Accident and Serious Incident Reports: RI

Accident and Serious Incident Reports: RI

Definition

Reports relating to accidents and Serious Incidents involving a Runway Incursion. Reports are organised according to the nature of the incursion and may appear in more than one sub-category.

ATC Error

On 14 November 2019, a Boeing 737 was instructed to stop its takeoff whilst still at low speed when the controller saw snow clearance vehicles entering the runway ahead. The Investigation found that the vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the tower controller and that only the monitoring of surface movement radar and the external environment visually had removed the risk of a more serious consequence arising from the incursion. The airport operator’s snow response plan was not specific to their airport and consequently of limited practical value.

On 11 September 2019, a Boeing 737-800 landed at night on Runway 13 at Malaga only 520 metres behind a departing Boeing 737-800 which was about to become airborne from the same runway. The Investigation noted the relatively low level of aircraft movements at the time, that both aircraft had complied with their respective clearances and that the landing aircraft crew had judged it safer to land than to commence a late go around. The conflict was attributed to non-compliance with the regulatory separation minima and deficient planning and decision making by the controller.

On 19 July 2020, a Boeing 737-800 was instructed to reject its takeoff on runway 24R at Palma after the driver of an airport vehicle already on the same runway in accordance with its own clearance heard the takeoff clearance being issued to the 737 and advised the controller of his position. The Investigation found that the TWR controller involved had comprehensively failed to adhere to relevant procedures set out in the applicable Operating Manual and the provisions of the Air Traffic Regulation in regard to the use of phraseology, active listening and surveillance of the airport manoeuvring area.

On 22 September 2017, a Boeing 747-400F taxiing in after landing requested and received further taxi instructions from GND on reaching its clearance limit when the controller assumed it had already crossed the active runway ahead. An Airbus A330-300 crew beginning takeoff saw the 747 beginning to cross, rejected the takeoff and stopped well clear of the other aircraft. The Investigation found that the GND controller had failed to check which side of the runway the 747 was on before issuing his clearance and noted that the controllable red stop bar system was not active or required to be.

On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a small aircraft which had just landed on the same runway until it appeared in the landing lights with rotation imminent. After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway. The Investigation attributed the conflict primarily to controller use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.

On 27 July 2018, Amsterdam ATC cleared a Boeing 737-800 to line up for departure from an intermediate taxiway but the 737 crew then heard the controller issue a takeoff clearance to an Embraer ERJ190 from the full length of the same runway. Having stopped past the holding point but clear of the actual runway and reported on the runway, they were then given a takeoff clearance, too, but held position. The 190 crew heard the 737 takeoff clearance and rejected their own takeoff, passing clear of the 737 at high speed. The Investigation suggested a review of intersection takeoffs.

On 17 March 2017, a Bombardier CRJ 700 which had just landed on runway 35R at Lyon Saint-Exupéry was about to cross runway 35L as cleared when its crew saw the departing Airbus A319 on runway 35L accelerating towards their intended crossing position and braked to a stop before entering the runway. The Investigation found that both aircraft had complied with all instructions issued by the TWR controller and concluded that safety management processes at the airport were not commensurate with the incursion risk involved and had been unchanged since an almost identical incident a year previously.

On 21 April 2006, a Boeing 737-800 cleared to take off from Brisbane began to do so whilst a vehicle was crossing the same runway in accordance with an ATC clearance issued on a different frequency. The aircraft crew saw the vehicle as they accelerated but decided that it would be clear by the time they reached its position. The vehicle driver reported that he was still within the runway strip when the aircraft passed. Since the occurrence, the adoption at Brisbane of the ICAO recommended procedure of using one frequency for all runway occupancy is being “actively considered”.

On 29 July 2008, a Boeing 737-700 taking off from Toronto in accordance with its TWR clearance was about a third of the way down the runway when three vehicles, which had previously been cleared to enter the same runway by a GND controller were seen. The aircraft became airborne approximately 760 metres from the vehicles.

On 27 May 2012, an Airbus A320 departing Barcelona was cleared by GND to taxi across an active runway on which a Boeing 737-800 was about to land. Whilst still moving but before entering the runway, the A320 crew, aware of the aircraft on approach, queried their crossing clearance but the instruction to stop was given too late to stop before crossing the unlit stop bar. The 737 was instructed to go around and there was no actual risk of collision. The Investigation attributed the controller error to lack of familiarisation with the routine runway configuration change in progress.

Accepted ATC Clearance not followed

On 7 September 2019, the crew of a Boeing 737-800 completed a circling approach to runway 18R by making their final approach to and a landing on runway 18L contrary to their clearance. The Investigation found that during the turn onto final approach, the Captain flying the approach had not appropriately balanced aircraft control by reference to flight instruments with the essential visual reference despite familiarity with both the aircraft and the procedure involved.It was concluded that the monitoring of runway alignment provided by the relatively low experienced first officer had been inadequate and was considered indicative or insufficient CRM between the two pilots.

On 18 September 2018, an Airbus A320 crewed by a Training Captain and a trainee Second Officer departing Sharjah was cleared for an intersection takeoff on runway 30 but turned onto the 12 direction and commenced takeoff with less than 1000 metres of runway ahead. On eventually recognising the error the Training Captain took control, set maximum thrust and the aircraft became airborne beyond the end of the runway and completed its international flight. The Investigation attributed the event to the pilots’ total absence of situational awareness noting that after issuing takeoff clearance, the controller did not monitor the aircraft.

