What happened
On October 23, 2020, at approximately 16:15 UTC, a Boeing 737-800, registration EI-EBC, was performing a commercial passenger flight departing from Málaga-Costa del Sol Airport (LEMG). Simultaneously, a Beechcraft B200, registration EC-MUP, was on final approach to the same airport for an emergency medical services flight.
The incident began when the air traffic controller at the local control position provided taxi instructions to the Boeing 737-800 without specifying a particular holding point. Consequently, the crew of EI-EBC taxied to the holding point nearest to the threshold of runway 13. The controller then instructed the aircraft to line up on the runway and wait behind the incoming traffic, which was 2.4 NM from the threshold.
While the Boeing 737-800 was in the process of its takeoff roll, the controller authorized the Beechcraft B200 to land, noting the preceding aircraft was in sight. However, the departing aircraft was still occupying the runway. The horizontal separation between the two aircraft reduced to a minimum of 0.8 NM as the Beechcraft B200 overflew the runway threshold.
The investigation
The CIAIAC investigation examined the sequence of movements, communications, and operational procedures at the Málaga tower. The investigation reviewed the controller's instructions, the use of language in radio telephony, and the airport's operational manuals regarding runway occupancy and separation. The investigators also analyzed the historical context of separation loss events at LEMG and the effectiveness of previous action plans implemented by ENAIRE.
Findings
- The air traffic controller failed to specify a precise holding point for the departing aircraft.
- The controller authorized the takeoff of EI-EBC while the arriving EC-MUP was only 2.2 NM from the threshold, without confirming if the departing crew was ready for immediate departure or informing them of the arriving traffic's position.
- The controller used English to communicate with the departing aircraft but switched to Spanish for the arriving aircraft, violating established regulations regarding a single language for ground-to-air communications.
- The controller authorized the landing of EC-MUP while the runway was still occupied by the departing Boeing 737-800.
- Deficient planning of the arrival and departure sequence was the primary cause of the loss of separation.
- There was evidence of operational pressure to utilize available gaps in arrivals and a tendency to use nominal separation gaps for multiple departures.
- The investigation noted a recurring pattern of separation loss events at this airport, despite previous mitigation plans.
Safety action
- REC 15/22: Recommended that ENAIRE establish additional mitigation measures in coordination with AESA to address the risks of separation loss at Málaga Airport.
- REC 16/22: Recommended that AESA review the proposed additional mitigation measures.
- REC 17/22: Recommended that ENARE review compliance with English language usage requirements in air traffic control communications at Málaga Airport.