Bulgaria A319 at Paris on Nov 25th 2014, runway incursion

Last Update: July 23, 2019 / 18:41:09 GMT/Zulu time

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Incident Facts

Date of incident
Nov 25, 2014

Classification
Incident

Flight number
FB-431

Aircraft Registration
LZ-FBB

Aircraft Type
Airbus A319

ICAO Type Designator
A319

A Bulgaria Air Airbus A319-100, registration LZ-FBB performing flight FB-431 from Sofia (Bulgaria) to Paris Charles de Gaulle (France), had safely landed on CDG's runway 08R and was taxiing towards the apron.

A Freebird Airlines Airbus A320-200, registration TC-FBJ performing flight FH-542 from Paris Charles de Gaulle (France) to Istanbul Sabiha Gokcen (Turkey), had been cleared for takeoff from runway 08L and was accelerating for takeoff when LZ-FBB taxied past the hold short line of runway 08L. The A320 continued takeoff and the flight for a safe landing in Istanbul.

The French BEA reported in their weekly bulletin that the occurrence was rated a serious incident, the BEA have opened an investigation.

On Jul 23rd 2019 the BEA released their final report concluding the probable causes of the serious incident were:

The event took place during a period of dense inbound traffic with aircraft arriving with a reduced separation. This additional workload led the LOC controller to pay greater attention to inbound aeroplanes, probably to the detriment of those on the ground, in particular when they were no longer on the runway.

An inadequate phraseology was used to deal with the taxiing priorities between Air France flight 1089 and Bulgaria Air flight 431. The message “Bulgaria 4 3 1, number one, keep on taxiing” was not in fact accompanied by a reminder that the crew must hold short of runway 08L. This message led to an erroneous interpretation by the crew of the Bulgaria Air flight who understood it as a clearance to cross the runway.

The crew of the Air France flight had the meaning of this message clarified. The crew of the Bulgaria flight were not able to understand the exchanges in French between the controller and the crew of the Air France flight. The controller did not connect the question from the crew of the AFR1089 flight with a possible ambiguity as to the meaning of the phraseology that he had used to manage priorities.

In addition, the configuration of the Paris-CDG runways can make it difficult for crews to detect an aeroplane taking off, notably when they cross a runway. The crew of flight LZB431 thus entered runway 08L without seeing flight FHY542 taking off. The RIMCAS alarm was triggered due to the conflict. The controllers considered that it was then too late to intervene.

The BEA described the sequence of events:

At 08:18:43, the LOC controller(6) indicated to the crew of flight LZB431, which had just vacated runway 08R via taxiway V5: “Bulgaria 4 3 1, hold short of 0 8 L, holding point S 6.” The crew of flight LZB431 correctly read back.

At 08:18:51, the LOC controller cleared the crew of flight FHY542 to take off from runway 08L. Another aeroplane, AFR1089, landed on runway 08R and vacated via taxiway V6.

At 08:19:34, the LOC controller indicated to the crew of flight LZB431, “Bulgaria 4 3 1, number one, keep on taxiing.” The crew of flight LZB431 read back using the same terms as the LOC controller.

At 08:19:37, the LOC controller told the crew of flight AFR1089 to taxi behind the 319 Bulgaria on left. The crew of flight AFR1089 asked whether they were cleared to cross. The LOC controller replied no. These exchanges were carried out in French.

At 08:20:17, LZB431 entered runway 08L via S6. The RIMCAS(7) warning was triggered one second later. FHY542, performing the take-off run, was at approximately 1,500 m before the intersection with taxiway S6 and at an indicated airspeed of 139 kt.

At 08:20:37, FHY542 flew over the intersection with S6 at a height of around 500 ft. LZB431 had vacated the runway and was stopped on taxiway T9.

The BEA analysed:

The Aeronautical information service phraseology guide stipulates the followingphraseology for the air traffic controller:

ˆ- Managing priorities when taxiing: “Rapidair 3 2 4 5, give way to Citron Air coming from your right, taxi holding point runway 2 7 via B 7.”

ˆ- Holding short of a runway: “Rapidair 3 2 4 5, hold short of runway 1 8” and then crossing a runway: “Rapidair 3 2 4 5, cross runway 1 8 right.”

- Crossing a runway without holding: “Rapidair 3 2 4 5, keep taxiing, cross runway 1 8 right.”
Incident Facts

Date of incident
Nov 25, 2014

Classification
Incident

Flight number
FB-431

Aircraft Registration
LZ-FBB

Aircraft Type
Airbus A319

ICAO Type Designator
A319

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