United UA57 cleared for wrong runway - sweepover to lined up Easyjet

[Ray_Y]

found on avherald (respecting copyright so my own words)

20th of July 2020
United 787-10 on final to 09L at CDG
ATC error cleared them on 09R
UA swinged over
Edit: Easyjet 320-200 was told to line up and wait for t/o clearance on 09R, warned on radio
G/A at 260ft AGL
rated serious incident by BEA

[Check Airman]

Standard practice in the US to have the runway occupied on short final. Doubt the UA crew considered it a serious incident. Probably didn’t even need to do any paperwork.

[capngrog]

Well, there's "occupied" and then there's "occupied". As I'm sure you know better than I, a runway is "occupied", whether waiting at the numbers for takeoff clearance or clearing the departure end threshold. I'm not sure about that latter point, the aircraft may to still have to be physically in contact with the runway surface, but that is how I recall it having been explained to me. Then again, there's "short final" and then there is "short final".

Here's a link to the AvHerald article:
Incident: United B78X at Paris on Jul 20th 2020, cleared to land on wrong runway, ATC error saved by Easyjet (http://avherald.com/h?article=4da9fc9a&opt=0)

I don't know, but it sounds pretty serious to me ... but not as serious as the Air Canada 'Bus lining up to land on the full (of taxiing/stopped aircraft) taxiway at SFO.

[Ray_Y]

Well, 3 mistakes adding up. Error 1 by ATC confusing 09R with L. Only one letter, but serious. Error 2 by UA crew to swing over without questioning the unforseen change. Error 3 by UA crew to go around so late, at low altitude. METAR reports clear visibility, so how could they miss to spot the waiting Easyjet until being so close? That last error is quite hard to understand and needs to be investigated the most. I hope this was not as bad as it reads.

Good job of the Easyjet crew for keeping good SA. The only clue they had was the radio transmission mentioning the wrong runway (Here I assume there was no explicit call to swing over by UA crew)

[FlyingStone]

Something to keep in mind for all the French air traffic controllers and pilots...

Would easyJet crew be able to maintain the same level of SA, should the aircraft performing a sidestep speak with ATC in French?

[giggitygiggity]

This clearance most likely occured at 9nm when it would have seemed "reasonable" at that point (usually you get "Landing Clearance" in CDG after checking into tower frequency and announcing which Runway you're lined up for).

If ATC cleared them at the typical point (1-2nm when the runway was actually clear) like every other European airport, it would have seemed quite odd to switch runways then and the UA crew would have probably questioned the clearance. Specific mistakes aside here, to me just stands as another reason that "clearing someone to land #3" is really poor practice, as much as you're 'used to it' in the US.

There is no encumbrance to ATC expedition by waiting to clear someone to land when the runway is actually clear... Clue's in the word isn't it?

I know I've had this precise debate with some of the above posters here before, but apart from arguing that they're used to it, I cannot see any safety advantage in issuing clearances like this. Hopefully this will be the thing that shakes up CDG to the standard of rest of the sensible world.

[Globally Challenged]

Something to keep in mind for all the French air traffic controllers and pilots...

Would easyJet crew be able to maintain the same level of SA, should the aircraft performing a sidestep speak with ATC in French?
Exactly! This was the first thing that occurred to me. The French and their ridiculous pride over safety approach to reducing the SA of other crews.

Several times I’ve had busy Paris / CDG controllers issue me with instructions in French - typically when they are so busy that you have to wait some time before you can get a word in to request a proper clearance.

[fox niner]

Does UA use the hud in their 787’s? If so, did the flight path vector cue, and all the other green muck in your field of sight, compromise the field of vision of the landing aircraft?
perhaps they could not see the easyjet very clearly though the hud.

[flyfan]

Error 3 by UA crew to go around so late, at low altitude. METAR reports clear visibility, so how could they miss to spot the waiting Easyjet until being so close? That last error is quite hard to understand and needs to be investigated the most. I hope this was not as bad as it reads.

