E190, Comodoro Rivadavia Argentina, 2019
E190, Comodoro Rivadavia Argentina, 2019
Summary
On 8 August 2019, an Embraer 190 crew taking off from Comodoro Rivadavia in accordance with their clearance saw a vehicle crossing the runway ahead but based upon its distance away and speed judged that continued takeoff was safe and this then occurred. The vehicle was not authorised to cross the runway. The conflict risk was assessed as heightened by ATC use of a discrete frequency for communications with airside vehicles thereby reducing the situational awareness of both pilots and vehicle drivers. It was also noted that absence of vehicle read backs to ATC instructions was common and went unchallenged.
Event Details
When
08/08/2019
Day/Night
Day
Flight Conditions
On Ground - Normal Visibility
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Intended Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Taxi
Location - Airport
Airport
General
Tag(s)
Inadequate Airport Procedures,
Inadequate ATC Procedures
HF
Tag(s)
Procedural non compliance
RI
Tag(s)
Accepted ATC Clearance not followed,
Incursion pre Take off,
Runway Crossing,
Vehicle Incursion,
No Single Runway Occupancy Frequency
Outcome
Damage or injury
No
Non-aircraft damage
No
Non-occupant Casualties
No
Off Airport Landing
No
Ditching
No
Causal Factor Group(s)
Group(s)
Air Traffic Management
Airport Operation
Safety Recommendation(s)
Group(s)
Air Traffic Management
Airport Management
Investigation Type
Type
Independent
Description
On 8 August 2019, the crew of an Embraer 190 (LV-CPJ) being operated by Austral on a scheduled domestic passenger flight from Comodoro Rivadavia to Mendoza in normal day visibility observed a vehicle crossing the runway ahead as they accelerated during takeoff but decided that takeoff could be safely completed based on their distance from the vehicle and its observed crossing speed. This proved to be a correct judgement and there was no actual risk of collision with the flight subsequently taking off normally.
Investigation
An Investigation was carried out by the Argentine Transportation Safety Board (JST). The Investigation was able to access relevant recorded ATC communication data but this was only available for the TWR VHF frequency with airside vehicle traffic controlled on a discrete UHF frequency which was not subject to recording. CVR and FDR data was not available or sought.
The pilots’ flying experience details were not recorded but their licensing status was found to be in order. It was also noted that the TWR controller and the Assistant also on duty, who were both 33 years old, had similarly in-order licensing status as controllers.
What Happened
The flight was taking off from the parallel taxiway to the only runway at Comodoro Rivadavia which had been designated as a temporary runway for the duration of planned work on runway 07/25. At an undetermined point during the takeoff roll, the crew saw a vehicle crossing the runway ahead but having assessed their distance from it and its speed, they correctly determined that the takeoff could be safely completed with no residual risk. The prevailing weather conditions and runway conditions were good and the plan to continue was successfully executed.
Why It Happened
It was found that the vehicle concerned, which was a being driven by an employee of the contractors carrying out work on the temporarily closed normal runway, had not been given permission to cross the (temporary) runway. Personnel employed on the contract stated that they had received training on regulatory procedures for use of the dedicated UHF frequency used by ATC for communication with vehicles operating airside which were understood to have included the requirement that receipt of a clearance from ATC must be followed by a read back to ensure it had been correctly understood. ATC stated that the vehicle involved had not requested a crossing clearance or otherwise been issued with one.
It was observed that ATC use of a different (UHF) radio frequency for airside driver communications than the TWR VHF frequency meant that neither pilots nor vehicle drivers had any situational awareness of potential conflicts between vehicles and aircraft.
It was found that although the runway works project had been subject to a prior assessment of operational risks which might arise through the SMS of each agency involved, each organisation had produced and implemented its own action plan to mitigate them. Each of these had identified runway incursion as a risk but no evidence that any integrated review of the incursion risk had been carried out was found. The fact that an alternative vehicle route to the closed runway which did not require the temporary runway to be crossed and the fact all access points to the temporary runway had been placarded as no entry for vehicles had not prevented the incursion.
Overall, it was concluded that “the measures adopted in respect of training, adequacy of procedures and supervision were not sufficient and/or adequate in some aspects”. This appeared to have explicitly included the “Restricted Radio Operator” course provided by the National Communications Entity (ENACOM) which was found to lack any standards or procedures in relation to the issues specifically applicable to the airside environment.
The Cause of the runway incursion during the takeoff of the ERJ 190 aircraft was the vehicle crossing the runway without authorisation to do so.
Three Contributory Factors to the event were identified as:
- Communication between the TWR and the vehicle driver was not effective in both directions, as the driver did not understand an instruction not to cross the runway and because the controller did not request that this instruction be read back.
- The communications system used for coordination of airside ground traffic at the aerodrome used a frequency different from the one used for aircraft control.
- Mitigation measures implemented to prevent the danger of a runway incursion occurring were not effective.
Two Non-causal Risk Factors with a potential impact on operational safety were also identified as:
- The course established by the National Communications Entity (ENACOM) for authorisation to operate the VHF channel called "Restricted Radio Operator" does not provide the knowledge referred to the telecommunications standards and procedures in aeronautical jurisdictions.
- The airport in question could have directed mitigation actions taking into account the provisions in the Argentine Civil Aviation Regulations (RAAC) 153 Attachment AP-6 ‘Guidelines for the implementation of Information Systems surface movement guidance and control (SMGCS), item 11 Prevention of runway incursions’.
Three Operational Safety Recommendations were made as a result of the Investigation as follows:
- that the Administration National Civil Aviation (ANAC) implements a single VHF frequency communication system managed by the aerodrome control tower for the use and coordination of all vehicle and aircraft movements in the manoeuvring area in order to avoid deficiencies in communications between the different operational services [AE-1826-22]
- that the Administration National Civil Aviation (ANAC) implements a Platform Management Service in accordance with the guidelines expressed in ICAO Doc 9476-AN/927 ‘Manual of Surface Movement Guidance and Control Systems (SMGCS)’ at airports that are considered to have complex operations or those where special circumstances (works) affect the manoeuvring area and there is a high probability of a runway incursion. [AE-1827-22]
- that the National Communications Entity (ENACOM) review, adapt and update the programme defined for the course taken to obtain a "Restricted Radio Operator" licence and consider incorporating the procedures for communications in the aeronautical environment. [AE-1828-22]
The Final Report in Spanish was published by the Argentine Transportation Safety Board (JST) on 19 September 2022. No courtesy English language translation was provided.
