What happened
On 19 June 2024, at Seville Airport (LEZL), a runway incursion occurred involving an ATR72-212A, registration CN-COE, operated by RAM Express, and a Boeag 737-800, registration EI-DYC, operated by Ryanair.
The RAM Express flight, RAM925, was taxiing from stand 34 toward the runway 27 holding point. During the taxi, the crew experienced a MASTER CAUTION and ICING alert. While checking the weather radar, the crew inadvertently deviated from the assigned route, continuing straight onto taxiway E1 instead of turning left onto taxiway A.
Simultaneously, the Ryanair aircraft, RYR3262, was performing its takeoff run on runway 27. As the Boeing 737-800 reached its rotation point, the RAM Express aircraft reached the edge of the runway, positioned perpendicular to the active surface. The crew of the Ryanair aircraft flew over the ATR72-212A without noticing its presence. There were no injuries to the passengers or crew on either aircraft, and no damage was sustained.
The investigation
The CIAIAC investigation examined the taxi procedures, air traffic control (ATC) communications, and environmental conditions. The investigation established that the RAM Express crew suffered a loss of situational awareness due to a distraction caused by the icing alert and the subsequent radar scan.
Investigators also reviewed the ATC performance, noting that the controller provided an incomplete taxi instruction. While the crew provided an incorrect readback, the controller did not correct the error. Furthermore, the investigation looked into the airport infrastructure, specifically the lack of directional signage at certain gates and the transition from visual to instrument meteorological conditions (IMC) caused by heavy rain and thunderstorms.
Findings
- The primary cause of the incursion was the RAM Express crew's failure to adhere to taxi procedures.
- The crew's attention was diverted by an onboard icing alert and the use of the weather radar.
- The air traffic controller failed to correct an incorrect readback regarding the taxi route.
- The controller did not instruct the aircraft to stop before it reached the runway boundary, despite the aircraft taxiing in unauthorized areas for over one minute.
- A lack of directional and information signage at the G3 gate/taxiway A intersection contributed to the navigation error.
- Heavy rain and thunderstorms reduced visibility, and a delay in receiving the updated METAR meant that taxiway lighting configurations were not updated to reflect the change to IMC.