Serious incident Airbus A319-132 D-ABGC, Thursday 31 July 2008
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Date:Thursday 31 July 2008
Time:
Type:Silhouette image of generic A319 model; specific model in this crash may look slightly different    
Airbus A319-132
Owner/operator:Air Berlin
Registration: D-ABGC
MSN: 2468
Year of manufacture:2005
Engine model:IAE V2524-A5
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Zürich-Kloten Airport (ZRH/LSZH) -   Switzerland
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Zürich-Kloten Airport (ZRH/LSZH)
Destination airport:Düsseldorf International Airport (DUS/EDDL)
Investigating agency: BFU Switz.
Confidence Rating: Accident investigation report completed and information captured
Narrative:
An OLT Fairchild SA227AC Metroliner III (D-COLB), callsign OLT 212, was on a commercial scheduled flight from Bremen to Zurich. At 13:06:17 UTC the crew made contact with the Approach East air traffic controller (APE, Zurich Arrival). During the first call, the crew of OLT 212 asked whether an approach to runway 16 would be possible.
According to the Automatic Terminal Information Service (ATIS) runway 14 was in service for landings at this time. The APE ATCO initially cleared OLT 212 to continue its descent to FL 100. He informed the crew that they could expect a response to their request for runway 16 after the necessary coordination.
At 13:06:49 UTC the APE ATCO coordinated the runway change requested by the crew with the ATCO1 Aerodrome Control (ADC). The change of runway was approved by the ATCO1 ADC. Along with the instruction to turn onto heading 180 degrees, the APE ATCO informed the crew of OLT 212 at 13:07:18 UTC that it was now a radar vectoring to the runway 16 instrument landing system (ILS).
This radiocommunication was acknowledged correctly by the crew of OLT 212.
At 13:12:15 UTC the crew of OLT 212 was instructed by the APE ATCO to turn onto the runway 16 ILS final approach and the aircraft was cleared for final approach on the ILS. At 13:13:40 UTC the crew of OLT 212 reported to air traffic control that the aircraft was established on the runway 16 ILS. Shortly afterwards, the APE ATCO issued the crew of OLT 212 a traffic information about an aircraft flying in front of them which was 2 NM from the threshold of runway 14.
At the same time, the crew of OLT 212 were instructed to contact Zurich Tower (TWR).
At 13:14:34 UTC the crew of OLT 212 reported on the TWR frequency that they were established on the runway 16 ILS. At this time OLT 212 was approximately 8 NM from the threshold of runway 16. The ADC ATCO1 immediately cleared the aircraft for landing and provided wind information on this first call. After the crew of OLT 212 had acknowledged the landing clearance, the ADC ATCO1 cleared them to vacate the runway via taxiway E8 after landing.
At 13:16:38 UTC the crew of the Air Berlin Airbus A319, a scheduled flight to Düsseldorf with callsign BER 966Z, reported to the ADC ATCO1 that they were ready for take-off. At this moment the aircraft was taxiing to the runway 28 holding point.
The ADC ATCO1 cleared BER 966Z to line up on runway 28 and to wait there. His attention was then briefly drawn towards a helicopter on a photographic flight north of the runway 28 departure centre line which wanted to fly over this runway in a southerly direction. The pilot of the helicopter was instructed to wait as a take-off from runway 28 was about to take place.
The ATCO1 cleared BER 966Z for take-off at 13:17:19 and provided information about the helicopter.
Shortly before issuing clearance for BER 966Z, the briefing for the transfer of traffic control to a replacement air traffic controller began at the ADC workstation. During this transfer, the air traffic controller leaving the workstation suddenly noticed that OLT 212 had landed on runway 16 and was approaching the intersection with runway 28. He immediately informed the replacement air traffic controller who had already taken up his position at the ADC workstation. The latter immediately instructed BER 966Z, which was taking off, to abort the take-off.
The crew of BER 966Z confirmed receipt of this instruction and brought the aircraft to a standstill using manual braking. According to the crew’s information, the aircraft had reached a speed of approximately 65-70 knots prior to the takeoff abort.
The crew of OLT 212 had not heard the ADC ATCO1 issue take-off clearance to BER 966Z, though they had monitored the instruction to abort the take-off. However, there was no visual contact with BER 966Z as visibility on the first section of runway 28 was obstructed by buildings.
After it had landed, OLT 212 continued taxiing along runway 16, crossed runway 28 and vacated the runway via taxiway E8 as instructed. BER 966Z came to a standstill on runway 28 between taxiways Kilo and Juliet.
BER 966Z then vacated the runway and taxied back to the take-off runway. The scheduled flight to Düsseldorf took off approximately twelve minutes later.


Cause
The serious incident is attributable to the fact that ATC cleared an aircraft to take off from runway 28, even though an aircraft approaching runway 16 had previously received landing clearance and was about to land.
A contributory factor was the circumstance that there were no standardised procedures available to ATC during take-offs on runway 28 for flights which were cleared to land on runway 16 instead of runway 14 as an exception.

Accident investigation:
cover
  
Investigating agency: BFU Switz.
Report number: 2047
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report

Sources:

BFU 6X004-2/08

Revision history:

Date/timeContributorUpdates
12-Sep-2024 13:29 ASN Added
13-Sep-2024 19:25 ASN Updated [Aircraft type, Registration, Cn, Operator, Total fatalities, Location, Phase, Nature, Departure airport, Destination airport, Source, Narrative, Accident report, ]

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