What happened
On 20 July 2020, at Paris-Charles de Gaulle airport, a serious runway incursion occurred involving a United Airlines Boeing 787-10, registration N16009, and an EasyJet Airbus A3 and20-214, registration OE-IJF.
During the approach, the United Airlines crew was cleared for an ILS approach to runway 09L. However, the local controller, while managing heavy traffic on the parallel runway 09R, mistakenly issued a landing clearance for runway 09R. The United Airlines crew responded to the clearance by stating they "understand" and would perform a "sidestep for 9 Right." The controller did not verify this read-back.
As the Boeing 787-10 began its visual sidestep maneuver toward runway 09R, the EasyJet Airbus A320-214 was cleared to line up and hold at taxiway D5 on the same runway. The EasyJet crew, upon entering the runway, noticed the Boeing 787-10 banking toward them. The Airbus captain immediately requested a go-around. The United Airlines crew, having also spotted the Airbus on the runway, initiated a missed approach. The Boeing 787-10 passed over the Airbus A320-214 at a height of approximately 300 ft, narrowly avoiding a collision.
The investigation
The BEA examined radar data, flight data recorders, and radio communications. The investigation focused on the controller's workstation configuration and the communication exchange between the aircraft and the tower. It was established that the controller was operating from a secondary position (NE LOC) because the primary NW LOC control screen was inoperative. From this position, the controller lacked a direct view of the runway 09 thresholds. The investigation also looked into the use of non-standard phraseology by the flight crew and the impact of reduced traffic frequency during the COVID-19 pandemic on controller reflexes.
Findings
- A controller error (lapsus) led to the incorrect landing clearance being issued for runway 09R.
- The controller failed to check the read-back, which contained the specific mention of a sidestep to the wrong runway.
- The use of the non-standard term "understand" by the United Airlines crew, rather than a request for confirmation, may have contributed to the lack of immediate correction.
- The controller's focus was divided by managing multiple aircraft crossings and departures on runway 09R, as well as an impending change in workstation position.
- The controller's reduced practice due to the COVID-19 pandemic may have impacted operational reflexes.
- The secondary controller position used by the tower prevented a clear visual of the runway thresholds.