B738 / B738, Malaga Spain, 2019
B738 / B738, Malaga Spain, 2019
Summary
On 11 September 2019, a Boeing 737-800 landed at night on Runway 13 at Malaga only 520 metres behind a departing Boeing 737-800 which was about to become airborne from the same runway. The Investigation noted the relatively low level of aircraft movements at the time, that both aircraft had complied with their respective clearances and that the landing aircraft crew had judged it safer to land than to commence a late go around. The conflict was attributed to non-compliance with the regulatory separation minima and deficient planning and decision making by the controller.
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
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
Take Off
Location - Airport
Airport
General
Tag(s)
Copilot less than 500 hours on Type,
CVR overwritten,
Delayed Accident/Incident Reporting
HF
Tag(s)
ATC clearance error,
Plan Continuation Bias,
Procedural non compliance
RI
Tag(s)
ATC error,
Incursion pre Take off,
Incursion after Landing
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)
Air Traffic Management
Safety Recommendation(s)
Group(s)
Air Traffic Management
Investigation Type
Type
Independent
Description
On 11 September 2019, a Boeing 737-800 (EI-DYR) being operated by Ryanair on an international passenger flight from Hamburg to Malaga as FR1458 with 185 persons on board touched down on runway 13 at destination in night VMC before a second Boeing 737-800 (EI-ENH) which was also being operated by Ryanair and on an international passenger flight from Malaga to Liverpool as FR 9893 with 196 persons on board had become airborne from the same runway. The minimum distance between the two aircraft was subsequently found to have been 520 metres.
Investigation
A Serious Incident Investigation was carried out by the Spanish Commission for the Investigation of Accidents and Incidents (CIAIAC). The elapsed time between the date of the event and the date on which it was reported to the Commission meant that it was no longer possible to retrieve relevant data from either the FDR or the CVR of either of the aircraft involved. However, relevant data was available from the QARs of both aircraft as were recordings of all relevant ATC communications with both aircraft although intercommunication between the TWR and GND controllers was conducted by word of mouth and not recorded. Aircraft relative positions during the reduced separation were retrieved from ‘SATCA’, the automated air traffic control system, which also enabled synchronisation of the QAR data from both aircraft.
The 38 year-old Captain of the departing aircraft involved had a total of 7,430 flying hours experience, all except 188 hours of which were on type and the 30 year-old First Officer had a total of 1,650 flying hours experience all except 200 hours of which were on type. The 32 year-old Captain of the arriving aircraft involved had a total of 7,218 flying hours experience which included 6,842 hours on type and the 29 year-old First Officer had a total of 1,983 flying hours including 150 hours on type. The 40 year-old TWR controller involved had “11 years experience in air traffic control” and had become qualified to operate the TWR position at Malaga four months prior to the investigated event. It was noted that he had been on duty almost 7 hours and was in his second period in the TWR controller position following just over three hours in the GND/Clearance Delivery position. The 47 year-old GND controller on duty at the time also had 11 years air traffic control experience and had been qualified to operate the TWR position at Malaga for over six years.
What Happened
A single runway, 13, was in use for both arrivals and departures with excellent in-flight and on-ground visibility within the hours of darkness. The declared capacity applicable to single runway operations at the time was 16 arrivals and 16 departures per hour and movements were confirmed to have been comfortably within that limit.
The departing aircraft was instructed by GND to taxi to “the holding point for runway 13” without specifying which one of the available runway access routes available once past position A3 (see the illustration below) to use. The crew decided to taxi to HN-3, which was noted as being the default option specified in the AIP. However it was noted that the applicable ATC procedures had required that the GND controller should only clear the aircraft to holding point A3 so as to leave the TWR controller to decide which runway access to use. It was also noted that the use of HN-3 meant that the time taken to reach the runway from a standing start at its holding point once cleared to do so would be significantly longer than the alternatives because of both the distance and the uphill slope involved.
