Lingus A320 at Geneva on Jul 24th 2015, took off around runway incursion
Last Update: February 12, 2020 / 12:16:11 GMT/Zulu time
Incident Facts
Date of incident
Jul 24, 2015
Classification
Incident
Airline
Aer Lingus
Flight number
EI-681
Departure
Geneva, Switzerland
Destination
Dublin, Ireland
Aircraft Registration
EI-DEF
Aircraft Type
Airbus A320
ICAO Type Designator
A320
The British Airways A320 positioned for another approach and landed safely, the Aer Lingus A320 continued to Dublin for a safe landing.
The C525 had received taxiing instruction from the General Aviation Apron to runway 05 about 5 minutes prior to the occurrence and was taxiing along taxiway Z. About one minute prior to the occurrence tower transmitted "Two Niner Mike Foxtrott Right here Contact Apron" (editorial note of Jul 28th 2015: originally understood by this editor as an instruction to N990FV to contact Apron, 29MF however referring to Swiss 29MF, LX-2973 Dash 8-400 OE-LGL having arrived from Lugano, editorial update of Feb 12th 2020: with the final report it became clear that the "right here" occurred on tower to the Dash and "here right" on ground to the Cessna, both remarks therefore occurred, the "here right" should have instructed the Cessna to turn off taxiway Z into the holding bay Z and contact tower to await further clearance to cross the runway), issued the takeoff clearance for Aer Lingus, the C525 subsequently unexpectedly crossed hold short line Z coming to a stop at the runway edge while the Aer Lingus was already in the takeoff roll.
On Jul 28th 2015 Switzerland's SUST reported the Cessna Citation C525 registration N990FV committed a runway incursion at intersection with taxiway Z while the Aer Lingus A320 was taking off. The Air Prox Occurrence is being investigated by the SUST.
On Feb 12th 2020 Switzerland's SUST released their final report reporting the minimum distance between the aircraft was 24 meters/79 feet and concluding the probable causes of the serious incident were:
The serious incident is attributable to the dangerous convergence between an Airbus A320 on its take-off roll on concrete runway 05 and a Cessna C525 which had crossed the CAT I runway holding position of taxiway Z without clearance.
Factors contributing to the runway incursion:
- lack of a hot spot indicating the danger of a concrete runway 05 incursion at taxiway Z;
- lack of situational awareness of the flight crew of N990FV;
- lack of vigilance of the GND controller;
- lack of a stop bar at runway holding position CAT I on taxiway Z;
- air traffic control operational procedures not adapted to the risk of a runway incursion for aircraft taxiing from the north apron.
The SUST reported the Cessna crew was preparing for departure and had requested a departure clearance, which was properly received. The ground controller then changed before the crew reported to be ready for taxi. The SUST thus wrote:
At 08:41:19 UTC, N990FV called “Geneva GND” to report that it was ready to roll. In the interval between the two calls, a new air traffic controller took over the GND workstation. He answered: "Roger, November nine nine zero Foxtrot Victor, taxi to holding bay Zulu runway zero five.” N990FV read this back in these terms: “Zulu, runway zero five, niner zero Foxtrot Victor.” The workload and complexity in the GND sector were assessed as “normal” by its controller.
The pilots of the Cessna C525 started to taxi even though they had not completed the full flight preparation; they were under time pressure because a take-off slot had been assigned to them. They thought they would be able to reach taxiway Z by the shortest route and left the stand by the left. The GND controller did not notice that they were leaving in the wrong direction. This route is a dead end and they were obliged to turn around and pass by the east of the north apron to join taxiway Y which skirts grass runway 05, the centre line of which is 252 m from that of the concrete runway.
At 08:43:26 UTC, the ADC controller made radiotelephone contact with EIN68N, an Airbus A320 which was making a flight to Dublin and which was approaching the threshold of concrete runway 05. He intended fitting it in between a Dash 8 in final approach phase and a British Airways Airbus A320 established on the ILS3, the airspeed of which he brought down to its minimum value. The flight crew of EIN68N replied that they were ready to depart after the next landing.
The ADC controller, who was also handling the VFR traffic, then successively cleared the landings of a light aircraft on grass runway 05 and then the Dash 8 on concrete runway 05.
At 08:44:23 UTC, EIN68N was cleared to line up and prepare for an imminent takeoff after the landing of the Dash 8.
When they arrived at the end of taxiway Y, the pilots of N990FV saw, in front of them and slightly to the left, a light aircraft on final approach for grass runway 05. Its path would take it over taxiway Z which they would be using and which would give them access to the holding bay and then to concrete runway 05.