I wouldn't call that an error, with a busy airport the runway is quite often occupied till you're very close to the runway. Latest landing clearance I ever received was at maybe 20-30ft above the CAT I minima...
Or something like "XXX, after departing A320 cleared to land Rwy YY" which basically tells you: OK, there's still traffic on the runway. One can go all the way to the minima before going around, in case the departing traffic is still on the runway - and CAT I minima tend to be around 200ft AGL, so I can't see anything wrong here.


Good job of the Easyjet crew for keeping good SA.

Yep definitely.

[DaveReidUK]

Here's a fairly sparse plot from FR24 of the UAL GA:

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/953x438/ual57_corrected_ddfe43bff5f6ee597468f89151ac463946b84cb8.jpg

It could do with a few more data points, but it appears to show that:

a) the United initiated the sidestep at approximately 2.5 DME from the 09L threshold

b) the height AGL over the 09R piano keys was approximately 75' (not necessarily the lowest height achieved in the GA)

The EZY plot on FR24 is even more inconclusive, but is consistent with having entered the runway at D5.

Usual FR24 caveats apply, in spades.

[SpamCanDriver]

I know sidestep is pretty common in the US, but surprised they would attempt one at 2.5nm if that plot is correct.

[Ray_Y]

DaveReidUK

Oh great. So with all caution regarding the data validity, this is the picture including the assumed Easyjet Position on the rwy (NOT moving I understand):

https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/991x484/easyjet_position_e404fa4fc5bc66fc8ad58eb0b4a9d5de13e01b58.jp g

(a position which is somehow parallel to the threshold of original 09L)

Look at the threshold displacement between 09L and 09R, UA swung to a runway being much closer.

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/512x318/lfpg_rwy_09_b817b2e4e90eb7764159a1160463b0964a0895c8.jpg

[oceancrosser]

giggitygiggity

As a european pilot, I have to disagree with you there. I far prefer the way CDG (and the US) issue landing clearances to receiving landing clearances below 200’ (and even below 100’) at LHR and (to a lesser extent) LGW.

[andrasz]

...so how could they miss to spot the waiting Easyjet until being so close...
Paradoxically in good daylight visibility another aircraft is not so easy to spot on a runway, especially if it is not on the piano keys but further down. From rear with the shallow approach angle the most visible parts are the wings and HS, both of which are a dull grey closely matching the concrete of the runway.

[donotdespisethesnake]

Yeah, they should paint them a high visibility color, like orange or something.

[poldek77]

as it was in the morning probably they had also the sun just in front of them

[misd-agin]

donotdespisethesnake

I'm not sure how good your eyes are but from behind the amount of orange that might be seen might be able to cover a bikini in Ibiza.

[Ray_Y]

I'm really surprised how late the UA crew swinged over. In the FR24 plot, which is never precise enuff an in doubts for me, they were aligned with the runway just inside the airport perimeter. If it really was was that late, I accept that they didn't have a lot of time to spot another airplane occupying the runway. And especially that one said of being at a position for intersection takeoff. Wonder how they managed to be at height over threshold.

Some asked for the Easyjet not having lined up yet. We can't know, but indirect hints are there: If it was totally save, they wouldn't have complained right away. And: BEA ranked it a serious incident "landing clearence on occupied runway. Yes, we don't know if they were already lined up. But obviously the Easyjet already crossed the Holding Position and entered the runway zone.

So I modify:
Error 1: ATC
Error 2: crew swing over very late, and still without questioning. This was not a stabilized approach at all, and looks like they coudn't maintain sufficient situational awareness.

But this needs confirmation from accurate details.

[Ray_Y]

andrasz

If the swing over was that late as FR24 data suggests, you are absolutly right

[meleagertoo]

Er - what does "sweep over" mean?
35 years in commercial aviation and this is a first.

[Check Airman]

"sidestep" in FAA land

[Ray_Y]

oh dear! "swing over" was what I meant all the time. Sorry for this stupid confusion.

[sudden twang]

Been flying to FAA land for 30 years never heard of sweepover

[cappt]

I've been flying 25 years and never heard "sweep over" ? Where does this come from?

[Ray_Y]

see my comment, I corrected all posts I was able to.

[sudden twang]

Ray,

I realise that you are new here, but many of us try not to judge until we have all of the facts for example what were the UAs crew or the controllers fatigue levels?
The fact that you used sweepover now changed to step over when I’ve always heard side step used, is ironic when compared to your error 1.

