AT45 / B733, Munich Germany, 2004
AT45 / B733, Munich Germany, 2004
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
03/05/2004
Day/Night
Night
Flight Conditions
On Ground - Normal Visibility
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Take-off Commenced
No
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Taxi
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Landing
Location
Location - Airport
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
Outcome
Damage or injury
Yes
Non-aircraft damage
Yes
Non-occupant Casualties
No
Off Airport Landing
Yes
Ditching
Yes
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."
Related Articles
- Advanced Surface Movement Guidance and Control System
- SH33 / MD83, Paris CDG France, 2000: A very similar night occurrence at Paris CDG in 2000 in which the wingtip of a departing aircraft contacted the aircraft which had entered the runway contrary to clearance.
- Runway Incursion : Investigation Check List - Aircraft Operator
Further Reading
- For further information, see the full BFU Germany report