Not knowing if they were cleared without any further formalities to pass below this aircraft's path, they stopped at the “GATE Z” taxiway intersection sign and at 08:45:22 UTC reported to the GND controller that they were “holding at Z”. The latter thought this was a call from a different flight, Belavia BEL872, requested its source and obtained confirmation of the message. He replied “Roger, you may taxi into the holding bay.” Since the pilots did not seem to understand the clearance, the controller reconsidered and instructed them to let pass the traffic “on very short final for the grass”. The pilots reported that they had the traffic in sight, then entered taxiway Z located directly on their left, at a right angle.
The GND controller then replied to BEL872 which requested its departure clearance for Minsk: “Roger BEL872, expect route MOLUS 3N and I will call you back in a few minutes, unable yet to activate your flight plan.”
At 08:46:17 UTC, the ADC controller informed EIN68N that a helicopter was flying over the runway centre line from left to right then cleared it for immediate take-off at 08:46:31 UTC.
At the same time, when N990FV was approaching holding bay Z, the GND controller indicated “here right” to the crew (editorial note: to enter the holding bay and stop) and instructed them to contact the control tower on the 118.7 MHz frequency: “November nine nine zero Foxtrot Victor, here right and contact tower on one one eight decimal seven, goodbye.”
The commander replied that they were going right and read back the frequency change: “Going to right, eighteen point seven, goodbye, merci, nine zero Foxtrot Victor.” The Cessna C525, however, continued straight ahead at an average speed of 12 kt. It crossed the CAT I Z runway holding position markings4 at 08:46:56 UTC and approached concrete runway 05. The copilot, who was busy carrying out tasks in the cockpit, was not looking outside.
At 08:46:59 UTC, the RIMCAS5 safety net reported a critical convergence on the runway, generating the aural warning “RIMCAS” and illuminating the radar labels of N990FV and EIN68N in red on the screens of the SAMAX runway monitoring system. The latter was then approximately 670 m from the intersection of taxiway Z with concrete runway 05, at a speed of 77 kt. N990FV was advancing at 11 kt.
When the Cessna C525 was almost 30 m from the edge of the runway, the GND controller became aware of the runway incursion6, got up from his seat, swore and instructed it immediately to stop: “hold position here!”. The instruction given at 08:47:02 UTC overlapped the radiotelephone contact by a light aircraft which requested taxi clearance to the local aero club’s stands.
The ADC controller, who was busy with the workload and complexity of the traffic which he judged to be moderate to heavy, was not aware of the runway incursion by N990FV which, at that time, had still not contacted him. He did not hear the RIMCAS warning but, alerted by his colleague’s expressive reaction, saw the Cessna C525 approaching the edge of the concrete runway. He judged that EIN68N was moving quickly and that instructing a rejected take-off risked causing it to deviate to the left in the direction of the intruder. He consequently chose to inform it and to tell it to proceed to the right: “Shamrock six eight November, caution, ?????, proceed to the right, traffic is interfering on runway.” The message was transmitted at 08:47:05 UTC when the speeds of EIN68N and N990FV were 106 kt and 9kt respectively.
The commander of N990FV saw on his right, on concrete runway 05, the Airbus A320 on its take-off roll, braked hard and immobilised his aircraft.
EIN68N immediately acknowledged receipt of the warning and at the same time N990FV called ADC control, causing garbling.
The commander of EIN68N had already seen and reported to the copilot the aircraft on taxiway Z which was advancing slowly and which seemed to him not yet to have crossed the markings located before the edge of the runway. When he carried out a very slight evasive manoeuvre to the right, it appeared clear to him that the conflicting aircraft had stopped before the runway. He nevertheless scheduled a rejected take-off but considered that this manoeuvre was likely to cause handling difficulties. The Airbus A320 took off normally, positioned on the centre line of runway 05.
At 08:47:10 UTC the aural “RIMCAS” warning ended.
At 08:47:11 UTC the Airbus crossed taxiway Z and the tip of its left wing passed approximately 24 m from the nose of the Cessna C525.
At 08:47:25 UTC, the ADC controller instructed the British Airways A320 Airbus which was on final approach approximately 0.5 NM from the runway threshold to go around.
The SUST sumarized the testimony of the Cessna Crew:
For the purpose of the investigation, the commander and the copilot of N990FV were interviewed by the investigation bureau of the United States National Transportation Safety Board - NTSB.
The two pilots stated they had difficulties in understanding the air traffic controller because of his pronounced accent in English. The commander stated on several occasions that the radiotelephone conversations were unclear; the term “holding bay” was unknown to him.
They explained that a new standard instrument departure had been assigned to them while they were taxiing. The commander stated that such a change when they were rolling close to an active area constituted by the portion of taxiway Z located below the final approach path for grass runway 05 represented a challenge.
