Serious incident to the Airbus A320 OE-INE operated by easyJet and to the Robin DR400 F-GTZY on 31/12/2022 at Bordeaux-Mérignac AD

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• Safety recommendation

The day of the serious incident, the duty roster had programmed the presence of six controllers. Before the shift, the tower supervisor had, in agreement with his team, reduced the programmed number of staff to three controllers at the time of the serious incident.

The tower supervisor and controller B had come on duty at 07:30, followed by a third controller (controller A) at around 10:00. The latter, at the time of the event, held the combined GND, TWR, APP and INFO positions. The tower supervisor was acting as the TWR assistant and controller B was taking a break in the control tower cab.

After an Air France A321 had taken off, controller A cleared the DR400 registered F-GTZY to line up at threshold 23, asking him to hold his position due to the wake vortex. The pilot of the DR400 started his timer for a two-minute wait. Flight EJU 49 QH, performed by an easyJet Europe A320 was established on ILS 23, and waiting for clearance to land.

The VFR traffic had become very dense at this point. Controller A, obliged to interrupt the exchanges with the VFR flights, belatedly cleared the A320 to land, having forgotten that the DR400 was holding at the threshold. The pilot of the DR400, understanding that the A320 had been cleared to land although he was still at threshold 23, reported his presence to controller A, who immediately ordered the A320 to abort the approach.

The tower supervisor and controller B, surprised, then became aware of the situation. The crew of the A320, principally concentrated on the aiming point during the final approach, never identified the presence of an aeroplane at the runway threshold.

The easyJet crew carried out a nominal missed approach. The lowest point of the fight path was at a height of 103 ft, at a distance of around 290 m from the runway threshold. The A320 flew over the DR400 at a height of 178 ft and then continued on the standard flight path.

Position controller A quickly stepped back. The tower supervisor took the GND, TWR and APP positions without a TWR assistant and controller B who had been taking a break, took the INFO position.

In the absence of instructions from the control, the crew of the A320 asked to be vectored to shorten the standard missed approach path and return to land on runway 23. The aeroplane landed without further incident.

This report contains a safety recommendation concerning the check for the presence of controllers in the control position and at their workplace.

The BEA issues 1 safety recommendation:

- Recommendation FRAN-2023-023 / Automatic and nominative system for recording the presence of controllers at their place of work and in their control position:

The BEA recommends that:

- whereas insufficient manning of the control positions and an insufficient number of controllers present at their place of work contributed to the occurrence of the serious incident;
- whereas the latitude the control units implicitly give to the tower supervisors to reduce the number of controllers actually present during shifts compared with the number programmed on the duty roster, outside any legal framework;
- whereas the lack of visibility for management as to the number of staff actually present;
- whereas these practices are widespread at national level;
- whereas these practices, which have been in place for many years and are implicitly tolerated in the quest for social peace, mean that it is not possible to rely on a declaration system to reliably determine the manning of the control positions and the controller's presence at work;
- whereas the DSNA currently has no means of reliably and objectively knowing the control positions manned and the presence of controllers at their place of work;
- whereas the manning of control positions and the number of controllers present are essential components in the level of safety of the service provided;
- whereas this absence of reliable information prevents the DSNA from analysing the potential impact of these two factors in terms of safety, at both local and national level;
- whereas access to reliable information on the number of staff present at the workplace and in position would enable a more relevant analysis of safety events;
- whereas access to reliable information on the number of staff present at the workplace and in position would enable tower supervisors and their teams to be trained and made more aware of the risks involved in making position combining/splitting decisions;
-whereas access to reliable information on the number of staff present at the workplace and in position is an essential element for checking that the number of staff programmed by the duty rosters matches the traffic actually encountered,

the DSNA equip the control centres with an automatic and nominative system to record the presence of controllers in position and at the workplace, and ensure that this information can be used by the DSNA services, in particular to ensure the appropriateness of staffing levels and to enable the analysis of safety events.

The recommendation is being processed

The status of the recommendations is available at SRIS2: click here

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Note: in accordance with the provisions of Article 17.3 of Regulation No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation, a safety recommendation in no case creates a presumption of fault or liability in an accident, serious incident or incident. The recipients of safety recommendations report to the issuing authority in charge of safety investigations, on the measures taken or being studied for their implementation, as provided for in Article 18 of the aforementioned regulation.

General information

Local date	31/12/2022
Responsible entity	France - BEA
State or area of occurrence	France - 33 Gironde
Location	Bordeaux-Merignac AD
Human consequences	None
Aircraft consequences	None
Occurrence class	Serious incident
Occurence category	ATM: ATM/CNS, RI: Runway incursion - vehicle, aircraft or person
File number	BEA2023-0004

Flight Information

Aircraft category	Aeroplane - Large aeroplane
Operator	Austria - easyJet Europe Airline GmbH
Manufacturer / Model	AIRBUS - A320
Aircraft Registration	OE-INE
State of registry	Austria
Last departure point	United Kingdom - EGKK (LGW): London/Gatwick
Planned destination	France - LFBD (BOD): Bordeaux Mérignac
Flight phase	Approach
Serial number
Operator Type AG
Operation Type	Commercial Air Transport - Passenger - Airline

Second aircraft involved

Aircraft category	Fixed Wing - Aeroplane - Small Aeroplane - Small Aeroplane
Operator
Manufacturer / Model	ROBIN - DR400
Aircraft Registration	F-GTZY
State of registry	France
Last departure point	France - LFBD (BOD): Bordeaux Mérignac
Planned destination	France - LFBD (BOD): Bordeaux Mérignac
Flight phase	Taxi
Serial number	2445
Operator Type AG
Operation Type	Non-Commercial Operations - Pleasure - Local

BEA is the French air safety investigation authority for civil aviation. The sole objective of the investigation is to improve air safety. It is intended neither to apportion blame nor to assess responsiblity.

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