What happened
On January 22, 2022, at 21:21 local time, an EMBRAER 190-200 LR, registration EC-LFZ, operated by Air Europa Express, landed on runway 32R at Adolfo Suárez Madrid-Barajas Airport. At the same time, a BOEING 737-800, registration EC-MXM, operated by Air Europa, was on final approach approximately 3.1 NM behind the first aircraft.
As the Embraer was vacating the runway, the air traffic controller instructed the crew to expedite their exit. Instead of using the prescribed taxiway K5, the crew exited via taxiway K4. Simultaneously, the controller instructed the Boeing 737 crew to execute a "go-around" (motor y al aire). However, this instruction was obscured by overlapping radio communications from another aircraft. The Boeing 737 crew proceeded to land at 21:23:13, at which point the Embraer had already cleared the runway threshold of K4. The Boeing 737 subsequently exited the runway via the same K4 taxiway at 21:24:06.
The investigation
The investigation examined radar data and Quick Access Recorder (QAR) information from both aircraft. The analysis revealed that a controller handover occurred shortly before the incident, which coincided with the period when the aircraft were approaching the runway.
Investigators found that the controller's instruction to the Boeing 737 to perform a go-around was inaudible to the crew because it coincided with a transmission from another aircraft. Furthermore, the controller failed to use the standard "BREAK, BREAK" phraseology to separate the instructions for the two different aircraft. While the Boeing crew did not hear the go-around instruction, they also failed to respond to the controller's later warning that the runway was occupied as they crossed the threshold.
Findings
- The Embraer crew failed to adhere to established procedures by exiting via taxiway K4 instead of the K5 taxiway specified in the AIP.
- The Boeing 737 crew landed without express authorization from air traffic control.
- The air traffic controller failed to prioritize tasks effectively and did not use standard phraseology to separate transmissions.
- The controller's instruction to the Embraer crew to expedite their exit occurred 15 seconds after the aircraft had already passed the correct exit (K5).
Safety action
- A recommendation has been issued to ENAIRE to conduct a study regarding the number of medium-wake turbulence aircraft using taxiway K4 for runway 32R instead of the mandated K5, to determine if the current regulation should be updated.