Near collision at Manchester due to distracted controller

[Sgt.Peppeh]

Distracted controller RE: Manchester Airport Feb.04

"The controller stated that he had forgotten that he had given take off clearance to G-SMTJ (the Airbus) when he subsequently cleared EI-CJI (the Boeing) to cross the runway."


Only the reaction of the Air bus pilot saved the day,he aborted takeoff at just over 100MPH......Your comments please on his superb airmanship.





:cool:

[fireflybob]

Well done to the crew concerned!

Also bear in mind all the training provided by many during this pilot's career - airmanship is often taught by example.

Commiserations to the ATCO - anyone who has never made a mistake has never made anything.

Also interesting to compare this to some comments on the Manchester collision thread as to who is responsible (ultimately) for separation on the ground - I think this case proves the point!

[coopervane]

Check out http://news.bbc.co.uk/2/hi/uk_news/england/manchester/4001197.stm

My Travel A321 and Ryanair 737

Coop & Bear

Thought the Middle East was risky!!

[Scottie Dog]

The timing of the report could not have been worse, but Coopervane this refers to an event that happened a longtime ago (well it seems to be a longtime ago!!).

I think that you will find that it has already been refered to in the lengthy thread on the 'bump' last week.

[Danny]

Original thread disappeared but was resurrected here (http://www.pprune.org/forums/showthread.php?s=&threadid=121416).

This latest news is the result of the inquiry into the incident that happened last February.

[yeoman]

Slightly off thread, but would any ATCO care to comment on how much workload is created by the single access to T2 at EGCC? I have had a couple of interesting moments at the junction of Delta and November.

Whilst we're at it, anyone from MAPlc care to comment on who designed it and was it the same bloke who decided on the strength of concrete that would be required? Thought not.:E

[Co ordination unaffected]

I could let you know what allegedly distracted the atco, but i'd only be able to reveal it to the highest bidder.

[PPRuNe Dispatcher]

The AAIB bulletin is here :
http://www.dft.gov.uk/stellent/groups/dft_avsafety/documents/page/dft_avsafety_032608.hcsp

[cargo boy]

[mischief mode ON]Let's blame Ryanair anyway... ;) Additionally, the controller was aware that EI-CJI was clearing Runway_06R, was now ahead of the previously landed Boeing 737 and its operator was known to have a company culture of expeditious taxiing.A review of the location indicated that G-SMTJ would have been visible as EI-CJI approached the crossing position. Although the commander of EI-CJI considered that he had looked to his left, this was not effective. Additionally, the high ground speed (33 kt average) of EI-CJI may have made a late stop more difficult. Checks with the operating company of EI-CJI confirmed that the maximum ground speed whilst taxiing should be 30 kt. However, the flight crew had been requested to "Keep your speed up" and were complying with the ATC request. It may also be relevant that the Air 1 and Air 2 controllers were aware that the crews of the operating company of EI-CJI were expeditious on the ground.:eek: :E :ouch: [mischief mode OFF]

[coopervane]

Sorry chaps, didn't read the date on the news report/ It was reported on local radio as if it had happened yesterday. Good old media and fool me for believing it!

Coop & Bear

[Val d'Isere]

Your comments please on his superb airmanship.
Er! It's called look where yer going and stop if you see something in the way. :rolleyes:

[fmgs]

Val d'Isere:

If you had bothered to read the report, you'd find that he stopped before the 737 had entered the runway; he heard the 737 being cleared to cross 06L, and stopped. He made the decision to stop based on this, and the fact that the 737 was now moving towards the runway at some considerable speed. Had he waited until the 737 had entered the runway, things probably would have been considerably worse.

This is called excellent situational-awareness, and yes, airmanship.

Ensuring that one's brain is loaded before shooting ones mouth off is highly advisable, especially on this forum.

fireflybob:

I agree wholeheartedly about training and airmanship. The A321 Captain involved is one of the best around, a very highly respected and common-sense Training Captain. He is, and always has been, a great exponent of Airmanship.

[the grim repa]

ryanair pilots,who will be there to help you when the near miss becomes the real thing,just think of the latest collision at man.ryanair will not and that is for sure because it costs too much.
we your colleagues will be and to find out how,join the now large and ever increasing numbers of your brethern at www.repaweb.org .you will be astonished at the numbers and the amount of discussion.
remember,don't come crying after the event,have your say NOW!

[christep]

Am I alone in being quite worried about flying on an airline whose pilots have such a poor level of literacy as displayed in the preceding post?

