What happened
On 15 April 1999, a Dornier DO 328-100, registration G-BWWT, was parked at Stand 1 at London (City) Airport. During the morning preparations for a public transport flight, the crew requested engine start and received clearance from the Tower controller. Following this, the crew was cleared to taxi to holding point Bravo.
While taxiing, the crew encountered a cockpit warning regarding a windshield heat malfunction. While addressing this issue, the aircraft inadvertently crossed the holding position markings at Bravo. At that moment, a SAAB 2000 was on its landing roll on Runway 28. The SAAB passed approximately 10 metres from the nose of the stationary Dornier.
Following the near-miss, the Tower controller instructed the Dornier to enter the runway to backtrack and vacate at Alpha. The crew entered the runway and began a right-hand turn toward the threshold. This prompted the controller to issue immediate corrective instructions to turn left, hold position, and perform a 180-degree turn to vacate the runway at Bravo. Due to the presence of the Dornier on the runway, the controller was forced to instruct arriving traffic to execute a go-around.
The investigation
The investigation examined the actions of the flight crew and the sequence of communications between the aircraft and Air Traffic Control. It was established that the crew's attention had been diverted by an aural warning and a cockpit caption related to the windshield heating system.
Investigators also reviewed the airport's ground markings and lighting. The runway guard lights, commonly known as 'Wig-Wags', were found to be operational and flashing at the time of the event. The investigation also looked into the crew's interpretation of ATC instructions, noting that the crew initially misunderstood the instruction to backtrack as an instruction to line up on the runway.
Findings
- The primary cause of the incursion was the crew becoming distracted by a flight deck malfunction related to the windshield heat system, which led them to pass the holding point.
- A secondary confusion occurred when the crew misinterpreted ATC taxi instructions, leading to the unauthorized entry of the runway and the subsequent requirement for landing aircraft to go around.