Incident Overview
On March 22, 2015, at Warsaw Chopin Airport (EPWA), a runway incursion occurred on Runway 29 involving two Embraer aircraft: an E190 and an E170. The incident was classified as an incident (not an accident) by the Polish State Commission for Aircraft Accident Investigation.
Sequence of Events
The crew of the E170 received clearance to enter Runway 29 from taxiway A4 with instructions to backtrack and line up. Meanwhile, the E190 was taxiing via taxiway E for departure and was instructed, "number two for departure line up RWY 29 in sequence," which the crew acknowledged.
As the E170 reached taxiway N3, it received takeoff clearance. At that same time, the E190 began to enter Runway 29. The crew of the E170 reported this. The E190 crew was then instructed to cross the threshold of Runway 29 and vacate via taxiway L. The E170 took off first, followed by the E190 five minutes later.
Findings
The investigation determined that the runway incursion resulted from the tower controller using improper phraseology when issuing clearance to the E190. The phrase "...you are number two in sequence line-up runway 29…" overlapped with the configuration of the aircraft involved, as the E190 could not see the E170 taxiing on the runway until it reached the threshold. Additionally, when the controller cleared the E170 to enter the runway, the E190 crew was on a different frequency (ground control) and did not hear the clearance. Consequently, the E190 unexpectedly taxied onto Runway 29 ahead of the E170, which was preparing for takeoff.
The reaction occurred when the aircraft were approximately 200 meters apart. The E170 crew reacted first, followed by the tower controller, who instructed the E190 to cross the runway threshold and vacate via taxiway L.
The controller on duty held an air traffic control license with ADI and OJT ratings obtained in 2002 and 2008, respectively, and had valid medical examinations. He completed a refresher course on hazardous situations from January 27–31, 2014.
The incident was discussed with the pilots of both aircraft and was incorporated into training materials for periodic training.
Probable Cause
The Polish commission stated the cause as "Błędy w pracy ATM," which translates to "Errors in air traffic management."
Actions Taken
The entity that conducted the investigation took the following preventive actions: 1. Forward the final report to the Warsaw Airport Control Department to remind controllers of the obligation to use correct aviation phraseology. 2. Inform the participating controller of the conclusion of the proceedings and acquaint him with the results to reduce the likelihood of similar occurrences. 3. Forward the final report and collected materials to the ATS Personnel Training Center to incorporate them into the database of investigated events for use by instructors during initial and refresher training on correct phraseology.
No safety recommendations were formulated by the commission.