[DaveReidUK]

Confession time:

My previous graphic showing the sidestep (now corrected) contained an incorrectly calculated height over the threshold (caused by my reading down the runway heading column in my airport reference database, instead of runway elevation :\).

Actual height over the THR was approximately 75', rather than 375', my apologies for the senior moment, Specsavers appointment booked.

A320 fin height is 39' ...

[Pistonprop]

Looking at FR24 am I correct in sighting that the traffic preceding the UAL was AF443 (also a 787 btw) and that traffic did land on 09R (cue ATC having 09R subconsciously in their head)? I also note (according to my FR24 playback) that the Easy apparently lined up at an intersection some 1000 metres from the threshold of 09R? That may explain why United didn't see it (or may have initially thought it was well on the roll at that point. There's still a lot of pertinent information missing.

[Ray_Y]

DaveReidUK

First round of confession completed? ;)

For AVH reporting a Go Around at 260 feet AGL, this matches your calculation even less. Now we don't know which source was more accurate.

I couldn't find any good detaul on BEA website. But ... see next post

[Ray_Y]

Pistonprop

That matches an anonymous commenter on AV Herald. Sounds like from an insider, but how can we know? He states that the preceeding landing Air France 787 requested longer 09R due to brake issues. ATC cleared its landing on 09R. Then ATC approved Easyjet to line up 09R. Then ATC cleared UA57 to land on 09R. Easyjet "not fully lined up but braked hard exiting taxyway", the comment states. And added that ATC alarm system was also triggered.

Let's see what's real.

[Ray_Y]

Ray,

I realise that you are new here, but many of us try not to judge until we have all of the facts for example what were the UAs crew or the controllers fatigue levels?
I do try not to judge, and I swallowed most of the early thoughts. With such little info we can absolutly assume not seeing the complete picture. And certainly not to blame anybody (Did one 3rd world remark to be ironic and provocating, got me reset to a newbie status. Here we rather (ironic on) see an UA obedience culture and steep command gradient ATC to flight deck /irony off)

On the other hand I stay with the fact there was an error 1 by ATC, an error 2 by crew which now seems more important and an error 3 appearing less mystic now.


The fact that you used sweepover now changed to step over when I’ve always heard side step used, is ironic when compared to your error 1.
My error 1. Still I wanna write sweep, and swing doesn't come easy, it's so crazy. :ugh:

[DaveReidUK]

For AVH reporting a Go Around at 260 feet AGL, this matches your calculation even less. Now we don't know which source was more accurate.

Avherald's calculation is based on a transponder altitude of 500 feet. I have no idea where they got that value from, but FR24 clearly shows Mode S values down to 325' (https://www.flightradar24.com/download/?flight=24fbea79&file=csv&trailLimit=0&history=1595198100).

Adjust the FR24 value for QNH and runway elevation and there's no way you can make that equate to 260' AGL.

[ORAC]

https://www.thetimes.co.uk/article/planes-on-collision-course-at-charles-de-gaulle-airport-after-language-mix-up-sbdk2x2m0

Planes on collision course after Charles de Gaulle airport controller’s error

A slip of the tongue by an air traffic controller put a United Airlines jet on course to collide with an easyJet Airbus seconds before aborting its landing at Paris, an official report has revealed.

Potential disaster was only averted when the pilots of the easyJet Airbus A320 saw the United Boeing 787 bearing down on their runway less than 300ft off the ground as they pulled on to the same runway to take off, according to the Bureau of Enquiry and Analysis (BEA), the air accident investigation branch.

The incident on July 20 last year was triggered when the tower controller told United Flight 57, which was carrying 73 people from Newark, New Jersey, that it was cleared to land on runway 09 right at Charles de Gaulle airport. The jet was already low on the approach to the parallel eastward-facing runway 09 left but the pilots assumed that they had been instructed to “sidestep” to the right and line up to land on the right hand one.

