What happened
On October 18, 2022, at Venice Tessera Airport (LIPZ), a serious incident occurred involving two commercial aircraft: a Boeing 737-800, registration EI-EBE, and an Airbus A321-212, registration EC-JRE. The event took place under Low Visibility Procedures (LVP) due to heavy fog and visibility below 500 meters.
While the EC-JRE was on final approach to runway 04R, the EI-EBE was aligned on the same runway, awaiting takeoff clearance. During a shift change, the incoming Air Traffic Controller (ATC) incorrectly plugged his headset into a telephone line jack instead of the radio communication port. Consequently, the controller was unable to transmit to the aircraft.
Unaware of the failure, the controller cleared the EI-EBE for takeoff. The crew of the EI-EBE did not provide a readback, which went unnoticed by the controller. Approximately two minutes later, the crew of the EI-EBE, noticing TCAS traffic and unable to reach the tower, contacted the approaching EC-JRE directly via radio. The EI-EBE crew informed the arriving aircraft that they were occupying the runway and advised a go-around. Shortly after, the controller regained communication and instructed the EC-JRE to perform a go-around to avoid the aircraft on the runway.
The investigation
The ANSV conducted a field investigation at the ENAV SpA facility. The investigation revealed that the controller's workstation layout made it difficult to immediately identify the correct connection ports. Furthermore, the shift handover occurred during a critical operational phase, as the outgoing controller had already authorized the initial movements, leaving the incoming controller to manage the subsequent takeoff clearance in a developing scenario.
Findings
- The primary cause was a human error involving the improper connection of the headset to a telephone line, which prevented ground-to-air communications.
- The controller failed to notice the lack of readback from the EI-EBE crew following the takeoff clearance.
- The shift handover took place at an unstable moment in the operational sequence.
- The workstation design contributed to the error by obscuring the communication connectors from the controller's immediate view.