What happened
On November 29, 2007, at approximately 10:05 UTC, an Airbus A320, registration CS-TKK, took off from Madeira Airport (LPMA) without receiving takeoff clearance. The aircraft had previously been instructed to "line up and wait" on Runway 05. During the taxi, the commander handed control to the co-pilot and inquired about takeoff authorization; however, because the air traffic control (ATC) clearance had not been written down, the co-actualized the status of the clearance could not be confirmed. Operating under the assumption that authorization had been granted, the commander instructed the co-pilot to proceed with the takeoff.
Simultaneously, an Airbus A319 was performing a passenger flight, descending through 1,200 feet toward 600 feet for a runway 05 tailwind approach. As the CS-TKK climbed, the crew immediately identified the approaching traffic. Instead of following the Standard Instrument Departure (SID) procedure, which required a right turn, the crew maintained the runway heading to avoid the other aircraft. The tower controller, surprised by the unauthorized departure, issued instructions to the Airbus A319 to climb to 4,000 feet and instructed the CS-TKK to cap its climb at 1,500 feet. This resulted in the two aircraft crossing with a lateral separation of 1 nautical mile and a vertical separation of only 900 feet.
The investigation
The GPIAAF investigation reviewed radio communications and radar imagery, which confirmed the relative positions and the reduction in separation between the two aircraft. The investigation established that the crew of the CS-TKK did not record the ATC clearance in writing. The controller's actions were analyzed, noting that rather than ordering an aborted takeoff at high speed, the controller focused on managing the separation of the two aircraft in flight. The investigation also noted that while a Traffic Advisory (TA) was activated, no Resolution Advisory (RA) was triggered.
Findings
- The crew of the CS-TKK failed to write down the ATC clearance and proceeded with takeoff based on an incorrect assumption of authorization.
- The Airbus A319 crew was unaware of the unauthorized departure and was following instructions for a visual approach.
- The unauthorized takeoff was the primary factor leading to the loss of separation.
- The tower controller managed the conflict by adjusting the altitudes of both aircraft to maintain separation rather than attempting an aborted takeoff.
- The commander of the CS-TKK later contacted the tower to clarify the clearance, recognized the error, and apologized.
Safety action
To prevent a recurrence, it is recommended that the Flight Operations Department of SATA Internacional emphasize to its crews the necessity of maintaining a written record of all ATC clearances, particularly those involving ground maneuvers, altitude changes, or route variations. Furthermore, crews must be instructed to always request confirmation in the event of any doubt regarding instructions.