What happened
On 31 December 2022, an Airbus A320, operated by easyJet Europe, was on final approach to runway 23 at Bordeaux-Mérignac airport. At the same time, a Robin DR400, registered F-GTZY, was positioned at the runway threshold after being cleared to line up and wait. The DR400 pilot had been instructed to hold his position due to wake vortex separation requirements following the departure of an Air France A321.
Due to heavy VFR traffic, the air traffic controller was managing multiple combined positions, including ground, tower, approach, and information. While managing several radio exchanges, the controller cleared the Airbus A3 and0 to land, having forgotten that the Robin DR400 was still occupying the threshold. The pilot of the F-GTZY noticed the incoming traffic and alerted the controller. The controller immediately ordered the Airbus A320 to abort the approach. The crew performed a missed approach, passing over the Robin DR400 at a height of approximately 178 feet. Following the incident, the Airbus A320 requested a shortened path and landed safely on runway 23.
The investigation
The BEA investigation focused on the staffing levels and the management of air traffic control positions at the tower. Investigators established that although the duty roster had programmed six controllers for the shift, the tower supervisor had reduced the active staff to only three controllers. One controller was managing the combined GND, TWR, APP, and INFO positions. The investigation also examined the communication environment, noting that the controller was handling high-density VFR traffic and multiple simultaneous radio frequencies.
Findings
- The primary cause of the incident was the controller's failure to recognize the presence of the aircraft at the runway threshold due to the high workload of managing combined positions.
- A significant contributing factor was the reduced staffing level at the control tower, where the number of controllers on duty was lower than the programmed duty roster.
- The controller was managing a high volume of VFR traffic, which necessitated frequent interruptions and complex radio exchanges across multiple frequencies.
- There was a lack of a reliable system to verify the actual presence of controllers at their workstations or to monitor staffing levels against the duty roster.