Boeing 737-800 of UK leisure carrier Excel Airways with 197 people on board
began its take-off run at Manchester
with the pilots unaware that seven vehicles were carrying out scheduled work on
the runway surface at the other end, reducing the published take-off run
available (TORA), report investigators.
the time the crew saw the vehicles – which were out of sight beyond a rise in
the runway – there was no longer sufficient distance to stop, so the crew took
off over the top of the trucks, clearing them by 56ft (17m), says the Air Accidents
Investigation Branch (AAIB) in its final report.
causal factors for the incident, it says, were that the crew of the aircraft
(G-XLAG) did not realise take-off runway 06L/24R was operating at reduced
length because of work in progress (WIP) to remove rubber deposits from the
touchdown areas. That was despite the fact that the details were available to
them via notices to airmen (NOTAM), the aerodrome terminal information system
(ATIS), and spoken advice from air traffic control (ATC).
Board’s just-published report of the 16 July 2003 incident also describes how,
the previous night, three arriving aircraft were cleared to approach the same
runway which had been operating at a reduced usable length for part of each day
since 14 July because of WIP. The crews of the approaching aircraft were
informed of the reduced landing run available late on their approach, and since
it was less than they required all three had to go around. The first of the
three aircraft, a Lockheed L-1011 TriStar abandoned
its approach from a point 4.6km (2.5nm) from the threshold.
arrived for duty earlier than the required 1h before the planned 14:55 local
time take-off, but the captain telephoned him to say he was stuck in traffic
and would be a little late.
the copilot was assembling
the relevant flight data the refuellers
telephoned him requesting the fuel required. The copilot decided he would calculate and order the
required fuel before the captain’s arrival once he had checked the weather for
the flight planned route and the NOTAMS for the destination, which he did. But,
says the AAIB, he failed to check the NOTAMs
airport which stated the TORA for 06L was reduced to 1,926m from its full
length of 3,048m because of the WIP.
captain arrived 50min before take-off and met the copilot as he was leaving the crewroom, says the report. The captain told the AAIB
he checked the fuel figures but decided to scan the NOTAMs at the aircraft. On the flight deck the
commander programmed the flight management system (FMS) and the copilot listened to the ATIS, but
only recorded the runway in use and the weather information, but not the
warning of intense bird activity or the detail about the reduced TORA.
the copilot called for
departure clearance before start-up, Manchester Delivery said: “Expo 2146 hello
there, will you be able to accept the reduced take-off run available on 06L?”
The copilot replied: “Yeah
from Alpha Golf, Expo 2146,” indicating the crew intended to enter the runway
at holding point AG, rather than at the threshold of 06L, which would further
reduce the TORA. Manchester Delivery said “Okay that’s copied” and delivered
the departure details and squawk code.
report says: “By the time the aircraft pushed back, both pilots were aware that
some work was being conducted on 06L as a result of listening to ATC
communications with other aircraft.” Upon being questioned later the pilots
indicated they assumed the WIP was “either at the threshold end of 06L or in
the stop area, and that in either case it would not impinge on their
Ground cleared the aircraft to taxi to 06L, then the crew changed frequency to the Tower, which
confirmed 06L but did not specify a particular holding point. The copilot transmitted: “Tower Expo
2146 we’re taking it from Alpha Golf,” to which the Tower replied: “If you’re
happy with that, that gives
you, er, sixteen seventy
metres.” The copilot
acknowledged with “Roger”.
the aircraft lined up the crew could not see the vehicles the other end of 06L
because they were the other side of a slight rise in the runway, and reduced
take-off thrust was set on the assumption that the full runway was available.
When the pilots did see the vehicles they could no longer stop in time, says
the report, but by carrying out a rotation at the planned rotation speed, the
report says, they still cleared the highest vehicle by 17m.
the crew, nor the airport, nor air traffic control filed a report on the
incident to the Civil Aviation Authority (CAA), but a week later ATC provider
NATS, having received an internal report of the incident, filed the details to
the CAA. The AAIB report is also critical of the management of the runway work,
of the communications procedures between the various parties involved, and the
timeliness of the original NOTAM.
says: "The report highlights [the fact that] Manchester
followed laid down procedures, [but] we have taken the opportunity to review
and improve our working practices to ensure that this could not happen again."
says: “We commissioned a high-level internal investigation which was completed
in 2004, and wasted no time in putting improved procedures into place, ahead of
the AAIB’s report.”
UK CAA is conducting a review of recommended measures to be taken while work is
underway on runways and plans to report in March next year.