What happened
On June 13, 2014, a runway incursion occurred at Palma de Mallorca Airport during single-runway operations. The airport was operating exclusively on runway 24L following a fuel spill that closed runway 24R.
A Boeing 737-800, registration D-AHFH, operated by TuiFly, was taxiing toward runway 24L. The air traffic controller intended to insert this departure into the arrival sequence between the 4th and 5th arriving aircraft. The aircraft was cleared to line up and wait after the 4th aircraft landed. However, by the time the controller attempted to cancel the clearance due to insufficient separation, the Boeing 737-800, registration OO-JLO, operated by JetAirfly, was already on final approach.
As the 4th aircraft landed, the taxiing aircraft, D-AHFH, had already moved past the holding point and was positioned 60 meters from the runway centerline, placing it within the runway protection zone. The controller instructed the crew of OO-JLO to prepare for a go-around. In response, the crew of OO-JLO proposed a visual landing, noting they had the taxiing aircraft in sight and believed the maneuver was safe. The controller, using the non-standard phraseology "at your discretion," cleared the aircraft to land. The landing was completed without further incident, and no injuries or aircraft damage were reported.
The investigation
The CIAIAC investigation examined radar records, communications, and the decision-making processes of both the air traffic controller and the flight crews. The investigation analyzed the traffic sequence, which had shifted to a heavy inbound pattern minutes before the incident. Investigators also reviewed the letter of agreement between the Palma TACC and TWR, which specifies separation requirements for such traffic patterns.
Findings
- The primary cause of the incursion was the failure to coordinate an appropriate separation distance between arriving aircraft to safely accommodate the departure of D-AHFH.
- The controller did not instruct the preceding aircraft to exit the runway quickly, nor did they request a speed reduction for OO-JLO early enough in the approach to maintain necessary separation.
- The controller's decision-making was influenced by high workload due to the closure of runway 24R and accumulated traffic delays.
- A change in the traffic pattern to a predominantly inbound flow just minutes before the incident contributed to the loss of required separation.
- The crew of the approaching aircraft voluntarily chose to proceed with a visual landing despite the initial go-around instruction.