ASN Wikibase Occurrence # 228102
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| Date: | Tuesday 25 November 2014 |
| Time: | 08:20 UTC |
| Type: |  Airbus A319-112 |
| Owner/operator: | Bulgaria Air |
| Registration: | LZ-FBB |
| MSN: | 3309 |
| Year of manufacture: | 2007 |
| Engine model: | CFMI CFM56-5B6/P |
| Fatalities: | Fatalities: 0 / Occupants: |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Paris-Charles de Gaulle Airport (CDG/LFPG) -
 France
|
| Phase: | Taxi |
| Nature: | Passenger - Scheduled |
| Departure airport: | Sofia Airport (SOF/LBSF) |
| Paris-Charles de Gaulle Airport (CDG/LFPG) | |
| Investigating agency: | BEA |
| Confidence Rating: |  Information verified through data from accident investigation authorities |
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.
Accident investigation:
 |
|
Sources:
BEA
Images:
Graphic: BEA
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 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
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