The United co-pilot responded, asking for confirmation with an English expression that was not grasped by the controller. “Understand cleared to land 09 right, sidestep for 9 right”, the pilot said. This was a request for confirmation but the controller did not react. The Boeing pilot flicked off the automatic pilot and steered the jet manually on to the parallel approach. The sidestep manoeuvre, called a “doing a bayonet” in French, is occasionally used at busy airports.

The controller, unaware of her error, cleared the easyJet on to the same runway to take off. The pilots saw the Boeing but assumed in the dawn light that it was still aiming for the parallel runway, 250 yards away, where most landings were taking place. Only when they were already on the runway, did they realise the danger. The Boeing was less than a mile away descending through 300ft towards them travelling at about 160mph.

The easyJet co-pilot radioed: “Traffic landing 09 right” and told the Boeing: “Go around 09 right! Go around!”

The big jet, which was light with only a quarter of its normal passengers because of the pandemic, slammed on power to abort the landing. Its pilots had just spotted the easyJet Airbus at the same time. The Boeing came within 80ft from the ground, just 250 yards from the end of the runway before it began climbing away.

The controller told the investigators that “she thought her tongue had slipped because she was focused on Runway 09 right with [an] Air France Boeing 787 that had just landed there,” the report said. “She explained that controllers regularly made such slips of the tongue”.

The controller blamed her lack of recent practice because of the slowdown of air travel in the coronavirus crisis.

The report also faulted the United pilots for failing to use clearer language. They should have requested the controller to “confirm” her instruction. They noted, though, that there was no international standard on the phrase and that “understand” is commonly used by American pilots.

Non-French pilots have complained for years about the potential hazards caused by the use of both French and English at Paris airports. French airliners use French, leaving most other pilots on the frequency in the dark over what instructions they are being given. Most other countries require English only to be used at major airports. Air France pilots once threatened to go on strike when they were required to only communicate in English.

Just before she switched into English to order the wrong instruction, the controller had used French to clear an Air France Boeing to land on the right hand runway.

[Banana Joe]

Just stick to English before a disaster happens.

[Sick]

Banana Joe

It already has - remember the freighter pilot killed at CDG in the runway collision, unaware that the conflicting departing traffic had been issued a takeoff clearance in French.

[dmwalker]

Sorry to be so ignorant but wouldn't both aircraft have had TCAS operating at that time? I don't see any mention of that.

[V_2]

dmwalker

TCAS RAs and TAs become inhibited below certain radio altitudes.

[DaveReidUK]

Sick

Safety recommendation made after that May 2000 accident (https://www.bea.aero/fileadmin/documents/docspa/2000/f-ed000525a/pdf/f-ed000525a_22.pdf):

"(that) in the light of the analysis of this accident and previously acquired experience, the DGAC study the expediency and methods of implementation for the systematic use of the English language for air traffic control at Paris Charles de Gaulle aerodrome, as well as the extension of this measure to other aerodromes with significant international traffic."

As they say in France, "plus ça change ..."

[Gary Brown]

BEA report just published in French:

https://bea.aero/les-enquetes/evenements-notifies/detail/incident-grave-du-boeing-787-immatricule-n16009-exploite-par-united-et-de-lairbus-a320-immatricule-oe-ijf-exploite-par-easyjet-survenu-le-20-07-2020-a-ad-paris-charles-de-gaulle-95/

Not showing as available in English yet, but that usually follows in a few days.

UPDATE: English version just released, Sept 2nd 2021

https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-boeing-787-registered-n16009-operated-by-united-and-to-the-airbus-a320-registered-oe-ijf-operated-by-easyjet-on-20-07-2020-at-paris-charles-de-gaulle-ad/

[Gary Brown]

BTW, the BEA report clarifies the sequence of events in the last couple of seconds, in terms of situational awareness and reaction.

- EasyJet Captain (who was not PF) sees United descending but can't be sure which runway he's lined up to
- United sidesteps as per ATC instruction but asks (unclearly) for confirmation
- United , with good visual to threshold, sees Easyjet entering his new runway and executes a go round
- EasyJet PC does a final visual on the approaching traffic, realises United is for his runway, and issues and emergency go round instruction on the frequency; also stands on his brakes
- ATC (who does not have a visual to the threshold in question) hears this and at the same time gets an audible alert; she issues a go round instruction
- Simultaneously, the ground controller (who does have a visual to the threshold) by chance sees that the United and the Easyjet are in conflict, and turns to alert his colleague, who is at that moment issuing her go-around.

