What happened
Between January and March 2014, Brussels International Airport (EBBR) experienced five separate runway incursion incidents. All five occurrences were classified as Category D severity, meaning they involved the incorrect presence of an aircraft on a runway protected area without immediate safety consequences.
In each instance, an aircraft mistakenly entered the wrong runway or turned toward an inactive runway. Specifically, three Turkish Airlines flights, one EasyJet flight, and one EgyptAir flight all failed to follow the correct path at taxiway B1. In several cases, the crews turned right toward runway 19 instead of the intended left turn toward runway 25R. While air traffic controllers intervened to cancel take-offs or instruct aircraft to stop, the pattern of entering the wrong runway remained consistent across the different operators.
The investigation
The AAIU(Be) conducted a limited-scope safety study to determine if systemic changes were required. The investigation reviewed meteorological data, air traffic control communications, aerodrome markings, and the aeronautical charts used by the flight crews.
Investigators examined the physical layout of the airport, specifically the V-shaped configuration where runway 25R and runway 19 intersect, sharing a single entry point via taxiway B1. The study also reviewed the effectiveness of the visual aids, such as mandatory instruction signs and information boards, and evaluated the clarity of the phraseology used by Belgocontrol controllers.
Findings
Several contributing factors were identified during the analysis:
- Aerodrome layout: The primary safety issue was the physical configuration of the runway entry. The single taxiway leading to two different runway ends creates a high risk of confusion.
- Crew familiarity: Many flight crews were not sufficiently familiar with the Brussels airport layout, which made them susceptible to errors during taxiing.
- Phraseology confusion: Although controllers used standard ICAO phraseology, the instruction "runway 25 RIGHT cleared for take-off" was noted as potentially confusing, as pilots might interpret the word "right" as a directional instruction.
- Chart discrepancies: The aeronautical charts used by some operators, specifically the Lido charts, featured runway indications that were not aligned with the actual runway centerlines, contributing to navigational errors.
- Cockpit workload: High workloads during the taxi phase, including performing checklists and monitoring charts, may have reduced the crew's ability to maintain a "head-up" orientation.
Safety action
Following the investigation, several actions and recommendations were established:
- Safety recommendation 2014-C-5: The AAIU(Be) recommended that the Brussels Airport Local Runway Safety Team circulate a safety information letter to sensitize all flight crews to the specific hot spot at taxiway B1.
- Safety recommendation 2014-C-6: The investigators strongly recommended that the Brussels Airport Company conduct a study to redesign the runway entry. The proposed solution involves splitting taxiway B1 into two separate taxiways, each equipped with stop bar lights, to physically prevent aircraft from entering the incorrect runway.