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DH8D / B735, Exeter UK, 2009 (RI HF)

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Summary
On 30 October 2009, a Bombardier DHC8-400 being operated by Flybe on a scheduled passenger flight from Exeter to Edinburgh failed to follow its acknowledged ATC taxi out clearance to the runway holding point 08 and entered and lined up on the active runway at night in normal visibility at the same time as a Boeing 737-500 being operated by Astraeus Airlines on a non revenue positioning flight to Exeter, was landing on the opposite (26) direction of the same runway.
Event Details
When October 2009
Event Type HF, RI
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOMBARDIER Dash 8 Q400
Operator Flybe
Domicile United Kingdom
Type of Flight Public Transport (Passenger)
Origin Exeter
Intended Destination Edinburgh
Flight Phase Take Off
TOF
Flight Details
Aircraft BOEING 737-500
Operator Astraeus Airlines
Domicile United Kingdom
Type of Flight Public Transport (Non Revenue)
Intended Destination Exeter
Flight Phase Landing
LDG
Location - Airport
Airport Exeter
General
Tag(s) Aircraft-aircraft near miss
HF
Tag(s) Distraction
Ineffective Monitoring
Violation
Procedural non compliance
RI
Tag(s) Accepted ATC Clearance not followed
Incursion pre Take off
Incursion after Landing
Near Miss
Outcome
Damage or injury No
Aircraft damage "None" is not in the list of possible values (Minor, Major, Hull loss) for this property.
Injuries "None" is not in the list of possible values (Few occupants, Many occupants, Most or all occupants) for this property.
Fatalities "None" is not in the list of possible values (Few occupants, Many occupants, Most or all occupants) for this property.
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 30 October 2009, a Bombardier DHC8-400 being operated by Flybe on a scheduled passenger flight from Exeter to Edinburgh failed to follow its acknowledged ATC taxi out clearance to the runway holding point 08 and entered and lined up on the active runway at night in normal visibility at the same time as a Boeing 737-500 being operated by Astraeus Airlines on a non revenue positioning flight to Exeter, was landing on the opposite (26) direction of the same runway. The landing B737 was able to stop before reaching the other aircraft and clear the runway.

Investigation

An Investigation was carried out by the UK AAIB. It was established that the DHC8 had received and correctly read back taxi clearance to Holding Point A1 for a departure on Runway 08. The crew subsequently crossed Alpha One and lined up on Runway 08; as they did so, the Boeing 737 landed on Runway 26.

The relative positions of the two aircraft just prior to and during the incursion by the DHC8 are shown below.

Diagram taken from the Official Report (the Flybe DHC8 is G-JECL)

It was concluded that “the (DHC8) co-pilot was not adequately monitoring the commander” and that a concurrent discussion between the pilots about an earlier departure that day from the same airport was “likely to have conditioned (the crew) to expect the same clearance from ATC on (the incident) sector. It was also noted that the aircraft commander had asked for the ‘Line Up’ Check List despite the Taxi checklist not having been completed. It was considered by the investigation that “all of these factors (had) led the crew to become distracted enough to (exceed their taxi clearance limit)”.

It was noted by the Investigation that Exeter Airport does not have red stop bars and that UK Aerodrome Licensing requirements only specify their provision at Holding Positions intended for use in RVR conditions less than 800 m, which did not apply to A1.

It was also noted that, contrary to the requirements of the Flybe Operations Manual, the flight crew had continued to operate both the flight from Exeter to Edinburgh and the subsequent return flight to Exeter after the Incident and that a report of the event had not been filed by the crew with the Operator until the day afterwards or promptly notified by ATC to the AAIB at the time. As a result, the incident portion of the CVR had been overwritten.

The Final Report was published on 11 November 2010 and may be seen in full at SKYbray Bookshelf:AAIB Bulletin: 11/2010

No Safety Recommendations were made.

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