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ASN Wikibase Occurrence # 228102
Last updated: 13 October 2019
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Date:25-NOV-2014
Time:08:20 UTC
Type:Silhouette image of generic A319 model; specific model in this crash may look slightly different
Airbus A319-112
Owner/operator:Bulgaria Air
Registration: LZ-FBB
C/n / msn: 3309
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Paris-Charles de Gaulle Airport (CDG) -   France
Phase: Taxi
Nature:International Scheduled Passenger
Departure airport:Sofia Airport (SOF/LBSF)
Destination airport:Paris-Charles de Gaulle Airport (CDG/LFPG)
Investigating agency: BEA
Narrative:
An Airbus A319, registered LZ-FBB and operated by Bulgaria Air, as flight LZB431, was carrying out a flight from Sofia, Bulgaria to Paris, France.
An Airbus A320, registered TC-FBJ and operated by Freebird Airlines, as flight FHY542, was carrying out a flight from Paris, France to Istanbul, Turkey.
At 08:18 UTC, the LOC controller indicated to the crew of flight LZB431, which had just vacated runway 08R via taxiway V5: “Bulgaria 4 3 1, hold short of 0 8 L, holding point S 6.” The crew of flight LZB431 correctly read back.
The LOC controller then cleared the crew of flight FHY542 to take off from runway 08L. Another aircraft, AF1089, landed on runway 08R and vacated via taxiway V6.
At 08:19, the LOC controller indicated to the crew of flight LZB431, “Bulgaria 4 3 1, number one, keep on taxiing.” The crew of flight LZB431 read back using the same terms as the LOC controller.
The LOC controller then told the crew of flight AF1089 to taxi behind the A319 of Bulgaria on the left. The crew of flight AF1089 asked whether they were cleared to cross. The LOC controller replied no. These exchanges were carried out in French.
At 08:20, LZB431 entered runway 08L via S6. The RIMCAS (Runway Incursion Monitoring and Conflict Alert System) warning was triggered one second later. FHY542, performing the take-off run, was at approximately 1,500 m before the intersection with taxiway S6 and at an indicated airspeed of 139 kt. FHY542 flew over the intersection with S6 at a height of around 500 ft.
At that time LZB431 had vacated the runway and was stopped on taxiway T9.


Conclusion:
The event took place during a period of dense inbound traffic with aircraft arriving with a reduced separation. This additional workload led the LOC controller to pay greater attention to inbound aeroplanes, probably to the detriment of those on the ground, in particular when they were no longer on the runway.
An inadequate phraseology was used to deal with the taxiing priorities between Air France flight 1089 and Bulgaria Air flight 431. The message “Bulgaria 4 3 1, number one, keep on taxiing” was not in fact accompanied by a reminder that the crew must hold short of runway 08L. This message led to an erroneous interpretation by the crew of the Bulgaria Air flight who understood it as a clearance to cross the runway.
The crew of the Air France flight had the meaning of this message clarified. The crew of the Bulgaria flight were not able to understand the exchanges in French between the controller and the crew of the Air France flight. The controller did not connect the question from the crew of the AFR1089 flight with a possible ambiguity as to the
meaning of the phraseology that he had used to manage priorities.
In addition, the configuration of the Paris-CDG runways can make it difficult for crews to detect an aeroplane taking off, notably when they cross a runway. The crew of flight LZB431 thus entered runway 08L without seeing flight FHY542 taking off. The RIMCAS alarm was triggered due to the conflict. The controllers considered that it
was then too late to intervene.

Sources:

BEA

Accident investigation:
cover
  
Investigating agency: BEA
Status: Investigation completed
Duration: 4 years and 8 months
Download report: Final report


Images:

Photo of LZ-FBB courtesy AirHistory.net


Amsterdam - Schiphol (EHAM / AMS)
3 August 2018; (c) Aad van der Voet


Graphic: BEA

Revision history:

Date/timeContributorUpdates
11-Aug-2019 14:09 harro Added
11-Aug-2019 20:06 harro Updated [Cn]
11-Aug-2019 20:08 harro Updated [Departure airport, Destination airport]

Corrections or additions? ... Edit this accident description