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to cross the runway. This would indicate that he had not placed the FPS for G-SMTJ in the priority
position or had subsequently placed the FPS for EI-CJI below it. Evaluation of the RTF recording
could not resolve this aspect. However, at the time there were other activities that could have caused
some distraction to 'Air 1'. These included the Boeing 747 which crossed the runway and was holding
at 'D3'. Additionally, the controller was aware that EI-CJI was clearing Runway 06R, was now ahead
of the previously landed Boeing 737 and its operator was known to have a company culture of
expeditious taxiing. Finally, in his initial response to the check-in call from EI-CJI, 'Air 1' used a
different aircraft callsign which was probably for an aircraft that was on transfer from 'GMC' to 'Air
1'. All these factors resulted in the potential for distraction to 'Air 1' and it is considered highly likely
that the controller lost situational awareness at a critical time. Once this had happened, the system
relied initially on procedures to highlight to the controller that he had made a mistake. On this
occasion, the procedures were not effective. A review of the procedures and RTF
phraseology/discipline would therefore be sensible. ATC at Manchester is already carrying out a
review and NATS have also become involved with an intention of standardising procedures
throughout their airports. The aim is to use a standardised procedure but also to make use of the
experiences and ideas from all airports. With the action already in progress, it is not considered
necessary to make a formal recommendation in this respect.
Once the controller had made the mistake and because he did not immediately become aware of it, the
defence against the incident becoming an accident relied primarily on the flight crew of the two
aircraft. The clearance for G-SMTJ to takeoff was legitimate and correctly acknowledged. The
opportunity for this crew to recognise the mistake was when EI-CJI was subsequently given crossing
clearance. Evaluation of the CVR shows that the clearance to EI-CJI was transmitted concurrently
with the crew of G-SMTJ making standard internal cockpit calls. Therefore, it is understandable that
EI-CJI's clearance was not assimilated by G-SMTJ's pilots. However, the repeated clearance message
was heard and it was the initial 'trigger' for the aircraft's commander to recognise the situation and
commence action. Although the ground speed was above 100 kt, evaluation of the RTF and SMR
indicated that the prompt action of the commander of G-SMTJ effectively removed any risk of a
collision.
The actions of the crew of EI-CJI were also evaluated to determine if they could have made an early
appreciation of the situation. Without a CVR, it could not be determined if the take-off clearance to
G-SMTJ was transmitted when EI-CJI was on the 'Air 1' frequency. The commander of EI-CJI stated
that he waited for another transmission to cease before checking in with 'Air 1'. This transmission
Airbus A321-211, G-SMTJ and Boeing 737-2E7, EI-CJI
9
could only have been the take-off clearance or perhaps the latter part of it. The crew of EI-CJI would
have been involved in after landing checks and it is understandable that the significance of the
preceding transmission was not appreciated. However, the aircraft then entered the active runway
with an aircraft accelerating towards it. A review of the location indicated that G-SMTJ would have
been visible as EI-CJI approached the crossing position. Although the commander of EI-CJI
considered that he had looked to his left, this was not effective. Additionally, the high ground speed
(33 kt average) of EI-CJI may have made a late stop more difficult. Checks with the operating
company of EI-CJI confirmed that the maximum ground speed whilst taxiing should be 30 kt.
However, the flight crew had been requested to "Keep your speed up" and were complying with the
ATC request. It may also be relevant that the Air 1 and Air 2 controllers were aware that the crews of
the operating company of EI-CJI were expeditious on the ground. The operating company has
undertaken to use the circumstances of this incident as a training aid for their crews.
It was also noted from the RTF recording that a double transmission occurred just after 'Air 1' had
cleared EI-CJI to cross the active runway. The response by EI-CJI was overlaid by another aircraft
checking-in on frequency. The crew of this aircraft had apparently not listened before checking-in
because the normal procedure would have been to allow an acknowledgement to be transmitted. The
result was additional RTF and an unnecessary distraction for the controller.
Summary
The incident occurred following a human error by a controller. While procedures are continually
　
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