On 22 August 2019, a Boeing 737-800 positioning visually from downwind after accepting clearance to make an approach to and landing on runway 03L at Hyakuri instead lined up on temporarily closed runway 03R and did not commence a go around until around 100 feet agl after seeing a vehicle on the runway and the painted runway threshold identification. The Investigation concluded that the event occured due to the captain not thoroughly performing the visual recognition of runway, and the FO not adequately monitoring the flight status of the aircraft thus failing to correct the runway misidentification made by the Captain.

On 24 October 2020, an Airbus A350-900 took off in daylight from runway 07R at Barcelona without a clearance to do so when an Airbus A320 was on approach to land on runway 02 which involves an approach path that crosses over runway 07R and lateral separation was reduced to 2.8nm. The Investigation attributed the inadvertent failure to await clearance to “some form of reduced alertness” on the part of the crew.

On 28 November 2020, a Boeing 737-300F taxiing for an early morning departure at Singapore Changi crossed an illuminated red stop bar in daylight and entered the active runway triggering an alert which enabled the controller to instruct the aircraft to immediately exit the runway and allow another aircraft already on approach to land. The Investigation found that the flight was the final one of a sequence of six carried out largely overnight as an extended duty predicated on an augmented crew. The context for the crew error was identified as a poorly managed operator subject to insufficient regulatory oversight.

On 25 September 2019, an ATR 72-600 about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.

On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a small aircraft which had just landed on the same runway until it appeared in the landing lights with rotation imminent. After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway. The Investigation attributed the conflict primarily to controller use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.

On 9 August 2019, a Bombardier CRJ-200LR about to depart Toronto which had read back and actioned a clearance to line up on the departure runway then began its takeoff without clearance and only commenced a high speed rejected takeoff when a Boeing 777-300 came into view crossing the runway ahead. A high speed rejected takeoff was completed from a maximum speed of around 100 knots. The Investigation concluded that an increased crew workload, an expectation that a takeoff clearance would be received without delay and misinterpretation of the line up instructions led to the premature initiation of a takeoff.

On 28 January 2019, a departing Embraer 170-200 narrowly avoided collision with part of a convoy of four snow clearance vehicles which failed to follow their clearance to enter a parallel taxiway and instead entered a Rapid Exit Taxiway and continued across the runway holding point before stopping just clear of the actual runway after multiple calls to do so. A high speed rejected takeoff led to the aircraft stopping just before the intersection where the incursion had occurred. The Investigation noted the prevailing adverse weather without attributing any specific cause to the vehicle convoy’s failure to proceed as cleared.

On 2 February 2019, a Bombardier CRJ200 narrowly avoided collision with part of a convoy of snowplough vehicles which had entered the landing runway without clearance less than 10 seconds before touchdown and begun to position on the centreline. The Investigation found that despite the prompt initiation of a go-around on sighting the vehicles, the aircraft was likely to have cleared them by less than 100 feet. A number of opportunities for improved ground vehicle movement procedures were identified and the incursion was seen as indicative of a general need to more effectively address this risk at Canadian airports.

Incursion pre Take off

On 14 November 2019, a Boeing 737 was instructed to stop its takeoff whilst still at low speed when the controller saw snow clearance vehicles entering the runway ahead. The Investigation found that the vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the tower controller and that only the monitoring of surface movement radar and the external environment visually had removed the risk of a more serious consequence arising from the incursion. The airport operator’s snow response plan was not specific to their airport and consequently of limited practical value.

On 18 September 2018, an Airbus A320 crewed by a Training Captain and a trainee Second Officer departing Sharjah was cleared for an intersection takeoff on runway 30 but turned onto the 12 direction and commenced takeoff with less than 1000 metres of runway ahead. On eventually recognising the error the Training Captain took control, set maximum thrust and the aircraft became airborne beyond the end of the runway and completed its international flight. The Investigation attributed the event to the pilots’ total absence of situational awareness noting that after issuing takeoff clearance, the controller did not monitor the aircraft.

On 11 September 2019, a Boeing 737-800 landed at night on Runway 13 at Malaga only 520 metres behind a departing Boeing 737-800 which was about to become airborne from the same runway. The Investigation noted the relatively low level of aircraft movements at the time, that both aircraft had complied with their respective clearances and that the landing aircraft crew had judged it safer to land than to commence a late go around. The conflict was attributed to non-compliance with the regulatory separation minima and deficient planning and decision making by the controller.

On 24 October 2020, an Airbus A350-900 took off in daylight from runway 07R at Barcelona without a clearance to do so when an Airbus A320 was on approach to land on runway 02 which involves an approach path that crosses over runway 07R and lateral separation was reduced to 2.8nm. The Investigation attributed the inadvertent failure to await clearance to “some form of reduced alertness” on the part of the crew.

On 19 July 2020, a Boeing 737-800 was instructed to reject its takeoff on runway 24R at Palma after the driver of an airport vehicle already on the same runway in accordance with its own clearance heard the takeoff clearance being issued to the 737 and advised the controller of his position. The Investigation found that the TWR controller involved had comprehensively failed to adhere to relevant procedures set out in the applicable Operating Manual and the provisions of the Air Traffic Regulation in regard to the use of phraseology, active listening and surveillance of the airport manoeuvring area.

On 28 November 2020, a Boeing 737-300F taxiing for an early morning departure at Singapore Changi crossed an illuminated red stop bar in daylight and entered the active runway triggering an alert which enabled the controller to instruct the aircraft to immediately exit the runway and allow another aircraft already on approach to land. The Investigation found that the flight was the final one of a sequence of six carried out largely overnight as an extended duty predicated on an augmented crew. The context for the crew error was identified as a poorly managed operator subject to insufficient regulatory oversight.

