What happened
On the evening of 5 October 2016, a runway incursion occurred at Brussels Airport (EBBR) involving an Embraer ERJ-195 operated by Air Dolomiti and an Airbus A320 operated by Aer Lingus. The Air Dolomiti flight, traveling from Brussels to Munich, was preparing for departure from Runway 07R. After receiving instructions to "line up and wait," the crew proceeded onto the runway.
Simultaneously, the Aer Lingus aircraft was on final approach to land on Runway 0 and1. While the Air Dolomiti crew was positioned on the crossing runway, the captain initiated the take-off roll without receiving the necessary clearance from the tower. This movement placed the aircraft in direct conflict with the descending Airbus A320. Upon realizing the situation, the Brussels Tower instructed the Aer Lingus pilot to perform a go-around to avoid a collision. There were no injuries to the passengers or crew on either aircraft.
The investigation
Investigators examined the cockpit communications, flight data recorders, and the complex taxiway layout at Brussels Airport. The investigation focused on the coordination between Air Traffic Control (ATC) and the flight crews, specifically regarding the simultaneous use of intersecting runways. The inquiry also reviewed the workload of the crew during taxiing, noting that the night operations and a complex taxiway configuration contributed to the high mental workload. The investigation looked into the specific instructions provided by the tower and the lack of visual indicators at the runway intersection.
Findings
- The primary cause of the incident was the take-off without clearance by the Air Dolomiti crew while an aircraft was on final approach on the intersecting runway.
- The Air Dolomiti crew did not utilize a mnemonic or cross-check procedure to verify their take-off clearance.
- The crew experienced high workload and reduced situational awareness due to an unfamiliar and complex taxiway layout and nighttime conditions.
- There was a lack of effective doubt-clearing management within the cockpit.
- ATC provided limited traffic information regarding the crossing runway traffic when issuing the "line up and existing" instruction.
- The intersection of Runway 07R and Runway 01 lacked sufficient visual indicators to alert the crew to the status of the crossing runway.
Safety action
Following the incident, Belgocontrol implemented a new procedure requiring controllers to inform aircraft that are lining up to wait about the presence of landing traffic on the crossing runway. Air Dolomiti was encouraged to use the event as a case study for recurrent training. The AAIU(Be) issued several safety recommendations, including a requirement for flight crews to confirm take-off clearances between both crew members and a recommendation for Brussels Airport Company to study improvements to runway markings and taxiway complexity to reduce the risk of future incursions.