ASN Wikibase Occurrence # 305813
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| Date: | Saturday 31 December 2022 |
| Time: | 09:56 UTC |
| Type: |  Airbus A320-214 (WL) |
| Owner/operator: | easyJet UK |
| Registration: | OE-INE |
| MSN: | 7750 |
| Year of manufacture: | 2017 |
| Engine model: | CFMI CFM56-5B4/P |
| Fatalities: | Fatalities: 0 / Occupants: 185 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Bordeaux-Mérignac Airport (BOD/LFBD) -
 France
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | London-Gatwick Airport (LGW/EGKK) |
| Bordeaux-Mérignac Airport (BOD/LFBD) | |
| Investigating agency: | BEA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Following the take-off of an Airbus A321, the pilot of a Robin DR.400 (F-GTZY) was cleared to line up on runway 23 at Bordeaux Airport, France.
While the pilot of the DR.400 was still waiting for clearance to take off, the controller cleared easyJet UK flight U28013, an Airbus A320-214 (OE-INE), to land on runway 23. The pilot of the DR.400 reported his position on the frequency. The controller then ordered the crew of the A320 to fly a missed approach.
The lowest point of the trajectory was located at a height of 103 ft, at a distance of approximately 290 m from the runway threshold. The A320 flew over the DR400 at a height of 178 ft, then continued on the standard trajectory.
Contributing Factors:
Several factors may have contributed to the clearance for landing on an occupied runway:
- Reduced Staffing: A significant decrease in staffing levels, well below those scheduled, resulted in an unplanned consolidation of very different positions (Ground and Tower on one hand, Approach and Flight information on the other). This created a high workload for the controller handling all four positions simultaneously, potentially leading to the oversight of positioning the DR400 strip on the "runway" section of the strip board.
- Low Contrast: The low visual contrast between the DR400 and the runway surface at the runway threshold made it more challenging for both the controller in the tower and the A320 crew to visually perceive the DR400.
- Supervision Absence: The absence of supervision in the control tower by the shift manager, who was engaged in the assistant Tower function, may have contributed to the oversight.
- Insufficient Awareness of Risk: There was likely insufficient awareness of the risk generated by a shortage of controllers present at their workplace, especially in the case of an unforeseen increase in traffic or to provide relief in the event of a safety incident.
Factors contributing to the unplanned consolidation of different positions and inadequate control position staffing:
- Managerial Practices: The practice of shift managers to reduce the actual staffing levels compared to those scheduled, known and implicitly tolerated by the management.
- Lack of Monitoring Tools: The absence of a reliable, automatic, real-time tool to collect information on control position staffing and the number of controllers present at the workplace, and to analyze the potential contribution of these two factors in the event of a safety incident. Such analyses would allow shift managers and management to objectively assess the actual staffing needs and control position staffing based on planned or observed levels and types of air activities.
Factors that may have maintained a high level of risk after the serious incident:
- Understaffed Planning: The shift manager's planning of a staffing level below the scheduled level, preventing short-term relief or reinforcements.
- Failure to Reevaluate Organization: The failure to reconsider the planned organization despite the occurrence of the serious incident.
The awareness and proactive action of the DR400 pilot, who signaled at the runway threshold while the A320 was on short final, prevented the serious incident from esacalating into an accident.
Accident investigation:
 |
|
Sources:
https://bea.aero/en/investigation-reports/notified-events/detail/incident-to-the-airbus-a320-registered-oe-ine-operated-by-easyjet-and-to-the-robin-dr400-registered-f-gtzy-on-31-12-2022-at-bordeaux-merignac/
Location
Images:
Photo: BEA France
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 19-Dec-2023 08:41 | harro | Updated [Total occupants, Other fatalities, Narrative, Category, Accident report] |
| 19-Dec-2023 09:28 | harro | Updated [Other fatalities, Narrative, Photo] |
Corrections or additions? ... Edit this accident description
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