On 28 January 2019, a departing Embraer 170-200 narrowly avoided collision with part of a convoy of four snow clearance vehicles which failed to follow their clearance to enter a parallel taxiway and instead entered a Rapid Exit Taxiway and continued across the runway holding point before stopping just clear of the actual runway after multiple calls to do so. A high speed rejected takeoff led to the aircraft stopping just before the intersection where the incursion had occurred. The Investigation noted the prevailing adverse weather without attributing any specific cause to the vehicle convoy’s failure to proceed as cleared.

On 25 September 2019, an ATR 72-600 about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.

On 9 August 2019, a Bombardier CRJ-200LR about to depart Toronto which had read back and actioned a clearance to line up on the departure runway then began its takeoff without clearance and only commenced a high speed rejected takeoff when a Boeing 777-300 came into view crossing the runway ahead. A high speed rejected takeoff was completed from a maximum speed of around 100 knots. The Investigation concluded that an increased crew workload, an expectation that a takeoff clearance would be received without delay and misinterpretation of the line up instructions led to the premature initiation of a takeoff.

On 27 July 2018, Amsterdam ATC cleared a Boeing 737-800 to line up for departure from an intermediate taxiway but the 737 crew then heard the controller issue a takeoff clearance to an Embraer ERJ190 from the full length of the same runway. Having stopped past the holding point but clear of the actual runway and reported on the runway, they were then given a takeoff clearance, too, but held position. The 190 crew heard the 737 takeoff clearance and rejected their own takeoff, passing clear of the 737 at high speed. The Investigation suggested a review of intersection takeoffs.

Incursion after Landing

On 11 September 2019, a Boeing 737-800 landed at night on Runway 13 at Malaga only 520 metres behind a departing Boeing 737-800 which was about to become airborne from the same runway. The Investigation noted the relatively low level of aircraft movements at the time, that both aircraft had complied with their respective clearances and that the landing aircraft crew had judged it safer to land than to commence a late go around. The conflict was attributed to non-compliance with the regulatory separation minima and deficient planning and decision making by the controller.

On 22 September 2017, a Boeing 747-400F taxiing in after landing requested and received further taxi instructions from GND on reaching its clearance limit when the controller assumed it had already crossed the active runway ahead. An Airbus A330-300 crew beginning takeoff saw the 747 beginning to cross, rejected the takeoff and stopped well clear of the other aircraft. The Investigation found that the GND controller had failed to check which side of the runway the 747 was on before issuing his clearance and noted that the controllable red stop bar system was not active or required to be.

On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a small aircraft which had just landed on the same runway until it appeared in the landing lights with rotation imminent. After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway. The Investigation attributed the conflict primarily to controller use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.

On 28 April 2018, a Boeing 737-800 exited the landing runway at Perth and without clearance crossed a lit red stop bar protecting the other active runway as another 737 was accelerating for takeoff. This aircraft was instructed to stop due to a runway incursion ahead and passed 15 metres clear of the incursion aircraft which by then had also stopped. The Investigation concluded that, after failing to refer to the aerodrome chart, the Captain had mixed up two landing runway exits of which only one involved subsequently crossing the other active runway and decided the stop bar was inapplicable.

On 21 January 2018, a McDonnell Douglas MD-83 which had just landed on one of the two parallel runways at Isfahan, entered the roll out end of the other one and began taxiing on it in the opposite direction to an ATR72-600 which was about to touch down at the other end of the same runway. The Investigation found that the MD83 had failed to follow its taxi clearance but also that the TWR controller involved had failed to instruct the conflicting ATR-72 to go around, a requirement that was not optional despite the 4397 metre runway length.

On 26 May 2007, a Republic Airlines Embraer 170 taking off from runway 01L at San Francisco nearly collided with an aircraft which had just landed on intersecting runway 28R and come to a stop at the intersection. Both aircraft were operating in accordance with instructions to take off and land respectively issued by the same TWR controller. After an AMASS conflict alert issued 15 seconds in advance of the subsequent conflict, the controller involved instructed the aircraft on landing roll to hold ,

On 1 June 2010, an Airport RFFS bird scaring vehicle entered the active runway at Jersey in LVP without clearance and remained there for approximately three minutes until ATC became aware. The subsequent Investigation found that the incursion had fortuitously occurred just after an ERJ 190 had landed and had been terminated just as another aircraft had commenced a go around after failure to acquire the prescribed visual reference required to continue to a landing. The context for the failure of the vehicle driver to follow existing procedures was found to be their inadequacy and appropriate changes were implemented.

On March 20 2012 an Airbus A320 failed to taxi as instructed after vacating the landing runway 12L at Dubai and crossed the lit stop bar of an intersection access to runway 12R before stopping just in time to prevent a collision with a Boeing 777-300ER about to pass the intersection at very high speed on take off. Taxi clearance had been correctly given and acknowledged. The aircraft commander had extensive aircraft type experience but the inexperienced First Officer appeared to be undergoing early stage line training with a Safety Pilot present. No Final Report of the Investigation has been released and its status is unclear.

On 16 August 2007, a Westjet Boeing 737-700 which had just landed began to cross a runway in normal daylight visibility from which an Airbus A320 was taking off because the crew had received a clearance to do so after an ambiguous position report given following a non-instructed frequency change. When the other aircraft was seen, the 737 was stopped partly on the runway and the A320 passed close by at high speed with an 11 metre clearance. The AMASS activated, but not until it was too late to inform a useful controller response.

