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Seven Four". The subsequent acknowledgement by EI-CJI was overlaid by a transmission by another
aircraft checking in with 'Air 1'. 'Air 1' then confirmed the crossing clearance for EI-CJI and asked
"Who else was calling". At 1038:20 hrs, this other aircraft passed its message and G-SMTJ
called "Stopping" immediately after the response by 'Air 1'. At 1038:30 hrs, 'Air 1' instructed EICJI
to hold position and this was acknowledged.
The recording was also evaluated to determine if the precise movement of the FPS could be
determined. While the sound of the FPS being moved could be heard, it could not be determined
which FPS strip was being moved or where it had been moved.
Cockpit Voice Recorder (CVR)
There was no requirement for the CVR of either aircraft involved in the incident to be impounded but
the CVR of G-SMTJ was recovered by the parent company and held for the AAIB. This proved
useful in determining the relevant transmissions which could be heard by the crew of G-SMTJ.
Following the clearance to takeoff, the crew of G-SMTJ commenced normal cockpit checks during
takeoff; this included verbal cross-checking of instrument and annunciation displays. This intracockpit
communication was concurrent with the initial runway crossing instruction and
acknowledgement with reference to EI-CJI. However, the repeat message to cross occurred during a
silent period in the cockpit and resulted in the decision to stop by the commander of G-SMTJ. The
'Stop' decision was made shortly after the crew had cross-checked their ASIs at 100 kt.
Other relevant information
Following the incident, investigators visited the NATS initial training establishment and another
major NATS airport to compare the use of FPS with those at Manchester. This showed that, while the
basic principles are common, some differences have evolved.
Prior to the incident, Manchester ATC had already recognised an increase in the number of runway
incursions and were involved in a review of their FPS procedures. This review included an
examination of the procedures at another major NATS airport with the possibility of establishing the
same procedures at Manchester. Following the incident, NATS also carried out a review of the FPS
procedures in use at all their airports and are in the process of establishing a NATS common standard.
The International Civil Aviation Organisation (ICAO) has recognised that runway safety is a vital
component of aviation safety as a whole. Accordingly, there has been an action plan produced by
European organisations representing all areas of aerodrome operations entitled 'European Action Plan
for the Prevention of Runway Incursions'. The introduction to this document includes the information
that 'Over recent years there has been a number of runway incursions across the European region,
which resulted in two actual collisions, with a significant loss of life. Analysis of the available data
indicates that there is one runway incursion every three to four days within the region.' The
Airbus A321-211, G-SMTJ and Boeing 737-2E7, EI-CJI
8
document included recommendations to relevant organisations including national authorities,
aerodrome operators and aircraft operators. The time frame for completion of the various
recommendations varied from December 2003 to June 2008. The plan highlighted the importance of
continued situational awareness, based on effective working procedures at the airport, effective
communications between pilots and controllers, and effective communications between controllers
and vehicles on the airport. Manchester Airport and both of the operating companies of the aircraft
involved in this incident were recipients of the document and were using the content to update
their staff.
Discussion
The incident occurred following a human error by a controller. However, human errors will always
occur and effective safety relies on a back-up system which either makes it difficult to make a mistake
or immediately highlights the fact that a mistake has been made. Within aviation, the demand for
greater utilisation of resources results in less time to recognise and correct mistakes. Therefore, backup
systems have to be robust and regularly reviewed to retain their effectiveness.
In the situation at Manchester ATC, the introduction of a second runway increased the aircraft
movement rate but this increase was accompanied by the complications inherent in parallel runway
operations. While the FPS procedures were based on the basic NATS principles, there were slight
adaptations to cater for the local situation. For the incident on 29 February, the controller stated that
he had forgotten that he had given take-off clearance to G-SMTJ when he subsequently cleared EI-CJI
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