What happened
On January 28, 2001, a Cessna 441 was conducting a commercial instrument flight from PaderbornLippstadt to Düsseldorf. While on a stabilized instrument approach to runway 23R, the flight crew established contact with Düsseldorf Tower at 11:03. The controller offered a runway change (swingover) to runway 23L. The crew accepted the change and reported visual contact with the field at 11:04.
Shortly after, the controller cleared the aircraft for a "long landing" on runway 23L. However, the crew misidentified the approach path. As the aircraft descended, it flew over a Boeing 767 that was taxiing on taxiway M toward the 23L holding position. Radar data indicated the Cessna passed at an altitude of approximately 300 to 400 feet. The controller only noticed the error when the Cessna was nearly at touchdown on the taxiway. Although the controller issued an immediate instruction to go around, the pilot proceeded with the landing on taxiway M.
The investigation
The investigation examined the crew's actions during the runway change and the controller's monitoring of the approach. The investigation established that the crew performed the runway change based solely on visual references. During this maneuver, the pilot lost visual contact with runway 23R and subsequently misidentified taxiway M as runway 23L, and runway 23L as runway 23R.
The crew noted that visibility was affected by light haze and sun glare during the approach. The investigation also found that the controller's view of the area east of taxiway M was restricted due to the tower's location, and there had been no specific reason for the controller to actively scan that specific area for a runway excursion until the error was already underway.
Findings
- The pilot experienced a loss of situational awareness regarding runway positioning during the visual transition between runways.
- The crew misidentified taxiway M as the assigned runway 23L.
- The pilot did not realize the error even when flying over the Boeing 767, mistakenly assuming the controller's "long landing" instruction was due to the aircraft's position.
- Environmental factors, including haze and sun glare, contributed to the difficulty in maintaining visual references.
- No injuries or damage to the aircraft or third parties occurred, as the Boeing 767 was sufficiently far away at the time of the overflight.