[Timmy Tomkins]

Globally Challenged

I imagine most of us who used CDG have had this experience (multiple times) but the real disgrace is that it is stil going on even after the French investigators - of a fatal ground collision with a UK registered aircraft some years ago - recommended that all ATC be conducted in English.

[DaveReidUK]

See text of the Safety Recommendation, with a link to the report, in post #38.

[Dmitri]

Let's stick to the facts, gentlemen: tthis is a quote from the document clause named: "OBSERVATIONS BY THE UNITED KINGDOM". Nothing to do with the French Investigators.
Moreover, how this is relevant to this incident? Who was speaking french: United or Easyjet? Yet, it has happened.

[FlyingStone]

SERA.14015 (b):

Unless otherwise prescribed by the competent authority for specific cases, the English language shall be used for communications between the ATS unit and aircraft, at aerodromes with more than 50000 international IFR movements per year. Member States, where at the date of entry into force of this Regulation, the English language is not the only language used for communications between the ATS unit and aircraft at such aerodromes, may decide not to apply the requirement to use the English language and inform the Commission accordingly. In that case, those Member States shall, by 31 December 2017 at the latest, conduct a study on the possibility to require the use of the English language for communications between the ATS unit and aircraft at those aerodromes for reasons of safety, so as to avoid incursions of aircraft on an occupied runway or other safety risks, while taking into account the applicable provisions of Union and national law on the use of languages. They shall make that study public and communicate its conclusions to the Agency and the Commission.

Safety first, people. Clearly by far the best way to achieve this is by ATC speaking two different languages to aircraft on the same frequency. Well done.

[Dmitri]

AIP France, current version 15 JUL 2021
1.1.7 RADIOTELEPHONY PROCEDURES AND PHRASEOLOGY
......
Important note 1 : In France, it is possible to use the French language in radiotelephony on all aerodromes, including airports with more than 50 000 international IFR movements per year.

[DaveReidUK]

Dmitri

"Let's stick to the facts, gentlemen: this is a quote from the document clause named: "OBSERVATIONS BY THE UNITED KINGDOM". Nothing to do with the French Investigators."

No, it isn't.

It's a quote from the list of the BEA's Safety Recommendations. Nothing whatsoever to do with the UK's observations.

[FlyingStone]

Dmitri

And what is this supposed to tell us, apart from the complete disregard for safety in French airspace?

[Australopithecus]

That pride goeth before a fall? Or more likely, a collision?

[Gary Brown]

This is a question for any Controllers here, especially non-USA ones. Would you have heard « Understand cleared to land 09 Right, side step for 9 Right United 57 » as a request for confirmation?

Although there's no real discussion of the French / English issue in the BEA report just published (and in so far as there is discussion, it's to say that this was not a pure language issue), I'm interested in whether the Controller did not respond to this message at all becasue she heard it as a read-back, rather than a question. What's clear from BEA is that she was a tad overworked, in an ill-prepared Tower and team, and that she made a choice, at a busy moment, to shift seats and equipment. BEA largely attributes her lack of response to United to those factors, and a little to United's non-standard phraseology. But it's at least possible thet she simply did not understand the English she heard. Hence my question above to Controllers: What would you have thought United was saying (whether or not you approve of what he said)?

[Gary Brown]

I think you'll be shocked at the ATC setup and actions on that morning when the English version of the report comes out: disorganization in the room, as well as slips of the tongue!

BTW, surely well done to the EasyJet; but according to BEA United had already initiated a go round (having a good visual on the encroaching EasyJet) just before EasyJet PC chimed in. EsyJet stopped with half the a/c on the runway, still at right angles to it. United got as low as 80 feet when 250 meters out from the threshold (BEA uses both units.....), and passed over Easyjet at about 300 feet.

[Lissart]

I am a UK licenced ATCO (currently "resting") and a fluent French speaker, having lived there for a number of years. I have met several French ATCO's and discussed the job and language use with them. I should stress that I have never worked in ATC in France (despite putting a good bit of effort into that aim) nor have I had the challenge of speaking my second language operationally, except on 2 occasions in emergencies.