[pprecious]

While not casting any opinions on the crew or operating company, I was wondering why the operators of EI-CJI didn't recover the CVR in the same manner as the operator of G-SMTJ, in order to assist the AAIB investigation further.

[Gonzo]

....An eloquent demonstration of the benefits of us all speaking the same language on the R/T.

[fmgs]

pprecious:

I quote from the report:

"There was no requirement for the CVR of either aircraft involved in the incident to be impounded but the CVR of G-SMTJ was recovered by the parent company and held for the AAIB. This proved useful in determining the relevant transmissions which could be heard by the crew of G-SMTJ."

As I understand it, this was a decision made jointly between the Captain and the Operators Flight Operations and Flight Safety Departments. Just as one would expect from an open and conscientious Flight Safety culture.

Can't comment about the other operator.

[DFC]

Never let facts get in the way of having a Ryanair Bash!

Here is a quote from the report;

"During his time on duty, he considered that the traffic was light to medium. He also confirmed that there were no visitors during the time of the incident and that he had not been distracted by any telephone calls"

So how did someone call this thred ..."due to distracted controller"

The waffle in the report about some NATS operatives thinking that this operator has a reputation for "expeditious" movement on the ground is no more than that - waffle and has no place in a factual report.

The average speed of the aircraft as calculated from factual evidence is one thing......but unless there is hard evidence that this happens at times other than when asked for by ATC then the AAIB should not get involved in mud slinging.

Regards,

DFC

[NigelOnDraft]

DFC
.....is no more than that - waffle and has no place in a factual report I disagree. I read the AAIB bulletins carefully, and you will be surprised how many little bits of "waffle" (as you call them) they contain. I read them as sound airmanship "observations", and some I have not thought of previously, and modify my behaviour accordingly.

I work for an operator where airmanship is somewhat of a dirty word... we are all urged to make great efforts in certain directions, but constructive feedback between departments is not possible due to "politics". It is great when an AAIB report highlights a "point" - it can be used as an example, and for me anyway, fills in some of the holes that our operator chooses not to.

Read this report again. Apart from the dig at Ryanair's taxi speed (a reputation as well! justified?), that Ryanair may or may not take on board, the lesson is that ATC need to be careful of altering their SOPs to "accommodate" such practices (Lufty don't exactly hang around either). There are also digs about lights on for takeoff (Airtours.. were they on?), people changing to a frequency and transmitting before listening, and the failure of the Ryanair Captain to see the Airbus before he entered the runway (made all the more difficult by the speed at which he was taxing).

[AVIACO]

Good old Nigel on Draft - always brings a degree of level headedness to all subjects. And put as succintely (sp?) and eloquently as ever.

Ryanair taxi speeds have been something of a frequent topic on these boards for a long time. Remember the STN incident of many years ago??

[Anne.Nonymous]

DFC

If you read what the report said precisely you will see that he was not distracted by any telephone calls! There were other factors that could, and probably did, distract him.

It was an impartial AAIB report that first raised the 'distraction' word. All these factors resulted in the potential for distraction to 'Air 1' . Therefore I think the title is not wide of the mark.

On the subject of taxy speeds, some airlines have an 'event' in their performance monitoring system for taxy speeds in excess of 33 knots (type dependent) and others encourage time-saving by various means. From personal experience, I would say that Ryanair favour the faster taxy speeds and this seems to be the experience of others. Just an observation but observations by many soon become a reputation.:D

Anne :O

[alf5071h]

Many positive aspects of this incident were identified by fmgs and NigelOnDraft, in particular the A321 crew’s awareness of the taxiing situation and indicators of good safety culture. However, although a more serious outcome was averted by autonomous action, much of the industry’s safety strategy still relies on R/T. The weaknesses of this form of communication have been evident ever since Tenerife, a false perception from a stepped-on transmission. Yet in the MCT incident there was a overlaid transmission (although not crucial to the event) and a dual frequency operation that reduced the ability for everyone to have audio awareness. Apparently we still have a great deal to learn.

One common aspect in safety is to have defenses in depth, either through dual path systems, procedures, two people, or the dependency of crew and ATC working together. This incident appears to show that few of these existed in a reliable form that would prevent a runway incursion in the event of a single human error (a common safety issue). Thus what changes are likely; not to prejudge any activity at MCT, but in general could ATC’ers suggest alternatives or make comparisons with other operations. There were two controllers at MCT, is it feasible to have cross monitoring? A RIM warning was given, but not heard/seen, why not, human error, system design? Is there potential for confusion between DZ1 and D1; resulting in false situation awareness by either the crew or controller? I believe that the AAIB could have sought and published answers to a few more of these human factors questions.

