What happened
On 4 November 2004, at approximately 16:20 UTC, a Boeing 767-200, registration G-SATR, collided with a stationary Boeing 737-300, registration G-ODSK, while taxiing at Manchester Airport. The G-SATR was being operated on a scheduled flight to Goa, India, and was navigating the taxiway system following instructions from Air Traffic Control (ATC).
As the G-SATR commenced a right-hand turn onto Taxiway ‘V’, its left wing struck the right horizontal stabilizer of the stationary G-ODSK. The impact caused damage to the G-SATR's left wing leading edge and the G-ODSK's tail section. There were no fatalities and no injuries to the crew or passengers on either aircraft. Following the collision, the commander of the G-SATR briefly lost consciousness due to shock, but recovered after receiving first aid.
The investigation
The AAIB investigation examined the flight data, cockpit voice recordings, and ATC communications. The investigation established that the G-SDTR crew was managing several operational pressures, including a recent change in aircraft type, weight and balance considerations, and the need to complete pre-takeoff checklists under time constraints.
Investigators also reviewed the ATC procedures at Manchester. The Air 2 controller had amended the clearance limit for the G-ODSK from ‘V5’ to ‘T1’, which placed the stationary aircraft in a position that intersected the path of the turning G-SATR. While the Surface Movement Radar (SMR) could have identified the potential conflict, it was not being used for separation purposes due to the clear weather conditions.
Findings
- The primary cause of the collision was the misjudgement of available separation by the G-SATR commander.
- The commander's error was driven by a combination of physiological limitations, such as the inability to see the wingtip during a turn, and significant distractions caused by operational and time pressures.
- A false assumption was made by the crew that the ATC clearance implicitly guaranteed safe separation.
- The Air 2 controller's decision to amend the clearance limit for the stationary aircraft contributed to the potential for conflict.
- The crew's attention was divided by the need to review performance figures and complete checklists during the taxi phase.
Safety action
- A recommendation was made for Manchester Airport ATC to review local working practices regarding south side taxiways to ensure standardization and accuracy in reflecting MATCC Part 2 requirements.
- A recommendation was made to review MATS Part 2 to ensure all south side taxiway information is included to assist controllers.
- A recommendation was made to consider mandating the recording of frequency 121.6 MHz at relevant aerodromes.