It is worth remembering that foreign ATCO's/pilots speaking English (2nd language) have many issues to deal with. They may well be interacting with other non-native speakers from other nationalities who will all have accents - more or less heavy and more or less inteligible - before one even begins to look at cultural issues about how language itself is used. For example, my French ATCO colleagues tell me that Spanish pilots speaking English are very difficult for them to understand. An American native English accent is very different from an Australian one isn't it? So folk who point out the benefits of increased situational awareness if "tout le monde" is speaking English may ignore the possibility of a misunderstanding arising when two French people are speaking their non-native language. It should be fine at major hubs when and when standard phraseology is applicable but what about when plain speech is required for non-standard situations? In the UK level 4 ICAO English is mandated for non-natives, just as it is on the continent. I have seen foreign potential ATCO's looking for UK work who fulfilled this requirement - and had fine standard phraseology - but who would have no clue (or struggle) when talking to the fire service or ops or the bird guy, especially when the pressure was on. It all depends on the unit but level 4 worries me..... In France the standard of so-called level 4 is highly variable. No problems at the big international places but at the smaller hubs where it is less often used, one can see a much lower standard. Of ALL the guys I have met (some major airports) none had English as good as my French because it is not what might be termed "street English". In other words the kind of flexibility you get from "living the language", rather than just technical use.
To my way of thinking, this incident has some cultural issues. SIdestep being common in the US right? How much training did this ATCO have in the background to cultural expectations from the nationalities flying in there? Did she have any notion that her slip of the tongue had (probably) instinctive implications for American flyers? Could she expect to have had some training in their procedures, their phraseology etc? Would that be appropriate? Surely, their English training MUST encompass some of these points?
On a technical ATC level, I am surprised that in so many of the incidents I have looked at, the ATCO's do not update the situational awareness of the pilots, preferring to content themselves with "just" standard phraseology. There was a classic some years ago at CDG held up as a perfect example of why English only should be mandated. The lander on the outside rwy was told to hold short of the inner - which they missed - and then a takeoff clearance was given in French for a departure on that inside rwy. The departure had to abort as the arrival infringed the runway. In my view - while it is axiomatic to say that if one common language was in use it MIGHT have helped - the problem could have been avoided if the arriving crew had been given situational awareness in full; "Hold short runwy 09L -DEPARTING TRAFFIC". (Or some such.) This incident was therefore not an example of "language" issues per se but weak, non-defensive controlling. Just 2 extra words.......

PS: Gary Brown: "Understand cleared to land..." Depends on the intonation, right? A heavy upwards inflection implies a question to be confirmed. At my last place there was one pilot from the UK who regularly used "understand" as confirmation in his readback. As a native English speaker I can instinctively understand the difference.

[Avman]

Just a thought. Irrespective of language or culture it is not common practice for ATC (and this includes the USA) to simply issue a landing clearance for another runway than for the one you are on approach for without any forewarning of any kind. Yes I know United queried it (in their own way) but should they not have seen more of a red flag simply by the manner the "amended" clearance was delivered? At the very least ATC would have transmitted "runway change to 9R, cleared to land 9R".But they would normally ask if you are able.

[midnight cruiser]

At large US hubs with multiple parallel runways, it's not at all uncommon.

[reverserunlocked]

From the looks of it, they side-stepped pretty close in, which would not necessarily be a big deal for a US crew for the reasons given above. I wonder had this been a non-US crew and less used to side stepping pretty late in the day, they may well have stuck with 09L.

[Gary Brown]

@ Lissart.

Thanks for that very thoughtful set of language thoughts. I suspect a well-attuned native English speaker can even detect an intention to query rather than to confirm even from a flat, laconic mid-western US pilot accent!

IMHO, the controller was so distracted that she really didn't "hear" the read-back / query at all. If she had, then the twice repeated "Nine Right" should surely have alerted her that something wasn't right. The BEA report focuses on her initial slip of the tongue - 9R instead of 9L - but she then missed that slip being repeated by the United.

