By Rudy Pont, BeCA Air Safety Committee Chairman

Facts

On 5 October 2016, an Air Dolomiti ERJ-195, operated on behalf of Lufthansa (DLH4TX) from Brussels to Munich, received a “line up and wait” instruction from the tower controller at C6 (holding point runway 07R). 20 seconds later, an Aer Lingus A320 (EIN638) on short final for runway 01, received its landing clearance. Despite the lack of take-off clearance, the Air Dolomiti took off from Runway 07R, causing a conflict with the landing A320. As soon as the conflict was detected, the tower controller instructed the Aer Lingus to go around.

Cause, contributing factors and safety recommendations

Unsurprisingly, the official investigation report (http://bit.ly/2uCOfGW) by the Belgian Aviation Accident Investigation Unit (AAIU) concluded that the cause of the incident was a “take-off without clearance” and identified the following contributing factors and associated safety recommendations:

• Not using a mnemonic (nose landing light) and/or cross-check for the take-off clearance.

Air Dolomiti added this mnemonic to their SOPs and updated the OM accordingly

• Limited traffic information/situational awareness given when delivering ATC clearances.

Belgocontrol ATCOs are now instructed to add the phrase “Landing traffic RWY XX” after a line-up clearance to improve situational awareness.

• Inadequate doubt-clearing management in the cockpit.

Air Dolomiti will include a doubt-clearing scenario in their training program and update OM.

• The unfamiliarity of the crew with the airport.
• Authorizing aircraft to line up on RWY 07R at a short distance from the intersection with RWY 01 without correlation with landing traffic on this latter.

Belgocontrol is requested to perform a study which defines the time-frame in which a “line-up and wait” (at position C6) instruction should be given, which reduces the risk of possible collision if not adhered to.

• Intersection and status of RWY 01 not indicated on RWY 07R.

Brussels Airport Company is requested to perform a study “to improve indications on runway 07R of both presence and status of runway 01/19”, for example runway status lights (http://bit.ly/2osg5TA).

• The complex taxiway layout (junction connecting 6 taxiways right before C6, the oblique angled entry taxiway including a part of the taxiway centreline lights).

Brussels Airport Company is recommended to make a study aimed to reduce the complexity of the taxi route to the current line-up position 2.

BeCA comments

BeCA wishes to commend the AAIU for its comprehensive investigation and the professional report. Our IFALPA accredited accident investigators were – among many other safety experts – happy to share their operational expertise on this specific incident. Most of the comments we made were taken on board, which shows that BeCA is an essential safety partner. BeCA is pleased with the factual and non-accusative language of the report and looks forward to sharing relevant experience and knowledge on any future incidents/accidents.

Once more, this incident demonstrates the inherent danger of crossing runway operations. As a pilot, always challenge a clearance if unsure and be aware of the presence of other traffic on crossing runways.