Background
On 30 October 2009 at 1900 UTC, a serious incident occurred at Exeter Airport, Devon, involving two commercial air transport aircraft: a DHC-8-402 Dash 8 (registration G-JECL) and a Boeing 737-5H6 (registration G-PJPJ). The Dash 8 was scheduled to operate from Exeter to Edinburgh, while the Boeing 737 was on a positioning flight with no passengers.
History of the Flight
The Dash 8 crew had completed three earlier sectors that day, all delayed by at least 15 minutes. The incident occurred on the fourth sector, which began with an uneventful pushback and start. The crew received taxi clearance to Holding Point Alpha One for Runway 08, which they read back correctly. During the pushback, an empty Boeing 737 came onto the Tower frequency when at 8 nm finals and was cleared to land on Runway 26.
During the taxi phase, the commander, who was taxiing, requested the co-pilot to complete the Taxi Checks. The co-pilot was predominantly "heads in" during the checklist. When the co-pilot challenged the commander with the last item on the Taxi checklist, 'CLEARANCES', the commander responded "to come" and instructed the co-pilot to continue with the Line Up checklist. The commander commented on their previous departure from Exeter, during which they had waited a long time on the runway for departure clearance after being given line-up clearance. He later stated that he had, by mistake, reverted to the previous clearance.
As G-JECL approached the entry point for Runway 08, the co-pilot commented on moving lights on the runway. The commander believed it was a car, but the co-pilot disagreed, saying it looked like an aircraft. At that point, the commander realized they had only been cleared to Holding Point Alpha One. The Tower controller, monitoring the Boeing 737's landing roll, saw the lights of G-JECL moving on the runway and asked "CONFIRM YOU'VE LINED UP?" The commander replied "AFFIRM". The controller responded "YOUR CLEARANCE WAS TO ALPHA ONE THERE'S TRAFFIC JUST LANDED ON 26 THRESHOLD." The Boeing 737 crew noticed G-JECL on the runway only when their aircraft's speed was approaching taxi speed, shortly before they vacated Runway 26 at Intersection Bravo. After the Boeing 737 cleared the runway, G-JECL received its clearance and departed.
Analysis
The AAIB investigation noted that the crew did not realize Runway 26 was in use, as they did not register the Boeing 737's landing clearance while concentrating on their pushback. Both crew members were likely tired after a broken night's sleep and a busy day trying to regain schedule. The co-pilot was not adequately monitoring the commander, who was unfamiliar with the airport. The crew had been discussing their first sector at the time of the incident, conditioning them to expect the same clearance. The commander also asked for the Line Up checklist despite the Taxi checklist not being completed. These factors led the crew to become distracted enough to cross Holding Point Alpha One and line up on Runway 08 contrary to their ATC clearance.
Aftermath
The commander notified the operator's operations department after the fifth sector and filed an Air Safety Report the following day. The operator stated that it would publish a report in its flight safety magazine and that the Dash 8 Fleet Manager would examine remote bases culture and operating standards, emphasizing the importance of normal checklist procedures.
Exeter Airport does not have red stop bars at holding points, as it complies with CAP 168 requirements. The Flight Data Recorder from G-JECL captured the incident, but the Cockpit Voice Recorder recording was overwritten because the crew operated two additional sectors after the incident, contrary to the operator's Operations Manual.