In the past 5 years 7 aircraft took off a runway at Brussels Airport without clearance by Air Traffic Control (ATC). The last time this occurred was on 5 October 2016: an Air Dolomiti ERJ-195 took off runway 07R without clearance, an Aer Lingus Airbus A320 on short approach runway 01 was instructed to go around. A detailed report below.
SYNOPSIS
- Date and time: Wednesday 05 October 2016 at 18:41 UTC
- Aircraft: Airbus A320-214, msn 1983 and Embraer ERJ-195LR, msn 19000280
- Location: Intersection of Runway 07R and Runway 01, EBBR
- Type of flights: Commercial Aviation – Passenger
- Phase: Landing (A320) and take-off (Embraer 195)
- Destination: EBBR-Brussels (A320) and EDDM-Munich (Embraer 195)
- Persons on board: 2 pilots, 4 cabin crew, 156 passengers (A320) and 2 pilots, 3 cabin crew, 62 passengers (Embraer 195)
- Injuries: None
- Occurrence type: Runway incursion (RI)
Abstract
An aircraft of Air Dolomiti, operated on behalf of Lufthansa (flight number: DLH4TX) from Brussels to Munich, was preparing for departure from Runway 07R. The crew received the instruction “line up and wait” from the Brussels Tower. Another airplane, an A320 of Aer Lingus (flight number EIN638), was in final approach for landing on Runway 01. It was cleared for landing by the Brussels Tower. Flight DLH4TX took off from Runway 07R without take-off clearance, conflicting with the landing Aer Lingus aircraft. Brussels Tower instructed the Aer Lingus to go around.
Cause
The incident was caused by the take-off without clearance of an aircraft instructed to “line up and wait” on Runway 07R while an aircraft was in final approach of Runway 01.
Contributing factors
- Not using a mnemonic and/or cross-check for the take-off clearance by the DLH4TX crew.
- Limited traffic information/situational awareness given when delivering ATC clearances.
- Inadequate doubt-clearing management in the cockpit.
- The unfamiliarity of the crew with the airport.
- Authorizing aircraft to line up on RWY 07R at a short distance from the intersection with RWY 01 without correlation with landing traffic on this latter.
- Intersection and status of RWY 01 not indicated on RWY 07R.
- The complex taxiway layout (junction connecting 6 taxiways right before C6, the oblique angled entry taxiway including a part of the taxiway centerline lights).
History of the event
On 5 October 2016, an EMB195 aircraft of Air Dolomiti (Flight Number DLH4TX in this document), operated on behalf of Lufthansa from Brussels to Munich, was preparing for departure from Runway 07R. DLH4TX was slightly late and the crew, during push-back, requested to depart from the C5 intersection of Runway 07R. The Ground controller responded by giving a taxi route leading to the C6 intersection. The crew did not understand immediately the taxi route received due to the rapid speaking tempo and the crew requested clarification. The crew reported that the ground frequency was quite busy.
The Captain was at the controls, while the First Officer was dealing with the communication. The first officer reported high work load during taxi operations due to the “unfriendly airport lay-out” and taking into account that it was night. Both captain and first officer were listening out the same radio frequency.
Upon reaching the C6 intersection, the airplane stopped before the stop bar that was lit. After switching to the Tower frequency, the crew received the instruction “line up and wait” for Runway 07R and the first officer read back the instruction correctly. The stop bar lights dimmed, allowing the airplane to proceed.
Another airplane, an A320 operated by Aer Lingus (Flight Number EIN638 in this document), was in final approach for landing on Runway 01. It was cleared to land by Brussels Tower after DLH4TX received the instruction for lining up on the crossing runway (07R).
The DLH4TX captain reported the taxiway centreline lights were not easy to follow from the intersection during line-up. When entering Runway 07R, the captain was uncertain of their position and asked the first officer if they were on the Runway. The crew looked to the left and right and reported no traffic in sight. During the line-up, the crew stated they had an optimum visual field of Runway 01 and again did not notice any landing light in sight. Further, when aligned on Runway 07R, the captain asked the first officer whether they received the take-off clearance to which the first officer answered positively.
According to the Tower controller and the supervisor, the traffic at the moment of the incident was not dense. The Tower controller was managing the landings on the 01 as well as the take-offs on the Runway 07R.
Specifically for the line-ups from C6, the controller maintains eye contact with aircraft, because of the short reaction time necessary in case of incident. He stated his vision of the aircraft was good.
The crew of DLH4TX stated that they initiated the take-off run as soon as they were lined-up. They did not see EIN638 approaching, being concentrated on the take-off from Runway 07R in front of them.
The crew of EIN638 noticed DLH4TX starting to roll and was about to call ATC when the Tower controller, who had visual contact with both aircraft, promptly instructed EIN638 to go around. EIN638 responded immediately.
EIN638 eventually made an uneventful landing in EBBR.
After the event, the Tower controller was shocked and had to be replaced for the remainder of the shift.
Forum discussion: http://www.luchtzak.be/forums/viewtopic.php?f=7&t=61454
Read more: https://mobilit.belgium.be/sites/default/files/downloads/accidents/2016-21_final_report.pdf