On 16 August 2001, a Continental Boeing 737-500 which had just landed on runway 18R at Dallas-Fort-Worth crossed runway 18L in daylight in front of a Delta Boeing 737-300 which had originally been believed to be holding position but was then seen to be taking off from the same runway. The Delta aircraft rotated early and sharply to overfly the crossing aircraft and suffered a tail strike in doing so. Clearance was estimated to have been about 100 feet. Both aircraft were being operated in accordance with valid ATC clearances issued by the same controller.

Runway Crossing

On 22 September 2017, a Boeing 747-400F taxiing in after landing requested and received further taxi instructions from GND on reaching its clearance limit when the controller assumed it had already crossed the active runway ahead. An Airbus A330-300 crew beginning takeoff saw the 747 beginning to cross, rejected the takeoff and stopped well clear of the other aircraft. The Investigation found that the GND controller had failed to check which side of the runway the 747 was on before issuing his clearance and noted that the controllable red stop bar system was not active or required to be.

On 9 August 2019, a Bombardier CRJ-200LR about to depart Toronto which had read back and actioned a clearance to line up on the departure runway then began its takeoff without clearance and only commenced a high speed rejected takeoff when a Boeing 777-300 came into view crossing the runway ahead. A high speed rejected takeoff was completed from a maximum speed of around 100 knots. The Investigation concluded that an increased crew workload, an expectation that a takeoff clearance would be received without delay and misinterpretation of the line up instructions led to the premature initiation of a takeoff.

On 17 March 2017, a Bombardier CRJ 700 which had just landed on runway 35R at Lyon Saint-Exupéry was about to cross runway 35L as cleared when its crew saw the departing Airbus A319 on runway 35L accelerating towards their intended crossing position and braked to a stop before entering the runway. The Investigation found that both aircraft had complied with all instructions issued by the TWR controller and concluded that safety management processes at the airport were not commensurate with the incursion risk involved and had been unchanged since an almost identical incident a year previously.

On 28 April 2018, a Boeing 737-800 exited the landing runway at Perth and without clearance crossed a lit red stop bar protecting the other active runway as another 737 was accelerating for takeoff. This aircraft was instructed to stop due to a runway incursion ahead and passed 15 metres clear of the incursion aircraft which by then had also stopped. The Investigation concluded that, after failing to refer to the aerodrome chart, the Captain had mixed up two landing runway exits of which only one involved subsequently crossing the other active runway and decided the stop bar was inapplicable.

On 21 April 2006, a Boeing 737-800 cleared to take off from Brisbane began to do so whilst a vehicle was crossing the same runway in accordance with an ATC clearance issued on a different frequency. The aircraft crew saw the vehicle as they accelerated but decided that it would be clear by the time they reached its position. The vehicle driver reported that he was still within the runway strip when the aircraft passed. Since the occurrence, the adoption at Brisbane of the ICAO recommended procedure of using one frequency for all runway occupancy is being “actively considered”.

On 26 May 2007, a Republic Airlines Embraer 170 taking off from runway 01L at San Francisco nearly collided with an aircraft which had just landed on intersecting runway 28R and come to a stop at the intersection. Both aircraft were operating in accordance with instructions to take off and land respectively issued by the same TWR controller. After an AMASS conflict alert issued 15 seconds in advance of the subsequent conflict, the controller involved instructed the aircraft on landing roll to hold ,

On 27 May 2012, an Airbus A320 departing Barcelona was cleared by GND to taxi across an active runway on which a Boeing 737-800 was about to land. Whilst still moving but before entering the runway, the A320 crew, aware of the aircraft on approach, queried their crossing clearance but the instruction to stop was given too late to stop before crossing the unlit stop bar. The 737 was instructed to go around and there was no actual risk of collision. The Investigation attributed the controller error to lack of familiarisation with the routine runway configuration change in progress.

On 16 August 2007, a Westjet Boeing 737-700 which had just landed began to cross a runway in normal daylight visibility from which an Airbus A320 was taking off because the crew had received a clearance to do so after an ambiguous position report given following a non-instructed frequency change. When the other aircraft was seen, the 737 was stopped partly on the runway and the A320 passed close by at high speed with an 11 metre clearance. The AMASS activated, but not until it was too late to inform a useful controller response.

On 16 August 2001, a Continental Boeing 737-500 which had just landed on runway 18R at Dallas-Fort-Worth crossed runway 18L in daylight in front of a Delta Boeing 737-300 which had originally been believed to be holding position but was then seen to be taking off from the same runway. The Delta aircraft rotated early and sharply to overfly the crossing aircraft and suffered a tail strike in doing so. Clearance was estimated to have been about 100 feet. Both aircraft were being operated in accordance with valid ATC clearances issued by the same controller.

On 27 July 2010, a South African Airways Boeing 737-800 on take from Runway 21R was instructed to reject that take off when already at high speed because a Boeing 737-400 was crossing the same runway ahead. The rejected take off was successful. The Investigation found that both aircraft had been operated in accordance with clearances issued by the responsible position in TWR ATC where OJT was in progress.

Intersecting Runways

On 25 September 2019, an ATR 72-600 about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.

On 24 February 2010, a Garuda Boeing 737-800 misunderstood the runway exit instruction issued during their landing roll at Perth and turned onto an intersecting active runway. An expeditious exit from this runway followed and no actual conflict resulted. The phraseology used by air traffic control was open to incorrect interpretation by the flight crew and led to their premature turn off the landing runway despite a prior briefing on exit options.

