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06L should be 'interlaced with the outbounds in the central active bay'.
History of the incident
At 1033 hrs, a Boeing 747 landed on Runway 06R and control was transferred to 'Air 1'. One minute
later, a Boeing 737 landed and vacated the runway at the first available exit; control of this aircraft
was also transferred to 'Air 1'. At 1036 hrs, EI-CJI was advised, while on final approach, that the
aircraft was cleared to land and clear to roll to the end of Runway 06R to vacate. The ATC intention
was that EI-CJI would then be ahead of the previously landed Boeing 737. At 1037 hrs, EI-CJI had
landed and once clear of the runway, was transferred to 'Air 1'. Before transfer, the aircraft had been
advised to keep its speed up and that it was now ahead of the Boeing 737. The aircraft was cleared to
the hold at 'DZ1', one of the crossing points for Runway 06L.
Meanwhile, G-SMTJ had taxied for Runway 06L and control had been transferred from 'GMC' to
'Air 1'. At 1036 hrs, the controller instructed G-SMTJ to line up and wait on Runway 06L. The
controller then cleared the inbound Boeing 747 to cross Runway 06L and to hold at 'D3', a point to the
north of the runway. Once the aircraft had called clear of the runway, the controller cleared G-SMTJ
Airbus A321-211, G-SMTJ and Boeing 737-2E7, EI-CJI
5
for takeoff at 1037 hrs. Just after this instruction was acknowledged, EI-CJI checked in on the same
frequency and confirmed his clearance to 'DZ1'. After some slight confusion, 'Air 1' acknowledged
this message and cleared the aircraft to cross Runway 06L. There was then a double transmission
involving EI-CJI and another aircraft, which was probably one that had just been transferred from
'GMC'. 'Air 1' then repeated the clearance to EI-CJI and asked the other aircraft to pass their
message. After this message and the subsequent acknowledgement by 'Air 1', there was a
transmission from G-SMTJ of "Stopping". By then EI-CJI had entered the runway.
Weather information
At the time of the incident, the weather was good. The Automatic Terminal Information Service
(ATIS) broadcast 'Kilo', timed at 1020 hrs, included the following information: Runway 06R was in
use for landing; the surface wind was 340°/ 06 kt, variable in direction between 280° and 030°;
visibility was 40 km; cloud was FEW at 2,500 feet and BKN at 4,000 feet; and the QNH was
1023 Mb. The ATIS broadcast also advised that all hold short instructions were to be acknowledged
and read back.
Controller information
'Air 1' had been a qualified controller since 1996. He had been at Manchester since 2000 and was
fully validated in all positions in the 'Tower' and 'Approach'. Additionally, he was a current 'On the
Job Training Instructor' (OJTI).
The controller had completed a period of duty the previous day at 1200 hrs and returned to duty for a
planned start at 0700 hrs on the day of the incident. After self-briefing on the weather and other
relevant information, he was assigned as 'Air 2' and took over those duties at about 0655 hrs. The air
traffic was very light during the initial part of his duty and he was released from duty for a 30 minute
break at 0800 hrs. From 0830 hrs to 0930 hrs, he took the duties of Ground Movement Planning
(GMP) and then had a further 30 minute break. At 1000 hrs, he took the position of 'Air 1' and was
due to be relieved at 1130 hrs. During his time on duty, he considered that the traffic was light to
medium. He also confirmed that there were no visitors during the time of the incident and that he had
not been distracted by any telephone calls.
In an honest report, the controller stated that he remembered giving G-SMTJ line-up clearance but did
not remember giving subsequent take-off clearance; he recalled that he placed the associated FPS into
the 'Active Runway Bay'. His recollection was that he had given EI-CJI priority for crossing Runway
06L and his attention was on that aircraft as it approached the runway, particularly as the Boeing 747,
which had previously crossed was holding north of the runway. The controller thought that he had
placed the FPS for EI-CJI in the first priority position in the 'Active Runway Bay' ie closest to his
body. When G-SMTJ came into his view from the right along the runway, his initial thought was that
it had taken off without clearance and he looked down at the FPS to identify the aircraft. His initial
action was to instruct EI-CJI to hold position but by then, the aircraft had crossed the runway and GSMTJ
had called "Stopping". The controller could not remember seeing the RIM activate. Shortly
afterwards he was relieved from duty.
Pilot reports
G-SMTJ
As the commander of G-SMTJ lined up on Runway 06L, he saw EI-CJI vacating Runway 06R. He
　
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