What happened
On March 22, 2015, a runway incursion occurred on runway 29 at Warsaw Chopin Airport (EPWA). The incident involved two aircraft: an Embraer 170 and an Embraelung 190.
The crew of the Embraer 170 was instructed to back track from taxiway A4 and line up on runway 29. Simultaneously, the crew of the Embraer 190, taxiing on taxiway E, received instructions to follow the first aircraft in sequence for departure. While the Embraer 170 was near taxiway N3, it received takeoff clearance. At that same moment, the Embraer 190 began entering runway 29. The crew of the Embraer 170 noticed the intrusion and reported it to the tower. The tower controller subsequently instructed the Embraer 190 to cross the runway threshold and vacate via taxiway L. The Embraer 170 departed first, followed by the Embraer 190 five minutes later.
The investigation
The investigation focused on the communications between the tower controller and both flight crews. It was established that the Embraer 190 crew was operating on a different frequency (Ground) and did not hear the clearance issued to the Embraer 170. The investigation also examined the controller's qualifications, noting that the controller held valid licenses and had completed recent safety training. The incident was reviewed with both flight crews and integrated into training materials.
Findings
- The primary cause of the incursion was the use of improper phraseology by the tower controller when issuing the clearance to the Embraer 190.
- The instruction "you are number two in sequence line-up runway 29" created a dangerous situation because the Embraer 190 crew could not visually identify the Embraer 170 taxiing on the runway from their position.
- A lack of communication awareness contributed to the event, as the Embraer 190 crew was monitoring the Ground frequency and was unaware of the instructions given to the Embraer 170 on the Tower frequency.
- The separation between the two aircraft at the time of the near-collision was approximately 200 meters.
Safety action
- The final report was forwarded to the Warsaw Airport Control Department to remind controllers of the obligation to use correct aviation phraseology.
- The report and collected materials were provided to the ATS Personnel Training Center to be used in basic and recurrent training for air traffic controllers, specifically regarding the use of standard phraseology.