On 20 October 2014 a Dassault Falcon 50 taking off at night from Moscow Vnukovo collided with a snow plough which had entered the same runway without clearance shortly after rotation. Control was lost and all occupants died when it was destroyed by impact forces and post crash fire. The uninjured snow plough driver was subsequently discovered to be under the influence of alcohol. The Investigation found that the A-SMGCS effective for over a year prior to the collision had not been properly configured nor had controllers been adequately trained on its use, especially its conflict alerting functions.

On 12 October 2016, a BN2 Islander and a Bombardier DHC8-200 were involved in a near miss after the DHC8 took off from a runway which intersected with the runway on which the BN2 was about to land. The BN2 broke off its approach just before touchdown when the DHC8 was observed accelerating towards the runway intersection on its take-off roll. The Investigation noted that the aerodrome involved relied on visual separation and use of a CTAF and found that although both aircraft were aware of each other, the DHC8 crew failed to fully utilise visual lookout.

On 5 October 2016, an Embraer 195 took off at night without clearance as an Airbus A320 was about to touch down on an intersecting runway. The A320 responded promptly to the ATC go-around instruction and passed over the intersection after the E195 had accelerated through it during its take-off roll. The Investigation found that the E195 crew had correctly acknowledged a 'line up and wait' instruction but then commenced their take-off without stopping. Inadequate crew cross-checking procedures at the E195 operator and ATC use of intermediate runway access for intersecting runway take-offs were identified as contributory factors.

On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.

On 18 June 2010, an ATR 42 began a daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began take off from intersecting runway 16 with an ATC clearance. ATC were unaware of this until alerted to the situation by the crew of another aircraft which was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so prior to the runway intersection whilst the A340 continued departure on runway 16 .

On 31 January 2011, an Embraer 145LR being operated by Expressjet Airlines on a scheduled passenger flight from Cleveland OH to Dayton left landing runway 06R during a night landing in normal ground visibility and light winds and ended up on intersecting active runway 36. None of the 32 occupants were injured and only minor damage was caused to ground installations and the aircraft. No conflict with other aircraft resulted from the incursion onto runway 36 and after establishing that there was no major damage to the aircraft and after the taxiway route had been sanded the aircraft was taxied in to the gate for passenger disembarkation.

On 28 April 1999, a BAe 146-300 departing Birmingham began its daylight take off from Runway 33 without ATC clearance just prior to the touchdown of a PA38 on the intersecting runway 06. Collision was very narrowly avoided after the Controller intervened and the BAe 146 rejected its take off, just missing the PA38 which had stopped just off the runway 33 centreline. The Investigation noted the 146 pilots belief that a take off clearance had been issued but also that no attempt appeared to have been made to read it back or confirm it with the First Officer.

On December 6, 1999, United Airlines Boeing 757 failed to follow its taxi-in clearance after landing at night in thick fog at Providence RI and ended up at the edge of the runway it had just the landed on as a departing FedEx Boeing 727 passed very close by. The TWR controller, without surface radar available, then made unjustified presumptions about the 757s position and twice cleared a 737 to take off whilst the runway was still obstructed. Fortunately, the crew of that aircraft declined until safety was positively assured by the eventual arrival of the 757 at the terminal.

Intersecting extended centrelines

On 7 July 2016, an Airbus A320 crew cleared for a dusk visual approach to Rapid City mis-identified runway 13 at Ellsworth AFB as runway 14 at their intended destination and landed on it after recognising their error just before touchdown. The Investigation concluded that the crew had failed to use the available instrument approach guidance to ensure their final approach was made on the correct extended centreline and noted that it had only been possible to complete the wrong approach by flying an abnormally steep unstabilised final approach. Neither pilot was familiar with Rapid City Airport.

Towed aircraft involved

On 4 April 2016, a Boeing 737-800 crew taking off in normal night visibility from Jakarta Halim were unable to avoid an ATR 42-600 under tow which had entered their runway after ambiguity in its clearance. Both aircraft sustained substantial damage and caught fire but all those involved escaped uninjured. The Investigation concluded that contributory to the accident had been failure to use a single runway occupancy frequency, towing of a poorly lit aircraft, the potential effect on pilot detection of an obstruction of embedded approach lighting ahead of the displaced landing threshold and issues affecting controller traffic monitoring effectiveness.

A Boeing 767-300 departing from runway 24 at Amsterdam made a successful daylight rejected take off upon seeing a Boeing 747-400 under tow crossing the runway ahead. It was found that the crossing clearance had been given by the same trainee controller who had then cleared the 767 for take off after assuming that the towing traffic had cleared based on an unverified assumption based upon incorrect information which had been received earlier from an Assistant Controller. The conflict occurred with LVP in force and with visual surveillance of the runway from the TWR precluded by low cloud.

On 23 October 2001, at Toronto Pearson Airport, a B767 cleared for take-off was forced to reject the take-off when a tractor towing an A310 crossed the runway ahead of it. The tractor had been cleared to cross the active runway by ATC.

Near Miss

On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a small aircraft which had just landed on the same runway until it appeared in the landing lights with rotation imminent. After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway. The Investigation attributed the conflict primarily to controller use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.

