Serious incident Boeing 737-8AS (WL) EI-EBE, Tuesday 18 October 2022
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Date:Tuesday 18 October 2022
Time:09:15 UTC
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8AS (WL)
Owner/operator:Ryanair
Registration: EI-EBE
MSN: 37523/2788
Year of manufacture:2009
Fatalities:Fatalities: 0 / Occupants: 174
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Venice Airport (LIPZ) -   Italy
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Venice-Marco Polo Airport (VCE/LIPZ)
Destination airport:London-Stansted Airport (STN/EGSS)
Investigating agency: ANSV
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Ryanair flight FR793, a Boeing 737-8AS (EI-EBE), and Iberia flight IB3242, an Airbus A321-212 (EC-JRE), were involved in a serious runway incursion incident at Venice Airport (LIPZ).

During an instrument approach to runway 04R at Venice Airport (LIPZ) in low visibility conditions, the Airbus A321 executed a go-around following initial instructions from the crew of the Boeing 737-800 which was lined up on the same runway waiting for takeoff clearance.
Subsequently, EI-EBE completed its takeoff, while EC-JRE was vectored for a subsequent instrument approach and landing. The operations of both aircraft continued without further issues.


Cause.
The cause of the event is attributed to human factors, specifically the improper insertion by the controlling air traffic controller (CTA) of their headset device connector into the connector dedicated to telephone lines, resulting in the inability to ensure ground-air-ground radio communications. The following factors reasonably contributed to the occurrence of the event:

- The handover of control between the outgoing and incoming air traffic controllers occurred at a suboptimal time, which was potentially critical, characterized by an evolving operational scenario.
- The fact that the CTA in question did not notice the lack of readback of the takeoff clearance by the EI-EBE crew.
- The inability of the mentioned CTA to promptly identify the source of the malfunction that had made it impossible to ensure regular radio communications.
- The ergonomics of the CTA's control panel in relation to the connectors for communication devices.
- Low visibility conditions on the day of the event, which may not have allowed the EC-JRE crew to see the EI-EBE aircraft aligned and waiting on RWY 04R with sufficient advance notice.

Accident investigation:
cover
  
Investigating agency: ANSV
Report number: 
Status: Investigation completed
Duration: 11 months
Download report: Final report

Sources:

ANSV

Revision history:

Date/timeContributorUpdates
21-Sep-2023 09:54 harro Added
21-Sep-2023 10:13 Anon. Updated
21-Sep-2023 10:14 harro Updated

Corrections or additions? ... Edit this accident description

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