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CRJ2, Menorca Spain, 2011

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Summary
On 9 April 2011, an Air Nostrum Bombardier CRJ 200 landed at Menorca in daylight and good visibility on closed runway 01L which was parallel to 01R, the one for which landing clearance had been given. The explanation given by the pilot was that the wrong runway had been programmed into the FMS. The subsequent investigation found that all aspects of the notification and implementation of the runway closure had been in order and that crew error was the only cause.
Event Details
When April 2011
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BOMBARDIER Regional Jet CRJ-200
Operator Air Nostrum
Domicile Spain
Type of Flight Public Transport (Passenger)
Origin Madrid-Barajas Airport
Actual Destination Isla de Menorca/Menorca
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Landing
LDG
Location - Airport
Airport Isla de Menorca/Menorca
General
Tag(s) Non Precision Approach
HF
Tag(s) Data use error,
Distraction,
Manual Handling,
Procedural non compliance,
Spatial Disorientation
RI
Tag(s) Wrong Runway"Wrong Runway" is not in the list (ATC error, Accepted ATC Clearance not followed, Incursion pre Take off, Incursion after Landing, Runway Crossing, Intersecting Runways, Intersecting extended centrelines, Towed aircraft involved, Near Miss, Ground Collision, ...) of allowed values for the "RI" property.
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation
Investigation Type
Type Independent

Description

On 9 April 2011, a Bombardier CRJ 200 being operated by Air Nostrum on a scheduled domestic passenger flight from Madrid to Menorca was inadvertently landed at destination on closed runway 01L instead of the parallel runway 01R for which landing clearance had been given and acknowledged. Maintenance activity was under way but the personnel involved, who only became aware of the approaching aircraft at the last moment, were not affected. The paved surface used was clear of obstructions, the landing performed was normal and the aircraft was undamaged.

Investigation

An Investigation was carried out by the CIAAIC. It was noted that both pilots were experienced overall and on the aircraft type involved. It was found that all aspects of the notification and implementation of the runway closure had been in order, including the presence of 10 white painted ‘X’ marks to the prescribed specification on the paved surface.

The closed runway on which the landing had been made was found to have been out of use since 10 February for major maintenance. On the day of the occurrence, it was almost ready for return to service which was at that time scheduled for four days later. It was noted that the view from the VCR did not permit a controller to readily distinguish between the closely spaced approach tracks to runways 01L and 01R. It was also noted that the main runway at the airport was 01L, with 01R only being used in the event that 01L was not available. There was no Instrument Landing System (ILS) facility transmitting for runway 01L

The Automatic Terminal Information Service (ATIS) received by the flight crew had advised CAVOK conditions with very light winds and runway 19L in use but when the crew requested a landing in the opposite direction to shorten the approach, ATC agreed that once the aerodrome was in sight, visual positioning to that effect would be approved and this had subsequently occurred.

At the time of the unauthorised landing, there were two workers installing runway edge lights, as well as a vehicle alongside the runway. They were not affected – although neither worker was aware of the approaching aircraft until the last moment because they were facing in the opposite direction and used to aircraft noise arising from use of the adjacent runway.

The flight crew advised having had no awareness of their error until they found that the exits from the runway which they had used were all blocked by barriers. They stated that they had not seen any of the 10 white ‘X’ markings on the runway and confirmed that they attributed their error to entering runway 01L into the FMS and then following that guidance to the closed runway.

The formal statement of Causes by the Investigation was that:

“The incident resulted from the crew’s entering of the data for the closed runway, 01L, into the FMS computer by mistake, despite having information in the flight dispatch documentation warning that the runway normally in use was closed. The aircraft was guided to runway 01L and the crew, not noticing the runway-closed markings, landed on it.”

One Safety Recommendation was issued as a result of the Investigation as follows:

  • that Air Nostrum enhance its procedures for handling those circumstances in which the airports where it normally operates are in unusual configurations. [REC 19/12]

The Final Report IN-010/2011 was approved on 25 July 2012 and an English language version subsequently made available.

Further Reading