For operating crew it is essential to keep eyes and ears up at all times and be aware of traffic even when operating on different frequencies. This may necessitate a change to operating procedures, avoid checks when taxiing, and avoid hurrying during ground operations. Again if there are some good suggestions, then please share them us.

[gashcan]

Nigel - does it matter if the lights were on? (Report states that Airtours say yes, Ryanair say no - who cares?) - point is that due to an error, Ryanair entered a runway which was being used by another aircraft for take-off.

If you look down the runway from 'D' intersection, you can clearly see the threshold of both 06L and 24R. I would have thought that on a clear day with good weather, an A321 belting along would have been obvious - lights or not.

ATC made a human factors error for whatever reason. They happen to pilots, engineers and controllers everyday - we all make them. Whether we like it or not they will continue to happen, which is why there are often several layers of protection included in the various systems to mitigate their effects. None worked effectively on this occasion, except for the MYT crew initiating an abandonment

Ryanair crossed an active runway at an AVERAGE speed of 33kts, what then was the Ryanair's PEAK speed?

They crossed the runway without knowing or without seeing a conflicting aircraft on it's take-off roll.

It would appear that the Ryanair crew listened, but didn't hear, and looked but didn't see.

Could it be that they were distracted as well? Possibly by the pressure that exists for quick turn rounds and on-time performance - he had after all already overtaken the preceding landing aircraft which had vacated the runway previously.

Apparently Ryanair left MAN exactly half an hour later, on schedule, without saying a single word on the R/T regarding the incident. MYT left nearly two hours late.

As an aside, I have heard a rumour (unconfirmed of course!), that the incident wasn't reported to Ryanair by the crew and the first that the company knew about it was when the AAIB phoned them the next morning.

The lesson from this incident is clear. Be aware of what is happening around you and look both ways before crossing the road. If it's good enough for the Tufty Club, it's good enough for me - cos it could be me (or you) next.

[390cruise]

Yes Ryanair are famous for rather quick taxi speed BUT in their
defense this was a B737-200 so it might not have IRS to give
ground speed!! When I was on the 200 (Not Ryanair!)I did not have a clue about our taxi speed!

[NigelOnDraft]

Gashcan Nigel - does it matter if the lights were on? (Report states that Airtours say yes, Ryanair say no - who cares?) - point is that due to an error, Ryanair entered a runway which was being used by another aircraft for take-off. You are obviously not a (professional) pilot, or if one, one that follows your username well <G>

If you were a (professional) pilot, you would know that in order to prevent accidents, one places as many safety layers between yourself and an accident as possible.

You seem content to write off the whole thing as the controllers error, and that if the error had not been made, then no problem.

The rest of the world works by accepting there will be errors made. We try to avoid these, but we then put additional layers in to mitigate errors that are made. For instance, putting your lights on for the takeoff roll will increase the likliehood of your being seen... Now whether they were on or off was not considered worth pursuing by the AAIB (?), but the point is there - in the "waffle" as someone called it. Another layer was a good listen out by the Airtours skipper. Another layer was the ATC automated tool - which did "go off", but without an aural alert, proved useless here... but add an aural alert and another good layer can be built. Bear in mind in some circs some layers won't work e.g. night / poor vis.

Your points about the apparent lack of reporting by the Ryanair crew speaks volumes if true... when added to the excessive taxi speed and poor lookout...

[Scottie Dog]

As an outsider - ie not directly employed within the aviation industry - can I make an observation?

I have noticed recently that at least one controller at Manchester now adds a additional comment to their runway crossing clearance. The controller seems to use the expressions 'hold short - landing traffic' etc. And I have also heard a lineup clearance being given as 'line up and hold 06L - crossing traffic'.

To me it certainly makes one aware that there is something else moving, rather than just 'Hold short of 24R at D1'. Does this additional comment help to clarify the clearance, and should it be made mandatory?

[ComJam]

As far as i can see from fully reading the report the taxi speed of the Ryanair, his ability to see the other aircraft and whether or not the Airbus had his lights on are completely irrevelant.

The incident occurred following a human error by a controller.

[NigelOnDraft]

ComJam...

You obviously cannot read :( Try reading my post above, and apply the very basic, first, principle of aircraft incidents / accidents. They are rarely solely down to one cause...

