A Near Thing

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I thought this recap would be of interest.

Runway Incursion Prompts Calls For Safety Upgrades

Jul 12, 2017John Croft | Aviation Daily

 

WASHINGTON—Had the crew of an Air Dolomiti Embraer 195 waited a few seconds longer to takeoff on Runway 7R at Brussels Airport on the night of Oct. 5, 2016, the outcome of a serious runway incursion with a landing Aer LingusAirbus A320 on a crossing runway may have been far worse.

“The fact that DLH4TX [the Air Dolomiti flight] did not start the takeoff run 10-15 sec. later is just a matter of circumstances (chance),” Belgium’s Air Accident Investigation Unit (AAIU) said in the recently released final report. “Would that have been the case, then the outcome was the exposure of EIN638 [the Aer Lingus flight] to DLH4TX’s jet blast or a collision between the two aircraft.”

The Air Dolomiti crew was told by tower controllers to “line up and wait” on Brussels Runway 7R at the intersection with taxiway C6. The Aer Lingus flight was on short final to Runway 1, which intersects the Runway 7R centerline approximately 300 ft. beyond the C6 wait point. After turning on to the runway and lining up, the Air Dolomiti crew departed without a clearance to takeoff.

“The crew looked to the left and right and reported no traffic in sight,” the AAIU said. “During the lineup, the crew stated they had an optimum visual field of Runway 1 and, again, did not notice any landing light in sight. Further, when aligned on Runway 7R, the captain asked the first officer whether they received the takeoff clearance, to which the first officer answered positively.”

Once the E195 was rolling, the tower controller saw the motion and received an alert from the airport’s ground surveillance system, which monitors approximately 300 ft. on either side Runway 1’s centerline at crossing runways. “It was impossible for the tower (controller) to react fast enough in order to stop the departing aircraft before it reached the runway intersection,” the AAIU said. “However in this case, there was just enough time to instruct EIN638 to go-around, because this aircraft was still at a sufficient distance from the runway intersection.”

The Aer Lingus aircraft had also seen the E195 moving, and was about to call the controller when receiving the go-around command.

The Air Dolomiti captain and first officer were 52 and 45 years old, respectively, and highly experienced on the Embraer, with more than 4,000-hr. flight time, but were “not very” familiar with  Brussels Airport, he AAIU said. Neither was considered fatigued at the time of the incident. The AAIU faulted the Air Dolomiti crew for departing before being cleared, but noted that there were mitigating factors that, if addressed, could help avoid similar incidents in the future.

A review of similar incidents—crews taking off without a takeoff clearance—showed that Brussels Airport experiences about two such takeoffs every year. This failure rate also matches the frequency of similar events in the Belgian rail sector for red-signal violations by train drivers, according to the AAIU.

In its recommendations, the AAIU is calling on Brussels Airport to reduce the complexity of the taxi route to the incident takeoff position on Runway 7R (the Air Dolomiti crew had been confused by the taxi route), and to improve indicators that would alert crews to traffic on the intersecting runway.

The AAIU suggested that air navigation service provider Belgocontrol develop procedures to prevent controllers from issuing lineup-and-wait instructions for Runway 7R, depending on the closeness of traffic landing on Runway 1.

Separate from the recommendations, the airport asked controllers to advise crews of the nearest traffic when issuing lineup-and-wait commands, a memory item that could help crews refrain from taking off without a clearance.

The AAIU called on Air Dolomiti to modify its operations manual to state that takeoff clearance must be heard by each crew member and confirmed between them. If there are doubts, the crew must get clarification from air traffic control.

Air Dolomiti made several voluntary changes after the incident, including having its crews turn on their landing lights only after receiving takeoff clearance—a reminder to prevent taking off without a clearance.

“Air Dolomiti was using the ‘landing light’ procedure on its former fleet of aircraft, but discontinued it after the renewal of the fleet with Embraer 195 [aircraft],” the AAIU said . “Air Dolomiti wanted to streamline its procedures and stick to the aircraft manufacturer’s instructions, which did not include the ‘landing light’ procedure.”

[Moon The Loon]

Red HOLD SHORT lines in the runways similar to the taxiways, changed to green only with a takeoff clearance would be an improvement. Very expensive but one more tool in the chest of prevention of these events in the long term.

I watched a Canadian charter carrier depart Belfast one morning without a takeoff clearance. Pilots apologized after the fact. Fortunately there was no loss of separation on their departure.