rd 2014, that "the operations performed by each aircraft were hampered by being carried on the same runway heading" and a loss of separation occurred. The conflict was finally resolved when the Ryanair, climbing ahead of the Jet2.com, turned 90 degrees to the left and subsequently positioned for another approach to runway 13. The CIAIAC have opened an investigation into the occurrence.
The Ryanair Boeing landed safely about 18 minutes after going around, the Jet2.com Boeing continued to destination for a safe landing.
Radar data suggest the Ryanair overflew the Jet2.com aircraft with a vertical separation between 400 and 500 feet and no horizontal distance just after the Jet2.com became airborne.
In an interim statement issued on Oct 26th 2015 Spain's CIAIAC reported that both aircraft were in contact with Malaga Tower, EI-EBC was instructed to continue the approach and expect a late landing clearance while tower intended to release G-GDFR for takeoff prior to the landing. After G-GDFR was moving for takeoff landing clearance was issued to EI-EBC, however, the crew of EI-EBC had already initiated the go-around and followed the standard go-around procedure leaving no horizontal separation to the departing jet2.com aircraft. The jet2.com had been cleared to climb to 2200 feet and turn north, when the crew heard the Ryanair was to turn the same way they queried and the Ryanair Boeing was instructed to turn south. The CIAIAC concluded that it was during this phase that the separation between the aircraft eroded to 100 feet vertical and 0.5nm horizontal. The investigation has been completed and the final report is to be released in due time.
On Feb 24th 2017 Spain's CIAIAC released their final report concluding the probable cause of the serious incident was:
The incident was the result of two situations. The initial one produced by the decision to issue an aircraft a clearance to land on an occupied runway, followed by the second one during which the distance between the two aircraft jeopardized their safety. This latter situation was a consequence of the improper handling of the separation between the two aircraft (RYR57BQ and EXS21PM) by the LCL.
Contributing to the event was the fact that the departing traffic EXS21PM was taking off at a slower speed than the one expected by the controller, which evidences that the capacity of the controller to carry out his duties could have been better.
It is also considered that the procedure adopted to assess the competence of the LCL controller, due to the training processes established by the air navigation service provider during the specific training process in the unit, did not guarantee the suitability of this unit for the performance of their duties.
The CIAIAC analysed:
Aircraft RYR57BQ was in radio contact with the LCL post at the LEMG TWR, and was number two in the approach sequence to RWY 13, behind THY4EG. At the airport, EXS21PM was proceeding to the RWY 13 holding point.
At 11:17:56, the crew of EXS21PM informed the LCL they were fully ready for takeoff. LCL then cleared EXS21PM to enter runway 13 and line up. At that time the aircraft was, based on data taken from the QAR, 51 m away from the holding point on taxiway HN-1R and reducing its speed to 2.5 in the area near the holding point, before increasing its speed to 8 kt. RYR57BQ was 4.8 NM out on final and had a ground speed of 171 kt. THY4EG, which was ahead of RYR57BQ, had just landed and was still on the runway.
According to the statement made by the LEMG TWR LCL, an aircraft that is completely ready for takeoff may be issued a takeoff clearance as long as the next aircraft in the approach sequence is at least 5 NM out and traveling at 180 kt or less. In this case, RYR57BQ was within 5 NM and THY4EG had not yet cleared the runway. These measures are adopted by the controller, there being no written procedure at the unit.
At 11:18:26, after exiting the runway, THY4EG was transferred by the controller to the ground frequency, after which the controller cleared EXS21PM to take off from runway 13 at LEMG. At that time the aircraft was on taxiway HN-1R, some 73 m away from the runway threshold, while RYR57BQ was 3.6 NM out on final. EXS21PM did not stop at any time between being cleared to line up and starting its takeoff run. As it traveled on taxiway HN-1R, the aircraft was taxiing at 7 kt, slowing to a relatively slow 4 kt to turn onto the runway.
In this situation, the LCL did not instruct EXS21PM to expedite taxi, an instruction that could have been issued as per the applicable regulation, “EXPEDITE TAXI [REASON]”, and indicating that there was traffic on final approach.
