A320 / P28A, Seville Spain, 2022

A320 / P28A, Seville Spain, 2022

Summary

On 6 October 2022, a solo student pilot departing Seville in a PA28 was instructed to hold short of the active runway on reaching it, but without the controller noticing then entered the runway. An Airbus A320 already cleared to land then called that there was a light aircraft on the runway and after initially just repeating the clearance, the controller then saw it. The context for the conflict was assessed as the controller’s use of English for PA28 communications and Spanish for A320 communications and the absence of any requirement to activate controllable stop bars in visual daylight conditions.

Event Details
When
06/10/2022
Event Type
AGC, HF, RI
Day/Night
Day
Flight Conditions
VMC
Flight Details
Operator
Type of Flight
Public Transport (Passenger)
Intended Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Phase of Flight
Missed Approach
Flight Details
Type of Flight
Public Transport (Non Revenue)
Intended Destination
Take-off Commenced
No
Flight Airborne
No
Phase of Flight
Standing
Location - Airport
Airport
General
Tag(s)
Flight Crew Training, Inadequate ATC Procedures, Ineffective Regulatory Oversight, PIC less than 500 hours in Command on Type, Deficient Pilot Knowledge
AGC
Tag(s)
Language Clarity, Multiple Language use on Frequency, Read Back Clearance not followed
HF
Tag(s)
Procedural non compliance
RI
Tag(s)
Accepted ATC Clearance not followed, Incursion pre Take off, Visual Response to Conflict
Outcome
Damage or injury
No
Non-aircraft damage
No
Non-occupant Casualties
No
Off Airport Landing
No
Ditching
No
Causal Factor Group(s)
Group(s)
Aircraft Operation
Air Traffic Management
Safety Recommendation(s)
Group(s)
None Made
Investigation Type
Type
Independent

Description

On 6 October 2022, a Piper PA28 (EC-MBV) being operated by Flight Training Europe (FTE) and being used by a student pilot for a solo training flight from Seville to Jerez as AY 164A lined up without clearance in day VMC on the runway on which an Airbus A320 (EC-MAO) on a scheduled domestic passenger flight from Tenerife North to Seville as VLG4SK had already been cleared to land. The controller remained unaware of the incursion and the A320 crew, having observed "something on the runway", self-initiated a go around and subsequently landed after the PA28 had been taxied clear of the runway.

Investigation

An Investigation was carried out by the Spanish Commission for the Investigation of Accidents and Incidents (CIAIAC) using FDR from the A320 and surveillance radar data for the airport and recorded ATC communications with both aircraft.

The 41 year-old A320 Captain had a total of 11,541 hours flying experience of which 7,801 hours were on type. He had been employed by Vueling as a Captain since 2015 after initially joining the operator as a First Officer and completing 825 hours in that rank prior to a return to the rank of Captain in which he had accumulated 2,915 hours prior to joining Vueling. His 63 year-old First Officer had a total of 11,604 hours flight experience with Vueling.

The 22 year-old PA28 student pilot was enrolled on a integrated ATPL (Air Transport Pilot Licence) course with FTE (based at Jerez) and had 91 hours flying experience of which 50 had been in command. He had only flown to Seville once before, the previous day with an Instructor. It was noted that seven weeks after the investigated event, he had been given an internal English language proficiency test by FTE and had obtained the minimum required level which corresponded to ICAO level 4 proficiency in all sections except for the one on comprehension, in which he was graded as level 3, indicating “among other shortcomings, a degree of linguistic difficulty in understanding when in unexpected situations”. The student pilot's first language was Arabic. It was noted that “current legislation does not require trainee pilots to have the operational language proficiency level (level 4) during their training process” despite the fact that their licence training will include solo flying.

The 38 year-old Seville TWR controller was appropriately licensed with unit endorsements for TWR, GND and Aerodrome Radar positions and as an OJTI and Assessor having been a controller since 2015 and based at Seville since 2016. He had come on duty as the single position controller at 1800, fifteen minutes prior to the investigated event occurring after finishing an early shift the day before at 1300. His communications with the FTE aircraft were in English and those with the Vueling aircraft were in Spanish.

What Happened

The PA28 student pilot was returning to Jerez after being authorised to fly from their flight training school at Jerez to Seville and back. On contacting ATC (in English) to obtain a taxi clearance for the flight back to Jerez, he was cleared to taxi to the HP2 holding point (see the illustration below) for a departure from runway 09 and instructed to call back when ready for takeoff. Around half a minute later, the controller was called by the inbound A320 (in Spanish) which reported on a 9 mile final and was given landing clearance. About two minutes after this exchange, when the controller had previously observed that the PA 28 had stopped at the holding point, its student pilot called to say that he was “ready for takeoff”. The controller immediately responded with “hold position” but without specifying that this was because another aircraft had been cleared to land. Despite the fact that the readback was “unintelligible”, he did not visually confirm that the PA28 did not subsequently enter the runway. 

Seville airport layout SW

The layout of the southwestern part of the airport. [Reproduced from the Official Report]

About a minute after this, a further communication from the student pilot was received and almost immediately followed by a call from the A320 crew to say that they could see a light aircraft “at the head of runway 09”.The controller responded by confirming that the A320 was cleared to land but the crew repeated that there was a light aircraft on the runway and after responding that it was a runway incursion, the controller “immediately transferred the A320 to Seville APP without prior coordination”. The crew self-initiated their go around from just below 200 feet agl and at 830 metres from the runway threshold.

The TWR controller then contacted a second Vueling aircraft - an A321 - also on approach and advised it to continue but “to expect a missed approach” due to his uncertainty as to how long it would take to get the PA28 off the runway. With the flight on about a three mile final, its crew then decided to go around and the transfer to APP was coordinated. The controller then instructed the PA28 to leave the runway via taxiway HP2 but approximately a minute later, its pilot called to say he had cleared the runway via taxiway E1. Both inbound flights later landed without further event.

Why It Happened

The performance of both the TWR controller and the student pilot were on the evidence available, contributory to the incursion, in the former case by not actively monitoring clearance compliance by the PA28. The controller stated that he had been unaware that the ‘A’ in the callsign being used by the PA28 indicated that the flight was being operated by a solo student pilot even though it was becoming apparent that the student pilot was having difficulty in communicating with the TWR. However, what was considered even more significant was the controller’s failure to use English when communicating with the inbound aircraft whilst doing so when communicating with the PA28 since this would have removed any traffic situational awareness from the student pilot.

The wider context for the incursion was identified as the fact that, whilst fully in accordance with the relevant regulations, it was permissible for a solo student pilot with seemingly marginal English language skills to be authorised by their flight training school to fly into an airport used by commercial air transport aircraft without ensuring that such an approval was conditional on prior demonstration of the equivalent of ICAO level 4 English Language competency.

The absence of any requirement to make use of the airport’s controllable stop bar system was also identified as an unfortunate missed opportunity to manage the runway incursion risk in day visual flying conditions.

The Cause of the runway incursion was determined to have been “the student pilot's failure to comply with the procedures prescribed in the SERA.

Two Contributory Factors were formally recorded as follows:

  1. The fact that the controller did not change his communications to English.
  2. That fact that the airport stop bars were not used, as the Seville control tower Operating Manual does not stipulate their use during daylight hours in flight visual meteorological conditions.

The Final Report of the Investigation was approved on 27 September 2023 but only released online simultaneously in both the definitive Spanish version and in an English translation in February 2024.

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