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PRM1/CRJ2, Nice France, 2012

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Summary
On 29 March 2010, a Raytheon 390 operating a passenger charter flight failed to follow acknowledged taxi instructions in normal visibility at night and entered the departure runway at an intermediate intersection and turned to backtrack against an opposite direction CRJ200 which had just started its take off roll. There was no ATC intervention but the CRJ crew saw the aircraft ahead and were able to stop before reaching it. The Raytheon flight crew stated that they had “encountered considerable difficulties finding out where they were while taxiing” and ended up on the departure runway “without realising it”.
Event Details
When March 2012
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft RAYTHEON 390 Premier 1
Operator The World is Yours
Domicile United Kingdom
Type of Flight Public Transport (Passenger)
Origin Nice-Côte d'Azur Airport
Take off Commenced No
Flight Airborne No
Flight Completed Yes
Flight Phase Taxi
TXI
Flight Details
Aircraft BOMBARDIER Regional Jet CRJ-200
Operator Air Nostrum
Domicile Spain
Type of Flight Public Transport (Passenger)
Origin Nice-Côte d'Azur Airport
Intended Destination Barcelona/El Prat Airport
Take off Commenced Yes
Flight Airborne No
Flight Completed Yes
Flight Phase Take Off
TOF
Location - Airport
Airport Nice-Côte d'Azur Airport
General
Tag(s) Inadequate ATC Procedures,
Airport Layout
HF
Tag(s) Distraction,
Ineffective Monitoring,
Spatial Disorientation
RI
Tag(s) Accepted ATC Clearance not followed,
Incursion pre Take off,
Visual Response to Conflict
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

On 29 March 2010, a Raytheon 390 Premier 1A (M-FROG) being operated by a small charter business called The World is Yours failed to taxi for a night departure in normal ground visibility in accordance with its clearance. It entered the departure runway 04R ahead of a Bombardier CRJ200 (EC-HHV) being operated by Air Nostrum for Iberia on a scheduled passenger flight from Nice to Barcelona which had just begun its take off roll. The CRJ crew saw the other aircraft and rejected their take off from a low speed, coming to a stop before reaching it.

Investigation

An Investigation was carried out by the French Bureau d'Enquêtes et d'Analyses (BEA). It was established that the routes which had been followed by both the aircraft involved were as shown on the annotated aerodrome chart below:

The taxi routes followed by the two aircraft involved (reproduced from the Official Report)

It was established that the Raytheon crew had correctly read back their taxi clearance from their parking position to the holding point for a full length departure on runway 04R but it appeared that they had then become confused at the point where the taxiway centreline on taxiway ‘A2’ indicates two almost simultaneous right turn options, first onto taxiway ‘V’ (not in use and with the centreline unlit) and then onto taxiway ‘W’ (as cleared and with the centreline lit). The centreline lighting leading ahead onto taxiway ‘A3’ was also lit and the aircraft followed that line instead of the right turn into ‘W’ and then continued on ‘A3’ past the co located flashing Runway Guard Lights, marked runway entry Cat 1 holding point and its four embedded and flashing lights and the painted words ‘Runway Ahead’ and onto the runway where they turned right in the apparent belief that they were joining taxiway ‘W’. The crew reported that they “failed to notice that they had passed the holding point ‘A3’ and only realised that they were on the runway when they saw the white edge lighting”.

The Investigation found that at the time of the incident, both the AIP taxi chart (illustrated above) and the proprietary Jeppesen chart based on it failed to correctly depict the detail of the movement area layout at the junction of taxiways ‘A2’, ‘A3’, ‘V’ and ‘W’. This, and the use of lit taxiway centrelines on all taxiways available for use if so cleared (taxiway ‘V’ was not used when - as usual - landings were taking place on runway 04L) was identified as the key factor (apart from adequate crew vigilance) leading to the incursion. The actual layout at the taxiway intersections referred to above is shown below:

The actual taxiway layout at the time of the incident (reproduced from the Official Report)

The fact that, in the absence of surface movement radar and any system for detecting potential runway occupancy conflicts or a sufficient line of sight, “ATC was unable to estimate the precise position of the aircraft on the ground at that aerodrome location and was therefore unable to detect an error in the route taken” was also noted.

The formally-stated Conclusion of the Investigation was that “the incident was the result of the crossing of holding point A3 undetected by either the crew of the M-FROG or ATC”.

It was additionally concluded that whilst taxiing, the crew of M-FROG had encountered various problems which had made it difficult to locate their position, including:

  • the diagram of the junction of (taxiway A with) taxiways V and W on the aerodrome chart, which did not reflect reality
  • the lighting of taxiway A3, which probably distracted the crew’s attention
  • the extinguished lighting of taxiway V may have been responsible for the crew’s mistake while looking for the junction of taxiway W
  • the sign indicating taxiway W could not be seen clearly from the taxiway junction
  • the complexity of the area between runways 04L and 04R, which is an intersection of several taxiways and is very wide
  • the transition from the edge lighting to the reflective lighting

It was also concluded that the inability of ATC to detect the conflict and the low height of the Raytheon 390 cockpit also contributed to the incident.

Safety Action take by the Nice Airport Operator following the incident was noted as follows:

  • The Holding Point ‘A3’ has been designated as a Hot Spot - the first such designation in respect of runway 04R
  • The centreline lighting along taxiway ‘A3’ has been concealed and the use of this connecting taxiway has been prohibited at night.

Two Safety Recommendations were made as a result of the Investigation as follows:

  • that the DGAC should install equipment allowing ATC to detect and be alerted to the risk of a collision on the ground and in particular of a runway incursion at aerodromes with heavy traffic .
  • that the DSNA (the French State ANSP) should ensure that, at all aerodromes, the aerodrome charts precisely reflect the reality of the infrastructure.

The Final Report of the Investigation was issued in a French language version only in May 2011 and is also available here on SKYbrary in an unofficial English language translation.


Further Reading