The LCL also did not instruct RYR57BQ to alter its speed, which could have gained a few seconds. Such speed controls can only be used before mile 4, as per Spain’s Air Traffic Regulations.
Based on FDR data, the aircraft used taxiway HN-1R to enter the runway. The AIP states that this taxiway can only be used with permission from the GMC controller and that HN-3 is the preferred taxiway. It was not possible to determine whether such permission was given since it was not recorded on the audio tapes of the GND frequency. The aircraft’s crew acknowledged “taxi holding point 13”. In this regard, the controller indicated that holding point HN-1 is the most used by crews when another point is not given, since it is the closest to the runway. By the time EXS21PM was cleared to enter the runway and line up, it had already turned toward taxiway HN-1, though it had not reached the holding point. The aircraft was verified to have accessed the runway via HN-1R. It is not known which taxiway it was instructed to use.
At 11:19:06, the LCL notified RYR57BQ to expect a late landing clearance. At 11:19:20, EXS21PM was lined up on the runway and increasing engine thrust to start its takeoff run. RYR57BQ was 1.8 NM out on final. Until that moment the LCL could have changed the sequence by stopping EXS21PM from taking off and instructing RYR57BQ to go-around.
As EXS21PM was on its takeoff run, the LCL cleared RYR57BQ to land, but it had already started a go-around maneuver since the pilot thought that landing with EXS21PM still on the runway could compromise the operation. RYR57BQ started the go-around maneuver when it was over the runway threshold at an altitude of about 38 ft.
The crew of RYR57BQ could have requested that the clearance issued by air traffic control be amended in light of the proximity between the two aircraft. This would have helped identify the conflict a few seconds earlier.
Definitely, in the very moment that RYR57BQ was initiating a go-around maneuver, aircraft EXS21PM was still on the runway.
At 11:20:10, EXS21PM rotated and went airborne, some 1952 m away from the runway threshold. At that time, RYR57BQ was within 0.4 NM (740.8 m) of EXS21PM; that is, it had already passed the runway threshold, meaning that in case RYR57BQ had landed the minimum separation distances specified in the regulation would not have been complied with.
As the controller stated, when clearing an aircraft to land, he ensures there is 2200 m between the departing and landing aircraft and that the former is rotating. He does so by checking that the departing aircraft is past the intersection of the Firefighting Service, somewhere around G-4, and is lifting its wheels.
The QAR, FDR and radar data available show that the condition described by the controller was not met.
Finally, it is calculated that EXS21PM took 1 minute and 55 seconds from the time it was cleared to line up (it was 51 m away from the holding point), and 1 minute and 25 seconds from the time it was cleared to take off, until it rotated and became airborne. During that time, RYR57BQ traveled about 5 NM, equivalent to having an average speed of 160 kt, which is considered a normal approach speed.
Figure 12 shows the paths taken by the two aircraft, with that of RYR57BQ indicated in red and that of EXS21PM in blue. The first path diverges to the left from the runway heading and continues north. The second aircraft started to fly the assigned standard departure, which also included a turn to the right, but was disturbed by the wrong instruction given by the LCL.
The crew of RYR57BQ took their action without informing ATC of their intentions as they were focused in flying the aircraft and in maintaining the horizontal separation with the other traffic at sight, this way deviating gently leftwards of runway 13. . On the other hand, the LCL also instructed EXS21PM to turn heading north, to its left, and a new reduction in the separation was produced.
The radar data from that instant show that RYR57BQ was at 2200 ft, the altitude specified in the standard missed approach maneuver.
When the crew of EXS21PM noticed that the maneuver of RYR57BQ, and resulting from the instruction given to them by the LCL, put RYR57BQ in conflict with EXS21PM, they disengaged the autopilot and turned right to avoid the other aircraft. They then verified the direction of their turn with the LCL, who amended his instruction from turn north to turn south. At that time, the distance between the two aircraft was reduced to 0.5 NM and 100 ft.
Aircraft Registration Data
Incident Facts
Date of incident
Sep 17, 2014
Classification
Incident
Airline
Ryanair
Flight number
FR-2446
Departure
Leeds, United Kingdom
Destination
Malaga, Spain
Aircraft Registration
EI-EBC
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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