Access alternatives to the head of Runway 13. [Reproduced from the Official Report]
The TWR controller instructed the aircraft to line up when the inbound aircraft (which the departing aircraft crew had not been informed about and were not otherwise aware of) was 3.9 nm from the threshold. The aircraft reached and stopped at the HN-3 Holding Point and after a 40 second wait, was instructed to line up and wait with the inbound aircraft 3.9nm from the runway threshold.
The position of the two aircraft at 19:52:27. [Reproduced from the Official Report]
Nineteen seconds later (19:42:46), the departing aircraft was instructed to make an immediate takeoff and by the time it had begun to taxi up HN-3 towards the runway, at 19:52:58, the inbound aircraft was 2.6 nm from the threshold.
The position of the two aircraft at 19:52:58 [Reproduced from the Official Report]
By the time the departing aircraft was “approaching the runway threshold” (19:53:29), the inbound aircraft was 1.4nm from the threshold and passing approximately 450 feet aal:
The position of the two aircraft at 19:53:29. [Reproduced from the Official Report]
Half minute a minute later (19:53:59), as the inbound aircraft was passing 150 feet agl and about to cross the runway threshold, a landing clearance was issued with the departing aircraft just 710 metres (0.4nm) ahead and accelerating through a groundspeed of 94 knots:
The position of the two aircraft at 19:53:59. [Reproduced from the Official Report]
As the inbound aircraft crossed the runway threshold at 50 feet agl 4 seconds later at 150 knots groundspeed, the departing aircraft was at 111 knots and 710 metres ahead:
The position of the two aircraft at 19:54:03. [Reproduced from the Official Report]
As the departing aircraft began to rotate, the inbound aircraft was about to touch down and as it then did so at a ground speed of 141 knots, the departing aircraft, at a ground speed of 157 knots, was not yet airborne. The minimum distance between them of 520 metres was reached at this time:
The position of the two aircraft at 19:54:15 - Minimum on-runway separation. [Reproduced from the Official Report]
The applicable Air Traffic Regulations were noted to have required that “the minimum separation should have been at least the length of the runway in use”, in this case 3200 metres (1.7 nm) so that the minimum separation which occurred was only “approximately 16% of the statutory minimum”.
It was noted that a total of 34 similar loss of separation events between an inbound and a departing aircraft had been recorded as occurring at Malaga during single runway operations since the beginning of 2019. These had included four events in which the crew of an aircraft on approach had begun a go around on their own initiative and eight events in which the distance between the aircraft arriving and the aircraft departing had been less than 1 nm, a distance equivalent to just 60% of the statutory separation requirement.
The Cause of the event was formally documented as “an aircraft was given clearance to land on a runway that was occupied by another aircraft in the process of taking off, without respecting the regulatory distances”.
Two Contributory Factors were also identified as follows:
- Deficient planning by the air traffic controller, who took advantage of a gap between two landings to authorise a take-off.
- The absence of decision-making (to cancel the take-off, for example) by the air traffic controller involved.
Two “urgent” Safety Recommendations were issued during the course of the Investigation, on 4 November 2020 and 11 November 2020 respectively as follows:
- that ENAIRE, as the provider of air navigation services, should initiate a hazard identification and risk assessment process for the recent loss-of separation events at Málaga-Costa del Sol Airport (LEMG) and coordinate with AESA (the National Safety Regulation Agency) to propose mitigation measures. [REC 18/20]
- that the AESA should review the hazard identification and risk assessment process for the recent loss-of-separation events at Málaga-Costa del Sol Airport (LEMG), as well as the proposal for mitigation measures recommended to ENAIRE in recommendation REC 18/20. [REC 19/20]
The Investigation received an initial response from ANSP ENAIRE to REC 18/20 on 11 November 2020 which was “assessed as Unsatisfactory by the CIAIAC”. This was then followed on 24 February 2021 by both a revised response from ENAIRE to REC 18/20 and a response from the AESA to REC 19/20 which were “assessed as Satisfactory” by the CIAIAC and formally closed.
The Final Report of the Investigation was approved on 24 November 2021 and published simultaneously in English translation and in the definitive Spanish language on 23 December 2021.