In this case a controller error was the major contributory cause to an incident. Various other factors (lights? taxi speed? poor lookout?) made the incident somewhat closer to an accident than maybe needed to be the case. Fortunately, another "layer" - good listening out on the part of the Airbus skipper - prevented the accident, or a more serious incident. However, had the Airbus skipper missed that call (and he had just missed another one due to cockpit calls), then it could have been very close.

So we come onto the "other" layers. If the Airbus lights were off here, then putting them on might have caused the Ryanair skipper to see it. If the Ryanair guy had taxied more slowly, and been able to pay more attention to crossing, he again stood a better chance of seeing the Airbus.

An accident is when all the layers fail. Since you wish to strip away all the layers, and ignore their effects / the lessons we can all learn, you are a flight safety hazard. Whether that is a problem depends on whether you fly anything more complex than MS Flt Sim...

I presume when you come across a green light you speed through and don't look to see if anyone is coming across?

[sky9]

The real problem at Manchester is that 24L 06R was built in such a position that aircraft using it had to cross an active runway either before take off or after landing.

This was an accident waiting to happen; in this instance it was an incident. I would be interested to hear what the risk assessment calculation was for this layout when it was carried out at the planning stage; that is if there was one. But there again I started bitching about the layout soon after the second runway was opened and was assured by a Controller that my concerns were misplaced.

[ComJam]

A typically arrogant post from a BA Nigel who obviously knows all.

I'll ask for your advice next time i need to know how to suck eggs.

I was merely pointing out the conclusion of the report was that the controller was at fault in this incident, the other layers you have mentioned have no bearing on that.

If the Ryan had been taxiing more slowly it might not have happened, if the Airbus had had his lights on it might not have happened. Had the controller not got it wrong it would not have happened, the Ryan having confirmed his clearance to DZ1 short of 06L.

From your last comment i take it you stop at a green light to make sure it's safe prior to proceding, making you a hazard to road safety :)

Must get back to my Flt Sim now......:rolleyes:

[peatair]

sky9 has said:-

The real problem at Manchester is that 24L 06R was built in such a position that aircraft using it had to cross an active runway either before take off or after landing.

This was an accident waiting to happen; in this instance it was an incident. I would be interested to hear what the risk assessment calculation was for this layout when it was carried out at the planning stage; that is if there was one. But there again I started bitching about the layout soon after the second runway was opened and was assured by a Controller that my concerns were misplaced. [End Quote]

This observation contains a lot of truth. Before planning permission was granted to MAN Airport for the second runway there was a very lengthy public inquiry. However, this was not conerned with flight safety matters but rather with the "politics" and environment. This resulted in the need for SIDs from 24L to have to turn right at relatively low level in order to avoiud Knutsford!

The location of the second runway (i.e. 06R/24L) is to the south and parallel to the original runway (i.e. 06L/24R). Hence, to use the new runway the old has to be crossed by departures.

The licensing of an airport for public transport purposes is a matter for the Civil Aviation Authority. Details are in the Air Navigation Order. One presumes that this design was somehow examined by the CAA and "approved." Certainly, it is NOT for the ATS Provider let alone the individual ATCO to worry about this approval/licensing process.

The Manchester layout creates significant issues for ATC (provided by NATS) and, in my experience, they fall over backwards to instruct pilots approaching crossing points to "hold short" etc. They seem to have tried to make their procedures as robust as possible. Others on this "thread" have made a lot of very valid points - about taxying speeds, use of lights etc.

There is a need for caution on the part of pilots since a frequency change is involved as you approach 24R crossing point. Need is to change to Air 1 as soon as possible and get some situational awareness.

Would be nice to know what risk assessment Man Airport management did of all this. As you sit there waiting to cross and watching an aircraft landing, it does make you worry about the lander having a major tyre burst etc.

By the way, the easterly situation is not without its difficulties either. After landing on 06R you sometimes taxy along the taxiway between the 2 runways - (it runs parallel to both runways) - and you cannot see departures on 06L.

[sky9]

Peatair,

Your comments about tyre bursts was my major concern, I took it as far as I could right up to ICAO and I hit a brick wall. I am pretty confident that no Risk Analysis was undertaken because I asked to see them.

I'm afraid that the blame will be put on pilots and controllers and not where it should be; the designers.

[DFC]

Nigel,

I was making the point that if the AAIB were of the opinion that the taxi speed had a direct bearing on the incident then they should have made a safety recomendation regarding that. They chose not to and consequently, they have left the status quo i.e. pilots will taxi fast in certain cases and especially when encouraged to do so in order to please ATC and thus avoid delay.

