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Report: Ryanair B738 at Venice on Oct 18th 2022, takeoff clearance did not transmit forcing a go around
|By Simon Hradecky, created Friday, Sep 15th 2023 15:46Z, last updated Friday, Sep 15th 2023 15:46ZA Ryanair Boeing 737-800, registration EI-EBE performing flight FR-973 from Venice (Italy) to London Stansted,EN (UK) with 174 people on board, had been cleared to line up and wait runway 04R while low visibility procedures were in use, acknowledged the clearance, lined up and waited.|
An Iberia Airbus A321-200, registration EC-JRE performing flight IB-3242 from Madrid,SP (Spain) to Venice (Italy) with 203 people on board, was on final approach to runway 04R about 5nm before touchdown when tower cleared FR-973 for takeoff, FR-973 however did not move.
In the meantime FR-973 observed the landing traffic on their TCAS, and with silence on the radio for over a minute they began to transmit to the landing traffic advising them of their presence on the runway, the landing aircraft however did not react. The Boeing crew, seeing the landing traffic to descend through about 500 feet began to apply thrust to vacate the runway in a hurry when tower finally could be heard instructing the landing traffic to go around, which was acknowledged by the crew. The A321 went around, while the B738 maintained position.
The B738 departed a few minutes later, the A321 positioned for another approach and landed without further incident.
On Sep 15th 2023 Italy’s ANSV released their short final report in Italian only within 9 other brief final reports (editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, an Italian only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe.)
The ANSV concluded the probable causes of the serious incident were:
The improper insertion of the headset connector into the plug for the telephone line by the incoming tower controller resulting in the inability to transmit radio communication.
Contributing factors were:
– the handover from outgoing controller to incoming controller was not optimal, in itself critical in a developing operational scenario
– the incoming tower controller did not detect the absense of the readback of the takeoff clearance
– the incoming controller was not able to identify the source of the problem disabling him to transmit radio communication in time
– the ergonomics of the tower control panel in relation to connectors for communication devices
– the low visibility conditions at the time of the occurrence disabling EC-JRE to see the traffic aligned and waiting on the runway
The ANSV reported that a handover of tower controllers was taking place after the B738 had been cleared to line up and wait. The incoming controller plugged his head set into the connector for the telephone line instead the radio communication and cleared the B738 for takeoff, however, that clearance never transmitted. The controller also did not detect the absence of the read back of the takeoff clearance.
With over a minute of silence on the tower frequency the B738 crew observed the landing traffic descending through 1200 feet and transmitted that they were holding on the runway, however, there was no response, the A321 continued the approach. The B738 crew radioed a go around instruction on the guard frequency, again without reaction, and began to move to vacate the runway. When the A321 was descending through 400 feet tower could be heard instructing the A321 to go around, the crew read the instruction back and went around. The B738 thus held position waiting for tower instructions.
LIPZ 180750Z VRB02KT 0250 R04R/0300N FG OVC001 13/13 Q1027 BECMG 0600 FG=
LIPZ 180820Z VRB02KT 0400 R04R/0650U FG OVC001 14/14 Q1027 BECMG 0600 FG=