Serious incident to the Embraer ERJ190 - 100LR registered CS-TPV on 06/11/2017 at Nice Côte d'Azur (Alpes-Maritimes)

Investigation progression Closed
Progress: 100%

The crew left parking area 10B at 19:17, more than an hour late on the scheduled time, with a west-facing push-back proposed by the controller for taxiway T, for a flight bound for Lisbon.

The ground controller cleared the crew to taxi via taxiways T and A, and to hold at holding point A1 in order to take off from runway 04L. The crew read back the route but not the instruction to hold at the holding point. One minute later, at the crew’s request, the ground controller confirmed the taxi route. The crew then started up the second engine. A few seconds later, the first officer carried out the flight control tests while the aeroplane was taxiing.

When the aeroplane was in the middle of the bend from taxiway T to taxiway A, the crew contacted the tower controller and indicated that they were at holding point A1 for runway 04L, ready for departure. The tower controller cleared them to line up on runway 04L.

Forty seconds later, the tower controller cleared the crew to line up and take off from runway 04L. The aeroplane was at this point on taxiway U. The controller repeated the clearance ten seconds later and specified that they were to make a quick take-off. The crew requested to “stand by please.” The tower controller then asked them to hold at holding point A1. The crew replied that they were on the runway without using the word “negative” as specified by the standard phraseology. The controller replied “OK” and asked them to contact him when they were ready.

When the crew indicated that they were ready, the tower controller cleared them to line up and make a quick take-off from runway 04L. The crew read back the take-off clearance and started the take-off. Around 20 s later, the tower controller asked them to immediately cancel the take-off as they were on the taxiway. The aeroplane had travelled around 550 m from the application of thrust and the aeroplane speed was then more than 85 kt. The crew rejected the take-off. The crew then again asked for clearance to take-off which occurred at 19:33. The flight to Lisbon took place without any particular event.

The west-facing push-back from the aeroplane’s stand led the ground controller to choose, from habit, the route via taxiway T. As for the crew, they were used to using taxiway U to get to the runway 04 thresholds. They thus found themselves in an unusual situation without probably realizing it and even though they correctly read back the ground controller’s messages about taxiing.

The crew taxied without sufficiently looking outside for visual references (lighting, signs, indications) and without using and checking the charts at their disposal. The number of actions to be carried out, in particular due to the starting up of the second engine while taxiing, and the short taxiing time from push-back from the stand probably contributed to limiting the crew’s availability to monitor, check and confirm the position of the aeroplane while taxiing.

On arriving at the end of taxiway T, the captain mistook the taxiway A sign for the mandatory sign at holding point A1. He then thought that the runway in service, 04L, was the first route on his left as was usually the case when taking the route via taxiway U.

Focused on other tasks, neither the ground controller nor the tower controller checked the position of the aeroplane. Hence, they did not identify the positioning error of the crew.

The tower controller wanted to insert the take-off before two approaches due a few minutes later in order to gain time and avoid the aeroplane being even temporarily at a standstill at holding point A1. He gave the line-up and take-off clearance before the aeroplane had reached holding point A1. The aeroplane had not yet passed taxiway U. This practice, even if it is authorized in the operations manual, leaves room for the crew to make a route error which is difficult to detect by the controllers.

The change in lighting when making the turn, from blue edge lighting to green centreline lighting may have misled the crew and make them think that they had entered the runway. While lining up, they did not identify the difference between the colour of the taxiway lighting and runway lighting. Lastly, they were not alerted by the dimensions of the taxiway as this was as wide as a runway and there was no sign at the beginning of taxiway U to indicate their error.

The captain did, however, have a doubt, and asked the first officer to confirm where they were. The latter confirmed that they were on the runway. The crew did not call the controller for clarification as stipulated in the operator’s procedures.

The various alignment and take-off clearances from the tower controller to keep the traffic flowing probably increased the time pressure linked to the aeroplane running late which led the crew to accelerate the before take-off actions to the detriment of asking the controller for confirmation of the aeroplane’s position.

Lastly, the before take-off actions include a warning to check that the aeroplane is on the correct runway. The crew were aware of this warning but did not check that the 04L indication was actually present on the runway. It was not an item of the check-list.

Thanks to a ground radar, the ground controller detected the take-off run on the taxiway and the take-off was cancelled.

The BEA has issued two safety recommendations to the DSNA.

Publications

BEA issues 2 safety recommendations:

- Recommendation FRAN-2020-001 / Ground radar :

The take-off run on the taxiway was visually detected by the ground controller on the ground radar screen while the tower controller was busy managing the approaches. No alert had been triggered in the tower.

The Nice regional approach and control centre has an A-SMGCS ground radar. This system does not currently have all the alerts technologically available. A modification of the Nice A-SMGCS parameter settings would, in particular, supply controllers with an alert on the detection of an excessive speed on a taxiway, synonymous with a takeoff from a taxiway.

Consequently, the BEA recommends that he DSNA study the advisability of modifying the ground radar at Nice to allow
detection of a take-off from a taxiway.

The follow-up to this recommendation is finished / last response from the DSNA:

DSNA has launched a project to upgrade the A-SMGCS1 system in Nice as part of its compliance with Commission Regulation (EU) 716/2014 of June 27, 2014 on the implementation of the common pilot project (PCP) of support for the implementation of the European air traffic management master plan. This update will make it possible to add new alert services, including the CMAC2 alert (Conformance Monitoring Alerts for Controllers) subdivided into 16 sub-alerts including the detection of take-off from a taxiway. ("high speed" alert). "HIGH SPEED" The 'HIGH SPEED' alert is not to control a speed limitation on taxiways but to provide an early detection of Take-Off from a taxiway based on an abnormal speed or acceleration. The project is being defined, although initially planned for 2024, the DSNA is studying an acceleration of this schedule.

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- Recommendation FRAN-2020-002 / Control procedures :

Communication can be transferred from the ground controller to the tower controller as soon as the aeroplane no longer interferes with other taxiing traffic. The ground controller thus cleared the crew to contact the tower controller although the aeroplane was still on taxiway T. The tower controller, wanting to keep to the landing and take-off rate that he had defined, gave the line-up and take-off clearance although the aeroplane had not yet passed taxiway U and a route error was still possible.

The analysis of previous occurrences found that an early take-off clearance was a contributory factor and that a route error was more difficult for crews to detect at night.

The take-off clearance should not, therefore, be given so long as a route error is still possible, i.e. so long as the aeroplane has not passed taxiway U, if the aeroplane is not taxiing on the latter.

Consequently, the BEA recommends that the DSNA impose the setting up of a procedure so that the take-off clearance from runway 04L, at night, at Nice, takes into account the risk of a take-off from taxiway U.

The follow-up of this recommendation is in progress

Follow-up available on ECCAIRS (European Coordination Center for Accident and Incident Reporting Systems): click here

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Note: in accordance with the provisions of Article 17.3 of Regulation No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation, a safety recommendation in no case creates a presumption of fault or liability in an accident, serious incident or incident. The recipients of safety recommendations report to the authority in charge of safety investigations that have issued them, on the measures taken or being studied for their implementation, as provided for in Article 18 of the aforementioned regulation.