Created Friday, Jan 13th 2023 11:25Z, last updated Friday, Apr 5th 2024 19:11Z
An Easyjet Europe Airbus A320-200, registration OE-INE performing flight
U2-8013 from London Gatwick,EN (UK) to Bordeaux (France), was cleared to land on Bordeaux's runway 23. Immediately after receiving and reading back the landing clearance the pilot of another private aircraft waiting in position for takeoff radioed the tower, tower in turn instructed the A320 to go around. The aircraft went around from low height (about 400 feet AGL), positioned for another approach to runway 23 and landed safely about 15 minutes after the go around.
The French BEA reported following the takeoff of an Airbus A321 tower cleared the private aircraft to line up runway 23 and wait. While the aircraft was waiting in position, tower cleared the Easyjet A320 to land on runway 23. The private pilot radioed tower, who instructed the A320 to go around. The occurrence was rated a serious incident and is being investigated.
On Dec 19th 2023 the BEA released their final report in French (the English version to be released in due time) concluding the probable causes of the serious incident were:
- the reduction in the number of staff present, which was significantly lower than the number provided for in the duty roster, leading to an unplanned grouping in the MANEX of positions of a very different nature (SOL and LOC on the one hand, APP and SIV on the other) and thus a high workload for the controller who was simultaneously in charge of these four positions; this situation may have contributed to the DR400's strip not being positioned on the "runway" band of its strip board;
- low contrast between the DR400 and the runway surface at the threshold, making it more difficult for the controller to see the DR400 from the tower, and for the A320 crew to see it;
- the lack of supervision of activities within the control tower by the tower manager, who was himself involved in the LOC assistant function;
- a probably insufficient awareness of the risk generated by an insufficient number of controllers present at their place of work, particularly in the event of an unforeseen increase in traffic or to ensure relief in the event of a safety event.
The following factors may have contributed to the unplanned grouping together of positions of very different types, and to the inadequate arming of control positions:
- the practice of tower managers of reducing the number of staff actually present compared with the number provided for in the duty roster, a practice known and implicitly tolerated by management;
- the absence of a tool to reliably, automatically and in real time collect the number of controllers present at work and the number of positions manned, and to analyze the potential contribution of these two factors in the event of a security incident. These analyses would enable tower managers and supervisors to assess, on an objective basis, the real needs in terms of the number of staff present and the arming of control positions, depending on the levels and types of airborne activity forecast or observed.
The following may have contributed to maintaining a high level of risk after the serious incident:
- the tower manager's planning of a lower staffing level than that provided for in the duty roster, which did not allow for relief or reinforcements in the short term;
- the failure to question the planned organization, despite the serious incident.
The DR400 pilot's situational awareness and proactivity in reporting while the A320 was on short final prevented the serious incident from developing into an accident.
On Apr 5th 2024 the BEA released their English final report concluding:
The following factors may have contributed to the controller giving a clearance to land on an occupied runway:
- the reduction in the number of staff present, which was notably lower than the number programmed on the duty roster, leading to the combination of positions of a very different nature (GND and TWR compared to APP and INFO) not provided for in the OM and thus a high workload for the controller who was simultaneously in charge of these four positions; this situation may have contributed to the strip for the DR400 not being positioned on the "runway" band of the strip board;
- the poor contrast between the DR400 and the runway surface at the runway threshold, making it more difficult for both the controller in the tower and the A320 crew to see the DR400;
- the absence of supervision of the activities within the control tower by the tower supervisor, who was himself carrying out the TWR assistant duties;
- a probably insufficient awareness of the risk generated by an insufficient number of controllers present at their place of work, particularly in the case of an unforeseen increase in traffic or a controller having to be relieved in the case of a safety event.
The following factors may have contributed to the combination of positions of a very different nature not provided for in the OM, and to the insufficient manning of control positions:
- the practice of tower supervisors of reducing the number of staff actually present compared with the staff programmed on the duty roster, a practice which the management know of and implicitly tolerate;
- the absence of a tool to collect, reliably and automatically, and in real time, the manning of the control positions and the number of controllers present at the workplace, and to analyse the potential contribution of these two factors in the case of a safety event. These analyses would enable tower supervisors and management to assess on an objective basis, the real needs in terms of the number of staff to be present and the manning of control positions according to the levels and types of air traffic activity forecast or observed.
The following factors may have contributed to a high risk level being maintained after the serious incident:
- the tower supervisor planning for a lower number of staff than that programmed on the duty roster, which did not allow for relief or reinforcements in the short term;
- the failure to question the planned organisation, despite the serious incident which had occurred.
The situational awareness and proactivity of the pilot of the DR400, who reported his presence at the runway threshold when the A320 was on short final, prevented the serious incident from developing into an accident.
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