B744 / A321, vicinity London Heathrow UK, 2000

Summary: 

On 28 April 2000, a British Airways Boeing 747-400 on go around at London Heathrow Airport, UK, had a loss of separation vertically from a British Midland A321 stationary on the runway waiting for take-off.

Event Details
When: 
28/04/2000
Event Type: 
Day/Night: 
Day
Flight Conditions: 
On Ground - Normal Visibility

18666

Flight Details
Operator: 
Type of Flight: 
Public Transport (Passenger)
Intended Destination: 
Take-off Commenced: 
Yes
Flight Airborne: 
Yes
Flight Completed: 
Yes
Phase of Flight: 
Missed Approach

18667

Flight Details
Aircraft: 
Operator: 
Type of Flight: 
Public Transport (Passenger)
Flight Origin: 
Take-off Commenced: 
No
Flight Airborne: 
No
Flight Completed: 
Yes
Phase of Flight: 
Taxi
Location
Location - Airport
Airport: 
General
Tag(s): 
Aircraft-aircraft near miss, ATC Training
HF
Tag(s): 
ATC clearance error, Data use error, Ineffective Monitoring, Procedural non compliance
LOS
Tag(s): 
Required Separation not maintained, ATC Error, 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): 
Air Traffic Management
Safety Recommendation(s)
Group(s): 
Aircraft Operation, Air Traffic Management
Investigation Type
Type: 
Independent

Description

On 28 April 2000, a British Airways Boeing 747-400 on go around at London Heathrow Airport, UK, had a loss of separation vertically from a British Midland AIRBUS A-321 stationary on the runway waiting for take-off.

Synopsis

The following is extracted from the synopsis of the official AAIB Report:

"The incident occurred at London Heathrow Airport when Runway 09R was being used for take off and Runway 09L…for landing. At the time, the ATC controller with responsibility for Runway 09R was a mentor who was supervising a trainee. There was a local procedure whereby aircraft could land on Runway 09R if traffic conditions allowed.

With one aircraft [A321]…still on the runway…[the B747] was instructed to go-around at a late stage of its approach. During this procedure, the aircraft performing the go-around descended to 118 feet…above the runway; the aircraft on the runway had a tail fin height of 38 feet 7 inches.

The investigation revealed the following causal factors:

  • The ATC mentor allowed the situation to develop to the point where …[The B747]…could not be safely integrated with the departure of…[the A321]
  • When this became apparent, the initial actions of the mentor, on taking control of the RTF, were inappropriate."

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