[Gary Brown]

Avman

The BEA report (still only available in French) deals with that point quite specifically. The United crew stated that they were stable for 9L, had clear visual to both 9L and 9R, were well-used to late sidesteps, and had no real concerns when they got the (erroneous) instruction. Worth restating that United then saw the Easyjet incursion onto 9R and initiated a go-round a couple of seconds before anyone else intervened. However, BEA note that no sidestep option had been briefed for landing, and they query whether United could truly be described as stable for the eventual 9R landing attempt.

[lederhosen]

The swingover was initiated a bit low in my opinion and while the runways are not far apart the threshold of 09R is a lot closer. It demonstrates a confident pilot (in this case captain) after a long night flight, but a sink rate of 1200 feet at low level is not ideal. I think it was a marginal decision even with the longer runway. I have been offered a swingover onto this runway and politely declined, not least because I could not see the runway in low cloud with sun in my eyes. I wonder how common swingovers are on this runway.

[Gary Brown]

Question - having been (erroneously) give a side step to 9R and not having a reply to his "query", United's choice I guess was to a) continue to land on 9L even though he was (erroneously) no longer cleared to do so, or b) to decline the sidestep and go round?

[ATC Watcher]

Although I had decided long ago that I would restrict myself to comment on this UK national sport where the facts are disregarded ( either by ignorance or willingly) in favor of the ever popular French bashing , but here we go again ,
The BEA report and the Incident investigation ( in French) are giving the following facts .

1- Due to a technical issue, on the TWR the normal Control position for Runways 09 could not be opened. ( First day or reopening of the North TWR after being closed 2 weeks )
2-The controller had to work for another control position where she did not have visual on the 09 thresholds.
3- The standard configuration that morning was 09L for landings and 09R for take off.
4- She was alone on the position , despite being extremely busy , the Coordinator position supposed to relieve the workload, was not manned that morning .
4- After a missed APP on 09L due to a technical issue an AF requested to land on 09R ( much longer than 09L) which she could not refuse.
5- UA was cleared by APP for ILS 09L and was stabilized on 09L when transferred to tower the controller mistakenly ( lapsus) said clear to land 09 R while she later said she meant 09L.
6- UA replied :" Understand cleared to land 09 Right, side step for 9 Right United 57 »
7-The controller did not acknowledge the transmission but said she did not pick up the 09R reply, and did not associate the word "understand" with a request for confirmation .
8- The side step was performed at 900ft, 2,2 NM out with 09R has a much earlier positioned Runway threshold.

Now the remarks :
The FAA ahs a clear procedure for performing sidesteps, France ( and I suspect EASA) does not have something similar and it is not a common procedure , unlike in the US. .
The term " understand" is used in FAA phraseology while in rest of the world we use the term " Confirm " ( as is ICAO standard phraseology)
Not having readback confirmation from ATC on Final is something usual in the US, but not in Europe.

My own remarks :
If the UA was using the term "understand" to ask a question , the fact of not receiving an answer should not be considered as an approval to continue.
A simple " confirm 09R?" from UA would have eliminated the issue.
If there is something to learn from this incident is to use standard phraseology , especially when flying outside your home country,

Now to the dual language issue that always comes up when an incident is happening in CDG , This one was all in English , so not a factor here. For those here that want to perpetuate this crusade , you should start to fly a bit outside your home country . The vast majority of the world's airspace is controlled bi-lingual , outside of a few tiny Caribbean islands, the whole airspace south of Rio Grande is in Spanish or Portuguese, Canada up North is even partially bi-lingual
3/4 of Africa are bi-lingual, so is Russia and China. Most European countries are too, France of Course Spain , Portugal, etc.. but also Germany for instance on all their airports , Yes you can hear German on Frankfurt Tower for the VFR mid fields crossings or departures below the ILS... Almost all Military ATC is done in National language and operating from dual civil-military's airports
I think aiming at world peace has more chances of success that eliminating national languages from ATC .

[Gary Brown]

ATC Watcher

The one thing I'd add from the BEA report is that just before the incident "someone" had managed to fire up her normal position - the one with a view westwards to the thresholds - and she said that she intended to move positions as soon as workload allowed. But "She added that she was preoccupied by the anticipation of changing positions" at time of the incident.

