DH8D / B735, Exeter UK, 2009
DH8D / B735, Exeter UK, 2009
Summary
On 30 October 2009, a Bombardier DHC8-400 departing Exeter at night failed to stop as cleared at the runway 08 holding point and continued onto the runway on which a Boeing 737-500 had just touched down on in the opposite direction. The Investigation attributed the DHC8-400 crew error to distraction arising from failure to follows SOPs and poor monitoring of the Captain taxiing the aircraft by the First Officer. The failure of the DHC8 crew to immediately report the occurrence to Flybe, which had resulted in non-availability of relevant CVR data to the Investigation was also noted.
Event Details
When
30/10/2009
Day/Night
Night
Flight Conditions
On Ground - Low Visibility
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Taxi
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Non Revenue)
Intended Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Landing
Location
Location - Airport
Airport
General
Tag(s)
Aircraft-aircraft near miss,
Event reporting non compliant,
CVR overwritten,
Delayed Accident/Incident Reporting
AGC
Tag(s)
Read Back Clearance not followed
HF
Tag(s)
Distraction,
Ineffective Monitoring,
Procedural non compliance,
Violation,
Ineffective Monitoring - PIC as PF
RI
Tag(s)
Accepted ATC Clearance not followed,
Incursion pre Take off,
Near Miss
Outcome
Damage or injury
Yes
Non-aircraft damage
Yes
Non-occupant Casualties
No
Off Airport Landing
Yes
Ditching
Yes
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. However, the crew had 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 Runway Visual Range (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 Cockpit Voice Recorder (CVR) had been overwritten.
The Final Report of the Investigation was published on 11 November 2010. No Safety Recommendations were made.