On 28 April 2018, a Boeing 737-800 exited the landing runway at Perth and without clearance crossed a lit red stop bar protecting the other active runway as another 737 was accelerating for takeoff. This aircraft was instructed to stop due to a runway incursion ahead and passed 15 metres clear of the incursion aircraft which by then had also stopped. The Investigation concluded that, after failing to refer to the aerodrome chart, the Captain had mixed up two landing runway exits of which only one involved subsequently crossing the other active runway and decided the stop bar was inapplicable.

On 29 December 2011 a Golden Air ATR 72 making a daylight approach to runway 22R at Helsinki and cleared to land observed a Saab 340 entering the runway and initiated a low go around shortly before ATC, who had observed the incursion, issued a go around instruction. The Investigation attributed the breach of clearance by the Latvian-operated Saab 340 primarily to poor CRM, a poor standard of R/T and inadequate English Language proficiency despite valid certification of the latter.

On 26 May 2007, a Republic Airlines Embraer 170 taking off from runway 01L at San Francisco nearly collided with an aircraft which had just landed on intersecting runway 28R and come to a stop at the intersection. Both aircraft were operating in accordance with instructions to take off and land respectively issued by the same TWR controller. After an AMASS conflict alert issued 15 seconds in advance of the subsequent conflict, the controller involved instructed the aircraft on landing roll to hold ,

On March 20 2012 an Airbus A320 failed to taxi as instructed after vacating the landing runway 12L at Dubai and crossed the lit stop bar of an intersection access to runway 12R before stopping just in time to prevent a collision with a Boeing 777-300ER about to pass the intersection at very high speed on take off. Taxi clearance had been correctly given and acknowledged. The aircraft commander had extensive aircraft type experience but the inexperienced First Officer appeared to be undergoing early stage line training with a Safety Pilot present. No Final Report of the Investigation has been released and its status is unclear.

On 29 June 2012, a Piper PA31 taking off from runway 05 on a passenger charter flight just missed hitting an inspection vehicle which had entered the take off runway from an intersecting one contrary to ATC clearance. The overflying aircraft was estimated to have cleared the vehicle by approximately 20 feet and the pilot was unaware it had entered the active runway. The driver had been taking a mobile telephone call at the time and attributed the incursion to distraction. The breached clearance had been given and correctly read back approximately two minutes prior to the conflict occurring.

On 16 August 2001, a Continental Boeing 737-500 which had just landed on runway 18R at Dallas-Fort-Worth crossed runway 18L in daylight in front of a Delta Boeing 737-300 which had originally been believed to be holding position but was then seen to be taking off from the same runway. The Delta aircraft rotated early and sharply to overfly the crossing aircraft and suffered a tail strike in doing so. Clearance was estimated to have been about 100 feet. Both aircraft were being operated in accordance with valid ATC clearances issued by the same controller.

On 27 July 2010, a South African Airways Boeing 737-800 on take from Runway 21R was instructed to reject that take off when already at high speed because a Boeing 737-400 was crossing the same runway ahead. The rejected take off was successful. The Investigation found that both aircraft had been operated in accordance with clearances issued by the responsible position in TWR ATC where OJT was in progress.

On 25 May 2010 an Airwork SA227 Metroliner operating a cargo flight narrowly missed colliding with a vehicle on the runway during its night landing at Dunedin in normal visibility. The vehicle was subsequently found to have been on the runway without the appropriate authority in order to carry out a security inspection and the vehicle only co-incidentally at the side of the runway as its driver was unaware of the aircraft. It was noted such access had become a matter of custom and practice for which the context was inadequate procedures for control of airside vehicular access.

On 22 September 2018, a Saab 340B taking off in accordance with its clearance at Nassau came close to a midair collision over the main runway after a light aircraft began an almost simultaneous takeoff in the opposite direction of the same runway contrary to its received and correctly acknowledged non-conflicting takeoff clearance for a different runway without the TWR controller noticing. The light aircraft passed over the Saab 340 without either aircraft crew seeing the other aircraft. The Investigation noted that the light aircraft pilot had “forgotten” his clearance and unconsciously substituted an alternative.

Ground Collision

On 21 January 2010, a Cargolux Boeing 747-400F was in collision with an unoccupied van whilst about to touch down on runway 24 at Luxembourg airport in thick fog following a Cat 3b ILS approach. It was subsequently established that a maintenance crew and their vehicle had earlier been cleared to enter the active runway but their presence had then been overlooked. Comprehensive safety recommendations to rectify deficiencies in both ATC procedures and prevailing ATC practices were made by the Investigation.

On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.

On 20 October 2014 a Dassault Falcon 50 taking off at night from Moscow Vnukovo collided with a snow plough which had entered the same runway without clearance shortly after rotation. Control was lost and all occupants died when it was destroyed by impact forces and post crash fire. The uninjured snow plough driver was subsequently discovered to be under the influence of alcohol. The Investigation found that the A-SMGCS effective for over a year prior to the collision had not been properly configured nor had controllers been adequately trained on its use, especially its conflict alerting functions.

On 7 December 1983, a Boeing 727-200 taking off from Madrid in thick fog collided at high speed with a Douglas DC-9 which had not followed its departure taxi clearance to the beginning of the same runway. The DC-9 crew did not advise ATC of their uncertain location until asked for their position after non-receipt of an expected position report. The Investigation concluded that flight deck coordination on the DC-9 had been deficient and noted that gross error checks using the aircraft compasses had not been conducted. The airport was without any surface movement radar.

