MIAMI – The Bureau d’Enquêtes et Analyses (BEA) has issued its final report on the near-collision incident between United Airlines (UA) and EasyJet Austria (EC) aircraft.

The near-miss incident happened on July 20, 2020, at Paris-Charles de Gaulle airport (CDG), between UA flight 57, a Boeing 787, registration N16009, and an EC Airbus A320 registered under OE-IJF.

Exactly a year and four days ago, CDG was operating two of its four runways, namely 09L for landings and 09R for take-offs, both runways being the north set and facing eastward.

The first problem arose when the north tower controller, normally positioned in the LOC NW, had to operate from the LOC NE position due to a screen malfunction. The LOC NE position does not allow a direct visual with the 09 runways thresholds.

Image: CDG

Misunderstandings, Nonstandard Language


Moments before the incident event, two flights had landed on 09L and were still in a holding position, awaiting clearance to cross runway 09R while an Air France ((AF) flight was landing there. At the same time, two aircraft were at holding position at runway D5, including the EC Airbus A320 OE-IJF.

When establishing the first contact with the UA flight on an ILS approach to runway 09L, the tower controller made a slip of the tongue and cleared UA for a landing on runway 09R instead of 09L. The crew, understanding that they would have to perform a side-step to align to runway 09R, read back “understand clear to land 09R, sidestep 09R UA57.”

Not receiving any correction from the controller, UA 57 continues the approach, switching to visual and manual controls and performing a side-step for runway 09R.

Easyjet Airbus 320 OE-ICG, a type similar to the one involved in the incident. Photo: Daniel Sander/Airways

Flight Deck Crews Saved the Day


At the same time, the controller cleared the EC A320 for line-up on runway 09R. The A320 crew verified that the runway was clear and saw the UA Boeing 787 on final on runway 09L. The crew began the line-up run but, before arriving at the runway center-line, they re-checked the 09R approach line and saw the UA B787 performing a side-step for runway 09R at a height of 300ft and at 1300m (0.7nm) from the 09R threshold.

The EC crew called the tower to inform them the UA Boeing 787 was on final approach and, to gain time and avoid a potential collision, called the approaching aircraft directly, now at 200ft altitude, with a “go around 09R go around.” Four seconds later, with visual contact with the taxying A320 now established, the UA Boeing 787 aborted the approach at 105ft altitude and went around, overflying the A320 at a height of approximately 300ft.

Chronology of Events


TIMEEVENTHeight AAL
(Above Aerodrome Altitude)
and distance from runway 09R
threshold
05 h 17 min 26N16009 initiates side-step890 ft / 2,2 NM
05 h 17 min 50OE-IJF starts taxying from position D5 to align on 09R595 ft / 1,3 NM
05 h 18 min 14OE-IJF calls N16009 to go around200 ft / 0,42 NM
05 h 18 min 15N16009 is practically aligned with runway 09R
The RunWay Status Lights (RWSL) come on and turn red
180 ft / 0,34 NM
05 h 18 min 19Runway Incursion Monitoring and Collision Avoidance System activates
The tower controller confirms the go-around
105 ft / 0,17 NM

Contributing Factors


According to the BEA, the French equivalent of the US NTSB, The following aspects may have contributed to the incident resulting from a landing clearance on a busy runway:

  1. The controller’s management of traffic mainly concentrated on runway 09R with one landing, two departures, and two runway crossings on stand-by
  2. The unexpected change of controlling position from LOC NE to LOC NW caused by a screen malfunction
  3. The controller lack of practice due to the decrease in traffic induced by the Covid pandemic
  4. The use of non-standard language used by the Boeing 787 crew, using “Understand” in lieu of “Confirm” that would have alerted the controller
  5. By working on the LOC NW, with a west-facing configuration, the controller did not have a direct vision on 09 runways thresholds, a fact that may have concurred in not noticing the incorrect alignment of the incoming UA flight. This resulted in conflict with the authorization issued to the EC A320 to line up on runway 09R.

The vigilance of both flight deck crews contributed to the avoidance of a runway collision and a possible major air accident.

Article sourced from BEA final report.


Featured image: United Airlines Boeing 787-9 Dreamliner. Photo: Daniel Gorun/Airways