What happened
On January 13, 2020, at approximately 15:15 UTC, two training aircraft were involved in a near-collision at Madrid-Cuatro Vientos Airport (LECU). The first aircraft, a Cessna 172R (registration EC-KNI) operated by European Flyers, was on short final for runway 27. At the same time, a Piper PA-34-220T (registration EC-FIF) operated by Aerotec was authorized for takeoff on the same runway.
As the Cessna 172R was approximately 0.4 NM from the threshold at an altitude of about 230 feet above the runway, the Piper PA-3_4-220T began its takeoff roll. To avoid a collision, the pilot of the Cessna 172R initiated an unplanned go-around maneuver, performing a power-on climb to the left of the runway. The investigation determined that the minimum separation between the two aircraft reached approximately 0.22 NM during the critical moment of the event. There were no injuries to the crews and no damage to either aircraft.
The investigation
The CIAIAC investigation examined radar data, air traffic control communications, and meteorological reports. The investigation focused on the actions of the trainee air traffic controller and the instructor (OJTI) on duty. Investigators analyzed the sequence of movements, noting that while the Cessna 172R failed to follow standard reporting procedures regarding its position in the traffic pattern, the primary focus was on the controller's management of the runway occupancy.
Radar traces confirmed that the Piper PA-34-220T was at a speed of approximately 70 knots and 1,350 feet from the threshold when the separation was at its minimum. The investigation also reviewed the workload of the control tower, which was managing approximately six aircraft at the time of the incident.
Findings
- The primary cause of the incident was an incorrect perception of the operational situation by the trainee air traffic controller, which led to a loss of situational awareness regarding the proximity of the arriving aircraft.
- The trainee controller failed to provide essential traffic information, specifically failing to inform the Cessna 172R of the departing Piper PA-34-220T, and failing to warn the Piper PA-34-220T of the arriving Cessna 172R.
- A contributing factor was the lack of timely intervention by the instructor controller (OJTI).
- The controller failed to prioritize tasks effectively, specifically by not instructing the arriving aircraft to turn to crosswind earlier and by delaying the takeoff authorization for the departing aircraft until the arriving aircraft was too close to land safely.
- Meteorological conditions were favorable, with no significant visibility or wind issues that could have contributed to the event.