D328 / SB20, London City UK, 1999
D328 / SB20, London City UK, 1999
Summary
On 15 April 1999, a Dornier 328 crossed the holding point while a Saab 2000 was decelerating after landing on the same runway and the separation between the two aircraft was reduced to 10 meters as the landing aircraft passed. The runway incursion was subsequently attributed to distraction.
Event Details
When
15/04/1999
Day/Night
Day
Flight Conditions
On Ground - Normal Visibility
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Take-off Commenced
No
Flight Airborne
No
Flight Completed
No
Phase of Flight
Taxi
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
HF
Tag(s)
Distraction,
Ineffective Monitoring,
Procedural non compliance
RI
Tag(s)
Accepted ATC Clearance not followed,
Incursion pre Take off,
Incursion after Landing
Outcome
Damage or injury
Yes
Aircraft damage
None
Non-aircraft damage
Yes
Non-occupant Casualties
No
Occupant Injuries
None
Occupant Fatalities
None
Off Airport Landing
Yes
Ditching
Yes
Causal Factor Group(s)
Group(s)
Aircraft Operation
Safety Recommendation(s)
Group(s)
None Made
Investigation Type
Type
Independent
Description
On 15 April 1999, a Dornier 328 operated by ScotAirways was cleared to the holding point of RWY28 at London City. The Dornier 328 crossed the holding point while a Saab 2000 was decelerating after landing on the same runway and the separation between the two aircraft was reduced to 10 meters as the landing aircraft passed. The runway incursion was subsequently attributed to distraction.
London City, Runway 28
Synopsis
The official report on the Serious Incident produced by UK AAIB states:
"At 0702 hrs the Tower controller cleared a SAAB 2000 to land on Runway 28. The Dornier crew then requested taxi clearance and were cleared to taxi to holding point Bravo; this clearance was correctly acknowledged by the FO. At this stage there was a changeover of the Tower controller. The oncoming controller had only the two aircraft on frequency and was aware of their intentions and the clearances issued to them.
As the SAAB touched down, at 0704 hrs, the Tower controller noticed that the Dornier had crossed the holding position markings at Bravo. Just as he commenced a transmission to instruct the Dornier to stop the Dornier did so. The aircraft came to a halt with the main wheels on the lines marking the holding point. The SAAB had landed in the normal position and was now approximately 250 feet from Bravo and decelerating through about 50 kt. The SAAB passed in front of the Dornier at an estimated speed of 30 kt and cleared the runway at Alpha. It is calculated that the left wing tip of the SAAB passed 10 metres from the nose of the stationary Dornier.
There was further landing traffic on finals at 4 nm. The Tower controller instructed the Dornier 'enter to backtrack and vacate at Alpha', the FO replied 'enter and backtrack Runway 28'.
The Dornier entered the runway and started to turn right towards the threshold of Runway 28. The Tower controller immediately instructed the aircraft 'turn left, go to Alpha', he then told the Dornier to 'hold position' and instructed the landing traffic, now at 3 nm, to Go Around. The Dornier was then told to 'complete a one-eighty on the runway, come off at Alpha, return to Bravo'. The FO replied 'return to Bravo' and the aircraft then turned left and vacated the runway at Bravo. After completing a U-turn in front of Stand 1 the aircraft then repositioned correctly at the holding point at Bravo. When the next aircraft had landed the Dornier was cleared to enter Runway 28 to backtrack and line up. The aircraft was cleared for take off at 0709 hrs.
The Investigation
The UK AAIB concluded the following:
- The incident was caused when the Dornier crew, having been distracted by a flight deck warning indication, taxied their aircraft beyond the holding point to which they had been cleared. Later, some confusion occurred over the crew's misinterpretation of ATC taxi instructions which precipitated the necessity to instruct landing traffic to go-around.
No Safety Recommendations are included in the Report.
Related Articles
Further Reading
- The Final Report was published in August 1999.