On 22 November 1994 a McDonnell Douglas MD 82 flight crew taking off from Lambert- St. Louis at night in excellent visibility suddenly became aware of a stationary Cessna 441 on the runway ahead and was unable to avoid a high speed collision. The collision destroyed the Cessna but allowed the MD82 to be brought to a controlled stop without occupant injury. The Investigation found that the Cessna 441 pilot had mistakenly believed his departure would be from the runway he had recently landed on and had entered that runway without clearance whilst still on GND frequency.

On 18 January 1990, a Boeing 727-200 landing at Atlanta at night and in good visibility in accordance with an unconditional clearance failed to see that a Beechcraft King Air, which had landed ahead of it, had yet to clear the runway. The 727 was unable to avoid a collision after a late sighting. The 727 sustained substantial damage and the King Air was destroyed. The Investigation attributed the collision to a combination of the failure of the runway controller to detect the lack of separation resulting from their issue of multiple landing clearances and the inadequacy of relevant ATC procedures.

On 3 December 1990 a Douglas DC9-10 flight crew taxiing for departure at Detroit in thick fog got lost and ended up stopped to one side of an active runway where, shortly after reporting their position, their aircraft was hit by a departing Boeing 727-200 and destroyed by the impact and subsequent fire. The Investigation concluded that the DC9 crew had failed to communicate positional uncertainty quickly enough but that their difficulties had been compounded by deficiencies in both the standard of air traffic service and airport surface markings, signage and lighting undetected by safety regulator oversight.

On 4 April 2016, a Boeing 737-800 crew taking off in normal night visibility from Jakarta Halim were unable to avoid an ATR 42-600 under tow which had entered their runway after ambiguity in its clearance. Both aircraft sustained substantial damage and caught fire but all those involved escaped uninjured. The Investigation concluded that contributory to the accident had been failure to use a single runway occupancy frequency, towing of a poorly lit aircraft, the potential effect on pilot detection of an obstruction of embedded approach lighting ahead of the displaced landing threshold and issues affecting controller traffic monitoring effectiveness.

On 1 February 1991, a Boeing 737-300 had just made a normal visibility night touchdown on Los Angeles runway 24L in accordance with its clearance when its crew saw another aircraft stationary ahead of them on the same runway. Avoidance was impossible in the time available and a high speed collision and post-impact fire destroyed both aircraft and killed 34 of their 101 occupants and injured 30 others. The other aircraft was subsequently found to have been a Fairchild Metroliner cleared to line up and wait by the same controller who had then cleared the 737 to land.

On 19 November 1996, a Beech 1900C which had just landed and a Beech King Air A90 which was taking off collided at the intersection of two runways at the non-Towered Quincy Municipal Airport. Both aircraft were destroyed by impact forces and fire and all occupants of both aircraft were killed. The Investigation found that the King Air pilots had failed to monitor the CTAF or properly scan visually for traffic. The loss of life of the Beech 1900 occupants, who had probably survived the impact, was attributed largely to inability to open the main door of the aircraft.

Phraseology

On 19 July 2020, a Boeing 737-800 was instructed to reject its takeoff on runway 24R at Palma after the driver of an airport vehicle already on the same runway in accordance with its own clearance heard the takeoff clearance being issued to the 737 and advised the controller of his position. The Investigation found that the TWR controller involved had comprehensively failed to adhere to relevant procedures set out in the applicable Operating Manual and the provisions of the Air Traffic Regulation in regard to the use of phraseology, active listening and surveillance of the airport manoeuvring area.

On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a small aircraft which had just landed on the same runway until it appeared in the landing lights with rotation imminent. After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway. The Investigation attributed the conflict primarily to controller use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.

On 21 January 2018, a McDonnell Douglas MD-83 which had just landed on one of the two parallel runways at Isfahan, entered the roll out end of the other one and began taxiing on it in the opposite direction to an ATR72-600 which was about to touch down at the other end of the same runway. The Investigation found that the MD83 had failed to follow its taxi clearance but also that the TWR controller involved had failed to instruct the conflicting ATR-72 to go around, a requirement that was not optional despite the 4397 metre runway length.

On 29 December 2011 a Golden Air ATR 72 making a daylight approach to runway 22R at Helsinki and cleared to land observed a Saab 340 entering the runway and initiated a low go around shortly before ATC, who had observed the incursion, issued a go around instruction. The Investigation attributed the breach of clearance by the Latvian-operated Saab 340 primarily to poor CRM, a poor standard of R/T and inadequate English Language proficiency despite valid certification of the latter.

On 16 August 2007, a Westjet Boeing 737-700 which had just landed began to cross a runway in normal daylight visibility from which an Airbus A320 was taking off because the crew had received a clearance to do so after an ambiguous position report given following a non-instructed frequency change. When the other aircraft was seen, the 737 was stopped partly on the runway and the A320 passed close by at high speed with an 11 metre clearance. The AMASS activated, but not until it was too late to inform a useful controller response.

On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.

On 3 February 2018, a runway inspection vehicle was cleared onto the active runway at London Gatwick ahead of an aircraft which had just touched down and driven towards it having been cleared to do so because the aircraft crew’s confirmation that they would clear the runway before reaching the vehicle was considered by the controller as a clearance limit. The Investigation found that the associated runway inspection procedure had not been adequately risk-assessed and noted that many issues raised by it had still not been addressed by the time it was completed eighteen months later.

On 7 March 2016, an Embraer 190 entered the departure runway at an intersection contrary to an ATC instruction to remain clear after neither a trainee controller nor their supervisor noticed the completely incorrect readback. An aircraft taking off in the opposite direction was able to rotate and fly over it before either controller noticed the conflict. The Investigation was told that the crew of the incursion aircraft had only looked towards the left before lining up and concluded that the event had highlighted the weakness of safety barriers based solely on the communications and vigilance of pilots and controllers.

