History
On Monday 26 April 2004, at 13:09 UTC, aircraft DLH3703, an ATR42-500, taxied onto taxiway GOLF for departure from runway 05 and contacted Geneva Control Tower. At 13:10, flight KLM1931, a Boeing 737-300 (registration PH-BDB), reported established on the ILS for runway 05. An Avro RJ85, flight SWR607N, was on short final.
The aerodrome controller asked DLH3703 if ready for immediate departure; the pilot replied negatively. The controller was handling heavy traffic, including VFR aircraft. At 13:11, SWR607N was cleared to land. DLH3703 then stated readiness. At 13:12, the controller instructed DLH3703 to hold short of the runway, expecting departure behind the second landing aircraft (KLM1931).
At 13:13, SWR607N landed. While it decelerated, the controller did not notice DLH3703 had entered runway 05 and was lining up. The controller was busy with VFR traffic. At 13:14, he cleared KLM1931 to land. The pilot of KLM1931 saw DLH3703 on the runway, expecting an immediate take-off, but at about 300 ft above ground level decided to go around. About 10 seconds after the landing clearance, DLH3703 called the tower confirming it was on the runway. The controller immediately instructed KLM1931 to go around. The go-around was initiated at about 0.5 NM and 1700 ft.
Findings
- Weather: Wind 040° 7 kt, visibility 10 km, few clouds at 5000 ft, temperature +15°C, QNH 1016 hPa, NOSIG.
- Runway 05 in use.
- Grass runway closed to VFR.
- Controller held valid license.
- Communications on 118.7 MHz in English.
- 11 aircraft controlled in 7 min 22 sec: 3 departures, 5 arrivals, 3 VFR.
- At 13:09:55, DLH3703 called tower, said would call when ready.
- At 13:10:43, KLM1931 called, reported established on ILS.
- At 13:10:51, controller asked DLH3703 if ready for immediate departure.
- At 13:10:54, pilot answered no.
- At 13:11:24, SWR607N cleared to land.
- At 13:11:58, DLH3703 reported ready for take-off.
- At 13:12:30, controller instructed DLH3703 to hold short, expect departure behind second landing aircraft. No conditional clearance issued.
- At 13:12:33, DLH3703 acknowledged with "ROGER".
- At 13:13:09, SWR607N crossed threshold.
- DLH3703 pilot stated he believed he had clearance to line up behind the Avro RJ85 after it cleared threshold.
- Between 13:13:11 and 13:14:15, controller handled 15 communications, mainly with VFR.
- At 13:14:15, KLM1931 cleared to land at 1.5 NM, 2000 ft.
- At 13:14:20, KLM1931 read back clearance.
- At 13:14:22, controller handed SWR607N to apron frequency.
- At 13:14:30, DLH3703 stated it was on the runway.
- At 13:14:36, controller instructed KLM1931 to go around, climb to 7000 ft toward Saint-Prex VOR.
- At 13:14:42, KLM1931 read back at 0.75 NM from touchdown.
- KLM1931 pilot reported observing aircraft on runway, expected take-off, decided go-around at ~300 ft.
Analysis
Aircraft DLH3703 received instruction to hold short and expect departure behind second landing. The pilot acknowledged with "ROGER" instead of a proper read-back. The controller did not issue a conditional clearance. According to the pilot, he understood the instruction as permission to line up behind the next landing. The crew did not visually confirm the final approach was clear nor use TCAS. The crew only realized the conflict when KLM1931 was cleared to land and then alerted the tower.
Aircraft KLM1931, when DLH3703 entered the runway, was at 3-4 NM on ILS at 2800 ft. The crew may have assumed an immediate departure. Despite being cleared to land at 1.5 NM, the pilot did not inform the tower that the runway was obstructed. The go-around was initiated at about 300 ft.
The aerodrome controller, during a heavy workload, was distracted by a VFR conflict requiring head-down radar observation. He did not visually monitor DLH3703's compliance and issued a landing clearance without confirming runway clear. The lack of a proper read-back increased risk. The controller became aware only when DLH3703 reported being on the runway. He then issued the go-around. The controller noted that assistance from a TWR coordinator might have helped detect the error.
The TWR control unit comprised three positions: ADC, TRC, and GND.