[ Elle ajoute qu’elle était préoccupée par l’anticipation du changement de position. p.6 of BEA[i] ]

[donotdespisethesnake]

The usual scenario for these type of incidents is that ATC make a mistake, which the flightcrew don't realise and struggle to comply with, possibly due to poor handling skills, resulting in a dangerous outcome.

In this case, the flight crew were challenged with a last-minute ATC instruction, which was perhaps unexpected but to them quite reasonable, they correctly read back, and the ATC had an opportunity to correct but didn't. The flight crew then successfully executed the requested approach, but also initiated go around when they saw a traffic conflict.

It is quite fanciful to think that if the single word "confirm" had replaced the word "understand" the whole thing wouldn't have happened. I really can't see what the crew did wrong here, it seems they are being blamed for being TOO competent.

[Gary Brown]

I think we can go back to the "holes in the cheese lining up" accident model proposed by Prof. Jim Reason ..... The BEA report identifies 4 big holes in this particular cheese (and a few smaller ones....): none of them big, jagged, sudden holes, but big enough to let a nasty smell though if they had lined up - 3 ATC holes, and 1 Pilot hole. Which, by multiple decent situational awarenesses, enough decisive participants, a big sky, and a happy dose of luck, they didn't. Long may that last.

[ATC Watcher]

donotdespisethesnake

We are not in the business of apportioning blames and in this particular case nobody did a "mistake". A slip of the tongue ( lapsus) is per definition inconscient , You mean to say something but your brains says another and you do not realize it . It happens during periods of high mental workload, and happens quite often in our professions , although most of the times without consequences as it is corrected by the person seating besides you , the PF if you are flying your coordinator/ assistant if you are a controller. The first " hole" in this incident is that she was alone to take up Gary Brown remark about Reason's model. .
The UAL crew did not do any "mistake" either they performed what was asked as it is common to do so in the USA and they used the FAA phraseology they are most used to.. the other hole here.
Another hole was that the sophisticated automated conflict detection tool in the TWR supposed to detect such things did not activate ( reasons explained in the BEA report)
However 3 holes were closed and that is why it was only an incident :
The EZY crew by looking out if approach was free while lining up closed a hole, it was good airmanship.
The UAL crew spotted the attempted line up and performed a go around even before it was mentioned on the R.T another hole closed
The visibility allowed visual detection of the conflict.

Gary Brown : She added that she was preoccupied by the anticipation of changing positions" at time of the incident.
Indeed, most probably one of the reason that caused her lapsus.

[kit500]

When I flew for Continental Airlines we were operationally required to be stabilized by 1000' agl. Staggered runway threshold distances add an additional destabilizing element . A side step request by ATC below that altitude would elicit a simple "unable".

[Gary Brown]

UPDATE Sept 2nd 2021 - English version of BEA Final Report just published:

https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-boeing-787-registered-n16009-operated-by-united-and-to-the-airbus-a320-registered-oe-ijf-operated-by-easyjet-on-20-07-2020-at-paris-charles-de-gaulle-ad/

[Locked door]

I transited French airspace twice yesterday.

Not a single controller listened to any read back or corrected the three incorrect read backs we heard, not a single controller listened to our initial contact messages containing info like where we were direct to, what our cruise level request was etc. One called us easyxxx twice before we managed to convince him we were from a different company and there was plenty of French only chat.

They only transmit, they don’t listen to what comes before or after. It seems to be policy because almost all of them do it.

[ATC Watcher]

Curious comments , you have to be a bit more specific as to where and when it was and was was unsafe in your eyes. . In Cruise in Upper airspace the controller anywhere does not have to read back anything. If it is extremely busy he/she will only acknowledge the call, not the contents.
As to not picking up the incorrect read backs, it is definitively not a policy anywhere, but as some of us have Mode S downlink of your aircraft parameters, and those are more relevant , a bad habit of not concentrating on R/T readbacks but what you actually see selected in the FD might be starting here. Not good. Lastly one comment you made would indicate a call sign confusion, yes. that is still a real and serious issue. and valid for everyone, pilots too....