What happened
On 2 July 2022, at Josep Tarradellas Barcelona-El Prat Airport, a runway incursion occurred involving a Delta Airlines Airbus A330-323X, registration N803NW, and a Ryanair Boeing 737-8AS, registration EI-DYO.
During a configuration change to the west runway setup, the local arrivals controller coordinated a non-preferential take-off for the Delta aircraft on runway 24R. Due to delays in the arrival sequence, the takeoff slot for the Delta aircraft was rescheduled twice. During these changes, the controller failed to re-coordinate the bypass taxiway (S14) with the north ground movement controller and neglected to activate the stop bar lights.
As the Ryanair aircraft was taxiing across the runway extension via taxiway S14, the Delta aircraft commenced its take-off run. The north ground movement controller, alerted by another controller, ordered the Ryanair aircraft to stop. However, the instruction was given after the aircraft had already passed the stop bar. The aircraft came to a halt on the extension of runway 24R. At 14:08:11 UTC, the Delta aircraft overflew the stationary Ryanair aircraft at a vertical separation of approximately 700 feet. No injuries or aircraft damage were reported.
The investigation
The CIAIAC investigation examined the actions of the local arrivals controller, the north ground movement controller, and the operational procedures in place. The investigation reviewed the airport's lighting control and indicating system (SMP) and the specific checklist used for non-preferential take-offs.
Investigators analyzed radar data from the Surface Movement Guidance and Control System, which confirmed that the stop bar was not activated until the Delta aircraft was already accelerating down the runway. The investigation also assessed the ergonomics of the lighting control panel, noting that controllers must leave their primary position to operate it, and reviewed the effectiveness of the existing non-preferential take-off checklist.
Findings
- The incident was caused by the local arrivals controller's failure to adhere to procedures by neglecting to stop the flow of traffic across the S14 bypass taxiway.
- The local arrivals controller did not re-coordinate the take-off with the ground movement controller following changes to the departure sequence.
- The stop bar lights were activated only after the Ryanair aircraft had passed the bar and the Delta aircraft was already on its take-off run.
- The north ground movement controller instructed the Ryanair aircraft to hold after it had already entered the runway extension, and failed to use radar surveillance to monitor the aircraft's position effectively.
- The design of the non-preferential take-off checklist was found to be inefficient due to long, complex phrasing.
- The ergonomics of the lighting control system were inadequate, as the system cannot be monitored from the controller's main working position.
Safety action
- REC 25/23 & REC 26/23: It is recommended that AENA, in collaboration with ENAIRE, improve the lighting control and monitoring system at Josep Tarradellas Barcelona-El Prat Airport so that it can be monitored from the controller's principal working position.