Yes I believe that in this one case, the taxi speed in this case was a factor. Imaging you are travelling at 33Kt towards the runway having been told to expedite and are told to cross..........you look left and right..........but for how long are you focused in each direction and for that brief glance is there enough time to recognise that the aircraft you are looking at (with no lights?) is accelerating..........or could that aircraft be the other lander that ATC are expediting you ahead of and who is not taking off but taxiing................I don't think that there was enough time available at that speed for the pilot to even notice that the aircraft glanced at was moving.

However, the report leaves the reader to make up their own mind........which means that some people will get the message and some will not.
-------

gashcan,

The Ryanair left 30 minutes later without saying a word on the R/T......probably because there was little point telling a different controller that their friend had mucked up........ranting on the R/T after an incident is over is similar to people gesticulating under road rage........not very professional.

A possible reason for the MYT leaving late was that they had to wait that long for the CVR to be downloaded, brakes checked etc.

Ryanair had no reason for delaying the passengers.........other than waiting to have a row with the controller :)

-----

Of course, the Ryanair aircraft was fully visible to the pilots of the MYT and they had the same oportunity as the Ryanair pilot to recognise the location, ATC clearance issued and speed of the conflicting aircraft......but they accelerated and continued to do so until above 100Kt........they had the same responsibilities as the Ryanair pilot with regard to making sure the clearance issued by ATC was safe.....and they did the same thing as the Ryanair pilot they complied with their clearance because they didn't expect ATC to make a mistake.......They stopped.

What the report does not deal with is what would have happened if the MYT had continued to accelerate........i.e. it would have been close but because of the speed of the Ryanair it would have (just) got across the runway in time?............what if the Ryanair had ben travelling slower and the MYT did not pick up the slow roll into it't path?.........remember that wing-tip and SD360 accident in Paris?

What if the Ryanair had slowed and stopped at the runway edge?

This report causes more questions that answers!

Regards,

DFC

[DFC]

I see that the CAA has issued a FODCOM relevant to everyone involved in or with an interest in the safety issues arising from this incident.

Regards,

DFC

[sky9]

DFC

Yes, very much a matter of trying to clean up after the event. The sad fact is that we should all know that safety starts at the planning stage; or so the CAA tells everyone, yet an airport layout was approved that was totally dependent on procedures rather than design. What a shame that the CAA didn’t object at the Planning Inquiry. or that the AAIB didn’t use this incident to draw attention to the poor design. Never mind they will have another opportunity with the latest incident with BMIBaby before a big accident makes them take action.

They could start by reviewing the close proximity to the crossing Holding Points close to runway 24R. Yes we all know that they comply with ICAO criteria, but that doesn’t mean that they are a safe place to hold aircraft when 24R is the active landing runway. A 747 on the edge of the runway is mighty close to the nose of an aircraft at the holding points and as the Gerona accident proved a heavy landing that takes away the dogbox has all sorts of unexpected consequences.

[Carpathia]

390cruise,

If the aircraft is taxiing at 33 knots, you don't need an IRS read-out to tell you that you are going bloody fast, far too fast to enter an active runway in my opinion.

[peatair]

sky9 has said: QUOTE "The sad fact is that we should all know that safety starts at the planning stage; or so the CAA tells everyone, yet an airport layout was approved that was totally dependent on procedures rather than design. What a shame that the CAA didn’t object at the Planning Inquiry. or that the AAIB didn’t use this incident to draw attention to the poor design." END QUOTE

This is absolutely right. The entire situation shows a very clear need for a thprough review of the processes by which these airport designs are approved. As I pointed out in a previous post on this thread, the approval from an aviation safety viewpoint is NOT the purpose of the public inquiry. The CAA are by law the airport licensing authority for the UK and therefore they must carry responsibility for that which they approve. How then did they approve this design?

I have read - at this stage once only - the very lengthy FODCOM issued 17th November - FODCOM 25/2004. Naturally it contains a great deal of useful material. It certainly emphasises (para 5.6) not to rush during taxying.

The FODCOM has a lot to say about conditional clearances. Several years ago there used to be a Manchester controller who asked you if you could see the landing XXX type. Only if the answer was affirmative did he issue you with a CC. Seemed like a good "best practice" to me. Has the level of RT loading reached the point where this could not be done?

Another interesting point in the FODCOM is that a taxy clearance to a point BEYOND a runway does not imply a clearance to cross that runway - see para 5.7. I think this might make for interesting debate in court! Surely, the clearance limit should be to a position BEFORE the runway and a further clearance issued later. What do other readers think?