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A320 / B738 Barcelona Spain, 2012

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Summary
On 27 May 2012, an Airbus A320 departing Barcelona was cleared by GND to taxi across an active runway on which a Boeing 737-800 was about to land. Whilst still moving but before entering the runway, the A320 crew, aware of the aircraft on approach, queried their crossing clearance but the instruction to stop was given too late to stop before crossing the unlit stop bar. The 737 was instructed to go around and there was no actual risk of collision. The Investigation attributed the controller error to lack of familiarisation with the routine runway configuration change in progress.
Event Details
When May 2012
Actual or Potential
Event Type
AGC, HF, RI
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft AIRBUS A-320
Operator Air France
Domicile France
Type of Flight Public Transport (Passenger)
Origin Barcelona
Intended Destination Paris/Charles de Gaulle Airport
Flight Phase Taxi
TXI
Flight Details
Aircraft BOEING 737-800
Operator Ryanair
Domicile Ireland
Type of Flight Public Transport (Passenger)
Origin Palma de Mallorca
Intended Destination Barcelona
Actual Destination Barcelona
Flight Phase Missed Approach
APR
Location - Airport
Airport Barcelona
General
Tag(s) Inadequate ATC Procedures
AGC
Tag(s) ATC Clearance Cancelled
HF
Tag(s) ATC clearance error
Ineffective Monitoring
Procedural non compliance
RI
Tag(s) ATC error
Incursion pre Take off
Runway Crossing
Change of Runway Status
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Air Traffic Management
Safety Recommendation(s)
Group(s) Air Traffic Management
Investigation Type
Type Independent

Description

On 27 May 2012, an Airbus A320 being operated by Air France on a scheduled passenger flight from Barcelona to Paris CDG was cleared to taxi across an active runway at Barcelona in front of a Boeing 737-800 being operated by Ryanair which was on a scheduled passenger flight from Palma to Barcelona and cleared to land on the same runway with normal daylight visibility prevailing. Before entering the runway, the A320 crew, aware of the aircraft on approach, had queried their crossing clearance but the ATC instruction to stop was given too late to bring the aircraft to a stop prior to the unlit stop bar. A go around was ordered by ATC and there was no actual risk of collision.

Investigation

An Investigation was carried out by the Spanish Investigation Agency CIAIAC. It was established that a routine scheduled change of runway configuration was about to take place and the final aircraft movements on the outgoing configuration, including the 737 involved, had been decided and were known to the executive controllers on duty in both TWR and GND positions.

However, it was established that the ground controller had nevertheless cleared the departing A320 to taxi (see the diagram below) from its parking stand 13 to the holding point for departure runway 25L via taxiway ‘K’. The stop bar at K7 was explicitly included in the runway crossing involved which, since under local regulations GND controllers may only issue runway crossing clearances when a runway is inactive, tended, in the absence of contrary evidence and the fact that he had then switched the stop bar lighting a K7 off, to confirm that at the time of issuing the taxi clearance, he had forgotten the earlier briefing on the runway reconfiguration.

His adjacent colleague at the TWR position, unaware of his action, had then cleared the 737 to land on the still-active runway 02. Having then subsequently observed the imminent runway incursion by the A320 as it approached K7, he had instructed the GND controller to stop the aircraft. When this action was not taken quickly enough to enable the A320 to stop before crossing K7, the TWR controller told him to allow the A320 to continue taxiing and instructed the 737, by now at 400 feet aal, to make a go around. The Investigation found that the 737 had reached a minimum height of 300 feet as the go around was initiated and that the A320 had been stationary for 12 seconds before being re-cleared to continue across runway 02.

The taxi-out route taken by the Air France A320 in relation to the GND controller’s area of responsibility in day (WRL) runway configuration and the locations of lit stop bars during both day (WRL) and night (ENR) runway configuration.

The Investigation was informed that the A320 First Officer had observed the approaching 737 visually and both pilots had noted a corresponding return in their TCAS display at an initially-observed indicated height of 1200 feet above. They reported that this had prompted them to reduce taxiing speed slightly and seek confirmation of their crossing clearance from ATC. This was done using the call “(callsign) we cross” which was made when the aircraft was still some 50 metres from the unlit K7 stop bar in what was characterised from the recorded transmission as a hesitant tone. However, the GND controller had first replied to another aircraft and it was more than 25 seconds later, just after the K7 stop bar had been crossed, before the A320 was told to ‘hold position’ and did so briefly until the clearance to continue was received a few seconds later.

It was noted that the applicable Air France procedure stated that if doubt should arise during taxiing “the taxi must be interrupted and the position/clearance must be verified”. It was also noted that Air France aircraft are equipped with a RAAS (Runway Awareness Advisory System) that provides warnings about any imminent runway entry but that no mention of its activation was reported by the A320 pilots.

The GND controller’s actions in respect of the crossing of an inactive runway prior to recognising his error was noted to have been in accordance with the applicable procedure. It was noted that although he was an experienced controller with supervisory experience elsewhere, he had only completed unit validation for Barcelona relatively recently and had not had any previous operational experience of the runway configuration or received any classroom briefing on it. He had commenced his night shift one hour prior to the scheduled changeover from the standard ‘day’ runway configuration to the standard ‘night’ runway configuration - although another configuration had been used during the ‘night’ period before the ‘night standard’ with 02 as the landing runway had been restored.

In respect of controller validation training, the Investigation noted that “the training plan does not specify that the controller must receive on-the-job training on each of the airport’s operational configurations, or even on the preferred ones” and that “changes in configuration are covered on a theoretical level but the plan does not explicitly require a minimum amount of practical training on this aspect”. In respect of minimum experience on different runway configurations, it was noted that the Competence Scheme in place at the time of the event was “intended to ensure that the controller maintains the operational skills associated with the ratings and unit endorsements he possesses.” This was facilitated by the requirement that “a controller must be on duty for 80 hours a year as an executive controller in order to maintain his unit endorsements” and must complete one watch every six months at every post. However, it was noted that “this scheme does not require a minimum number of hours for each operational or preferred configuration.….or a minimum on-duty period during (runway) configuration changes".

It was concluded that, as noted in both the ICAO Doc 9870 Manual on the Prevention of Runway Incursions and the European Action Plan for the Prevention of Runway Incursions, the circumstances of the investigated event “once more underscore the importance of clarity, brevity and discipline in communications, deficiencies in which are present as contributing factors in a large number of runway incursion events.”

The formal statement of the Investigation in respect of the Causes of the Incident concluded that it occurred as a result of the A320 aircraft entering the runway after being cleared to do so by the ground controller, who did not coordinate this activity with the local controller responsible for giving clearance for landings and crossings of the runway, which was still active pending completion of the configuration change. The controller’s unfamiliarity with the conditions on that day, due to not having received practical training on that configuration, affected his handling of the situation and caused him to act in keeping with the configuration most familiar to him, one in which runway 02 is not used for landings, especially during a time period with few arriving aircraft.

Two Safety Recommendations were issued as a result of the Investigation:

  • that AENA modify the Training Plan for the Barcelona Tower so as to guarantee that a minimum amount of time is spent during the practical training periods in each and all of the preferred airport configurations as well as in changing configurations, before a controller receives the unit endorsement. [REC 29/13]
  • that AENA modify the Barcelona Tower Competence Scheme so as to guarantee that a minimum amount of on-duty time is spent in each of the preferred airport configurations, as well as in changing configurations as a requirement for tower controllers to maintain their operational proficiency. [REC 30/13]

The Final Report was approved on 26 June 2013.


Further Reading