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
Event Type: 
Day/Night: 
Night
Flight Conditions: 
On Ground - Normal Visibility

18777

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

18778

Flight Details
Aircraft: 
Operator: 
Type of Flight: 
Public Transport (Passenger)
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."

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