Created Friday, Feb 18th 2022 16:14Z, last updated Wednesday, Aug 17th 2022 20:08Z
An Aero Nova Embraer ERJ-195 on behalf of Air Europa, registration EC-LFZ performing flight
UX-6078 from Palma Mallorca,SP to Madrid,SP (Spain) with 64 passengers and 5 crew, landed on Madrid's runway 32R at 21:22L (20:22Z) and vacated the runway via taxiway K4 more than a minute after touchdown.
An Air Europa Boeing 737-800, registration EC-MXM performing flight UX-1026 from Paris Orly (France) to Madrid,SP (Spain) with 128 passengers and 6 crew, landed on Madrid's runway 32R at 21:23L (20:23Z) less than a minute after EC-LFZ, when EC-LFZ was still occupying the runway. The aircraft rolled out without further incident and vacated the runway also via taxiway K4.
Spain's CIAIAC reported they opened an investigation into the occurrence with both aircraft occupying the runway at the same time. The Boeing had been trailing the Embraer by 3.1nm horizontally at the time the Embraer touched down.
On Aug 17th 2022 the CIAIAC released their final report in Spanish only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Spanish only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).
The final report concludes the probable causes of the incident were:
Lack of adherence to procedures by both crews: The Embraer crew did not leave the runway via taxiway K5 as stipulated by the AIP, the Boeing crew landed without landing clearance. ATC should have prioritized his tasks better, he lacked a certain amount of pro-activity to prevent both situations from occurring: non-adherence to procedures due to not using standard phraseology.
The CIAIAC analysed that after review of the data it became clear that the Embraer had already crossed the hold short line of taxiway K4 when the Boeing touched down, the aircraft thus did not occupy the runway at the same time. It had initially looked like a runway incursion by the Boeing as they landed without having received landing clearance. However, at the time the Embraer passed the taxiway K5 - where it should have vacated the runway - the controller should have been more proactive, instructed the Embraer to hurry up, but did so only 15 seconds later and neither issued a landing clearance nor a go around instruction to the Boeing.
Had the Embraer vacated the runway at K5, the Boeing would not yet have reached the runway approach minima. The controller however, when he instructed the Embraer to hurry up 15 seconds after they had passed K5, immediately appended the instruction to the Boeing to go around without the required "BREAK! BREAK!", the last part of the transmission to the Boeing was unreadable most likely overlaid with the readback by the Embraer. Therefore it is almost certain that the Boeing crew did not hear the go around instruction.
Not hearing the go around instruction however is not a valid argument to continue the landing as no landing clearance had been issued.
The controller should have prioritized his tasks better in preventing the Embraer from rolling past taxiway K5, subsequently ensuring the Boeing crew did receive the go around instruction in addition to using the standard phraseology (Break! Break!).
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