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AT45 / B733, Munich Germany, 2004

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Summary
During the hours of darkness at Munich on 3 May 2004, an ATR42-500 was given a conditional line up clearance for Runway 08R but contrary to this clearance then taxied onto that runway as a Boeing 737-300 was landing on it. The landing aircraft missed the right wingtip of the ATR-42, which continued taxing onto the runway as it approached, by “a few metres”.
Event Details
When May 2004
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft ATR ATR-42-500
Operator Not Recorded
Type of Flight Public Transport (Passenger)
Origin Munich Airport
Intended Destination Verona Villafranca Airport
Take off Commenced No
Flight Airborne Yes
Flight Completed Yes
Flight Phase Taxi
TXI
Flight Details
Aircraft BOEING 737-300
Operator Not Recorded
Type of Flight Public Transport (Passenger)
Origin Amsterdam Airport Schiphol
Intended Destination Munich Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Landing
LDG
Location - Airport
Airport Munich Airport
General
Tag(s) Aircraft-aircraft near miss,
Inadequate ATC Procedures
HF
Tag(s) Distraction,
Ineffective Monitoring
RI
Tag(s) Accepted ATC Clearance not followed,
Incursion pre Take off,
Near Miss
Safety Net Mitigations
Malfunction of Relevant Safety Net Yes
A-SMGCS Available but ineffective
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation,
Air Traffic Management
Safety Recommendation(s)
Group(s) Air Traffic Management
Investigation Type
Type Independent

Description

During the hours of darkness at Munich on 3 May 2004, an ATR42-500 was given a conditional line up clearance for Runway 08R but contrary to this clearance then taxied onto that runway as a Boeing 737-300 was landing on it. The landing aircraft missed the right wingtip of the ATR-42, which continued taxing onto the runway as it approached, by “a few metres”.

The Investigation

The BFU Germany carried out an Annex 13 Investigation which found that "This Serious Incident had the following causes:

Immediate Causes:

  • Communications were unclear between the AT45 and Tower with respect to the issue of and application of a conditional clearance.
  • The AT45 taxied onto Runway 08R, for which a landing clearance had been given to another aircraft.
  • The AT45 crew had a restricted view of the final approach to Runway 08R
  • The Runway Incursion Monitoring (RIM) alarm function forming part of the Airport Surface Movement (ASRM) had been de-activated.

Systemic Causes:

  • The standard operational procedures for issuing clearances were not comprehensive or precise.
  • The fast exit taxiway B4 from Runway 26 L was used as a departure access taxiway for Runway 08R, together with issue of a conditional clearance.
  • The Runway Incursion Monitoring (RIM) function, intended to trigger a warning on the Air Traffic Control’s display, was unreliable and faulty."

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Further Reading