The serious safety incident took place in December. Due to wrong instructions issued by the control tower, a Lufthansa plane preparing to land was only 170 meters (558 feet) away from an El Al plane preparing for take-off.
A collision was averted thanks to the awareness of the El Al pilots and the activation of the planes' automatic warning systems.
The report reveals, however, that the flight inspectors took the incident lightly, although it was defined by a Transportation Ministry official as "the most serious safety incident in the history of Ben-Gurion Airport".
According to the report, "The tower controller claimed there was nothing unusual in the incident and referred to it as 'a life experience one can learn from'. Moreover, he did not feel the need to fill out a safety incident report after the incident."
The air controllers were suspended following the incident.
A transcription of the exchange of words between the control tower and the Israeli plane reveals the problematic communication between the inspectors and the pilots.
For example, when the pilots were dazzled by the lights on the runway, the lights remained on even though the inspector confirmed that he had heard their request to turn them down.
"The El Al crew's relatively long delay on the runway, after receiving an approval to take off, can be interpreted as a certain loss of trust in the tower due to the controllers' mistakes," Attorney Raz stated in the report.
The El Al pilot's awareness was expressed minutes before the incident. W hen the first officer in the cockpit noticed a Lufthansa plane approaching, he warned the pilot immediately: "This is all we need, a plane landing on us now. I know, with all the mess here."
Three second before the automatic warning system went off, he warned: "There is someone on top of us."
When the control tower instructed the German plane to take another turn in the air above the Israeli plane, the first officer on the El Al plane announced, "He is above us, commander!" At this stage, the automatic warning systems were activated due to the unusual proximity between the aircraft, preventing a collision.
The report also defined the air controllers' wireless communication procedures as "not confirming to the standard" and their performance as "slow". The inspector himself was a trainee, and the incident – in which the lives of 428 passengers and crewmembers were in danger – was "his first experience in preparing a runway for arrivals and departures at Ben-Gurion Airport".
The Israel Airports Authority said in response, "As we stated when the report was released, its findings were studied by the Israel Airports Authority and the required lessons were learned."