The commander recalled that he had been cleared to cross runway 05 after he had heard the registration of the aircraft which was landing on the grass runway.
The copilot stated that at the time of the serious incident he was not looking outside because he was busy finding the new standard departure.
The commander recalled having identified runway holding position CAT I Z but did not see the Wig-Wag runway guard lights.
The SUST summarized the testimony by the Ground Controller:
The GND controller stated that pilots seldom read back clearances in their entirety and that consequently he found it normal that the flight crew of N990FV had never read back the “Holding bay Z” limit.
He recalled having heard the aural “RIMCAS” warning but it was not that which drew his attention to the runway incursion by N990FV.
He was aware of the hot spot on taxiway Z and considered that it was primarily information intended for pilots.
The SUST analysed: "The aural “RIMCAS” (runway incursion monitoring and collision avoidance system) warning signalled the runway incursion of N990FV though did not attract the attention of the GND and ADC controllers who were managing ordinary traffic situations: the RIMCAS system therefore did not play its role of a safety net."
The SUST analysed: "When taxiing to runway 05, taxiways G, Z, Y and A widen to a holding bay. To enable optimal management of the traffic flows entering the runway, the stop bars at the Cat II runway holding position markings are not permanently illuminated. On taxiway Z, access to concrete runway 05 is therefore not barred by default by the lights, the red colour of which indicates to pilots an absolute boundary which must not be crossed. The risk of a runway incursion is identified there and was, moreover, indicated in advance by a hot spot on the aerodrome charts."
The SUST analysed human factors with respect to the ground controller:
Between the moment when the taxi clearance was requested by the copilot of N990FV and the occurrence of the serious incident, several facts reveal that the vigilance of the GND controller was relaxed:
- He accepted that the readback of the taxi clearance issued to N990FV at
08:41:29 UTC did not include the clearance limit “holding bay Z”;
- He did not notice that N990FV had left its stand to the left, towards a dead end;
- He did not realise that the hesitant and somewhat imprecise phraseology of the pilots of N990FV might be a sign of a lack of familiarity with taxiing on the airport's north apron;
- He did not anticipate that the light aircraft on final approach to grass runway 05 in the direction of the hot spot mentioned in the AIP constituted a disturbing factor for the pilots of N990FV, leading them to stop at “Gate Z”;
- When N990FV was taxiing to runway holding position CAT I Z, he did not check if his approximate instruction “N990FV here right..” had been obeyed by the flight crew of N990FV.
Although this lack of attention had no consequences as long as N990FV was the only aircraft moving on the north apron, it did, however, play a significant role in the evolution of the risk of collision when the aircraft was approaching concrete runway 05 which was in operation.
The SUST analysed the human factors with respect to the tower controller:
The ADC controller became aware of the runway incursion in an unexpected way: N990FV appeared and suddenly penetrated into traffic which he was monitoring, the speed of which he knew or was aware of. When launched on its take-off roll on the ground, in these circumstances EIN68N became his basis of reference in the convergence with N990FV. The ADC controller did not have time to evaluate and integrate the speed of the latter into the evolution of the conflict. Furthermore, the control tower is located almost opposite taxiway Z, which makes it difficult to evaluate the speeds of aircraft which are moving there. At the moment when the GND controller instructed N990FV to stop on the spot, the latter was moving at 9 kt.
It was therefore obviously under the influence of surprise that the ADC controller reported the danger to the flight crew of EIN68N and spontaneously how to avoid it. At this time the intruder was slowing down at approximately 1 kt/s2, which meant that it would stop in approximately ten seconds. Strictly speaking, the initial reaction of the ADC controller should have been to instruct EIN68N to reject its take-off in order to reduce the kinetic energies in the event of a collision. However, the recording of the radiotelephone communications shows that the instruction given initially consisted of alerting EIN68N by the term "caution" and then to indicate “proceed to the right” to avoid the danger represented by the runway incursion “traffic is interfering on runway”.
In his statement, the ADC controller expressed his concern about the risk of collision which an instruction to EIN68N to reject its take-off would involve.
By indicating the danger, he in fact transferred, directly and without delaying it by an instruction, the decision to continue or reject the take-off to its commander; adding “proceed to the right" is explained by the reflex action of wishing to avoid danger to the aircraft he was controlling.
Aircraft Registration Data
Incident Facts
Date of incident
Jul 24, 2015
Classification
Incident
Airline
Aer Lingus
Flight number
EI-681
Departure
Geneva, Switzerland
Destination
Dublin, Ireland
Aircraft Registration
EI-DEF
Aircraft Type
Airbus A320
ICAO Type Designator
A320
This article is published under license from Avherald.com. © of text by Avherald.com.
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