Dolomiti E195 at Brussels on Oct 5th 2016, departed without clearance forcing a go around on crossing runway

Last Update: March 30, 2017 / 18:25:19 GMT/Zulu time

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Photo of Air Dolomiti I-ADJO, Embraer ERJ-195 — Air Dolomiti I-ADJO, Embraer ERJ-195 (Photo credit: Paolins92 / Flickr / License: CC by)

Incident Facts

Date of incident
Oct 5, 2016

Classification
Incident

Airline
Air Dolomiti

Flight number
LH-2293

Departure
Brussels, Belgium

Destination
Munich, Germany

Aircraft Registration
I-ADJO

Aircraft Type
Embraer ERJ-195

ICAO Type Designator
E195

An Air Dolomiti Embraer ERJ-195 on behalf of Lufthansa, registration I-ADJO performing flight LH-2293 from Brussels (Belgium) to Munich (Germany) with 62 passengers and 5 crew, was cleared to line up runway 07R and wait, however, commenced their takeoff roll.

An Aer Lingus Airbus A320-200, registration EI-EZW performing flight EI-638 from Dublin (Ireland) to Brussels (Belgium) with 156 passengers and 6 crew, was on very short final to Brussels' runway 01 below 250 feet AGL when tower - with raised voice - instructed the aircraft to go around as result of the unexpected takeoff by LH-2293. The aircraft positioned for another approach and landed safely about 11 minutes after the go-around.

The Embraer crew got to hear that they had no takeoff clearance, but were now permitted to continue takeoff. The crew apologized after the aircraft had become airborne. The aircraft continued to destination for a safe landing.

On Oct 20th 2016 Belgium's AIB reported that the occurrence was rated a serious incident and is being investigated.

On Mar 30th 2017 Belgium's AIB released their final report concluding the probable cause of the serious incident (Class A) was:

The incident was caused by the take-off without clearance of an aircraft instructed to “line up and wait” on Runway 07R while an aircraft was in final approach of Runway 01.

Contributing factors

- Not using a mnemonic and/or cross-check for the take-off clearance by the DLH4TX crew.
- Limited traffic information/situational awareness given when delivering ATC clearances.
- Inadequate doubt-clearing management in the cockpit.
- The unfamiliarity of the crew with the airport.
- Authorizing aircraft to line up on RWY 07R at a short distance from the intersection with RWY 01 without correlation with landing traffic on this latter.
- Intersection and status of RWY 01 not indicated on RWY 07R.
- The complex taxiway layout (junction connecting 6 taxiways right before C6, the oblique angled entry taxiway including a part of the taxiway centerline lights).

The AIB reported that as soon as tower, who maintained good visual contact with the E195 due the close proximity to runway 01 and the short reaction times, noticed the E195 started moving he instructed the A320 to go around just as the A320 crew also having noticed the E195 moving was about to call tower.

The AIB reported the tower controlled was shocked by the occurrence and needed to be replaced for the remainder of his shift.

The AIB analysed human factors:

The DLH4TX crew received an instruction from ATC, read it back correctly, but eventually did not follow it.

We can compare this phenomenon with other human failures, such as passing a red light when driving the car without realizing. The frequency of this kind of human failure has been estimated for the rail sector (Buizingen railway accident report), specifically for the violation of red signals by train drivers. This estimation shows a failure rate of 10-5 for adequately selected and trained personnel.

This figure is of the same magnitude as the rate of take-offs initiated without clearance at EBBR (2 events for 230000 registered movements per year).