On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.

On 30 January 2016, an Embraer 190-100 crew lined up on their assigned departure runway in good visibility at night without clearance to do so just as an Airbus A320 was about to land on it. The Investigation attributed the incursion to crew error arising from misinterpretation by both pilots of a non-standard Ground Controller instruction to position alongside another aircraft also awaiting departure at the hold when routinely transferring them to Tower as an instruction to line up on the runway. The failure to use the available stop bar system as a basis for controller incursion alerting was identified.

Intentional Premature Rotation

On 16 August 2001, a Continental Boeing 737-500 which had just landed on runway 18R at Dallas-Fort-Worth crossed runway 18L in daylight in front of a Delta Boeing 737-300 which had originally been believed to be holding position but was then seen to be taking off from the same runway. The Delta aircraft rotated early and sharply to overfly the crossing aircraft and suffered a tail strike in doing so. Clearance was estimated to have been about 100 feet. Both aircraft were being operated in accordance with valid ATC clearances issued by the same controller.

On 1 April 1999, an Air China Boeing 747-200F which had just landed on and cleared runway 14R at Chicago O Hare failed to follow its correctly read back taxi-in clearance and crossed the landing runway at night ahead of a Boeing 747 taking off. The latter rotated abruptly and banked away from the taxiing 747, missing it by an estimated 75 feet. It was found that the Air China aircraft had realised it was going the wrong way but had slowed rather than stopped taxiing with the nose of the aircraft past the runway centreline as it was overflown.

Vehicle Incursion

On 14 November 2019, a Boeing 737 was instructed to stop its takeoff whilst still at low speed when the controller saw snow clearance vehicles entering the runway ahead. The Investigation found that the vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the tower controller and that only the monitoring of surface movement radar and the external environment visually had removed the risk of a more serious consequence arising from the incursion. The airport operator’s snow response plan was not specific to their airport and consequently of limited practical value.

On 28 January 2019, a departing Embraer 170-200 narrowly avoided collision with part of a convoy of four snow clearance vehicles which failed to follow their clearance to enter a parallel taxiway and instead entered a Rapid Exit Taxiway and continued across the runway holding point before stopping just clear of the actual runway after multiple calls to do so. A high speed rejected takeoff led to the aircraft stopping just before the intersection where the incursion had occurred. The Investigation noted the prevailing adverse weather without attributing any specific cause to the vehicle convoy’s failure to proceed as cleared.

On 12 December 2018, the flight crew of a Beechcraft 1900 landing at the uncontrolled airport at Trail after an into- sun offset visual approach failed to see a runway inspection vehicle coming towards them until after touchdown. Maximum reverse and braking and an increased vehicle speed to exit combined to prevent collision by 4 seconds. The Investigation found that the mandatory airport safety management system was dysfunctional with relevant driver procedures either not followed or nonexistent and noted that two other recent runway incursions had been deemed unrelated to airport operations so that no risk review was carried out.

On 2 February 2019, a Bombardier CRJ200 narrowly avoided collision with part of a convoy of snowplough vehicles which had entered the landing runway without clearance less than 10 seconds before touchdown and begun to position on the centreline. The Investigation found that despite the prompt initiation of a go-around on sighting the vehicles, the aircraft was likely to have cleared them by less than 100 feet. A number of opportunities for improved ground vehicle movement procedures were identified and the incursion was seen as indicative of a general need to more effectively address this risk at Canadian airports.

On 21 April 2006, a Boeing 737-800 cleared to take off from Brisbane began to do so whilst a vehicle was crossing the same runway in accordance with an ATC clearance issued on a different frequency. The aircraft crew saw the vehicle as they accelerated but decided that it would be clear by the time they reached its position. The vehicle driver reported that he was still within the runway strip when the aircraft passed. Since the occurrence, the adoption at Brisbane of the ICAO recommended procedure of using one frequency for all runway occupancy is being “actively considered”.

On 29 July 2008, a Boeing 737-700 taking off from Toronto in accordance with its TWR clearance was about a third of the way down the runway when three vehicles, which had previously been cleared to enter the same runway by a GND controller were seen. The aircraft became airborne approximately 760 metres from the vehicles.

On 4 April 2013, during a brief daytime runway closure for inspection purposes, a vehicle entered the runway without ATC awareness and was still there when the runway was re-opened and the first landing clearance was issued. TWR control subsequently observed the vehicle on the runway visually but, when they were unable to make contact with it, instructed the aircraft on final approach to go around when it was just under 1nm from touchdown. It was discovered that the vehicle involved had been in broken contact with another nearby aerodrome because the wrong radio frequency had been selected.

On 18 December 2010, the ATC Runway Controller responsible for runway 24 at Amsterdam gave a daylight take off clearance in normal visibility to a Norwegian Boeing 737-300 whilst a bird control vehicle which they had earlier given clearance to enter the runway was still on it. The departing aircraft overflew the vehicle without noticing it. The subsequent investigation highlighted significant differences between the procedures for active runway access at Amsterdam and corresponding international practice as well as finding that integrated safety investigation and overall safety management at the airport were systemically ineffective.

On 1 June 2010, an Airport RFFS bird scaring vehicle entered the active runway at Jersey in LVP without clearance and remained there for approximately three minutes until ATC became aware. The subsequent Investigation found that the incursion had fortuitously occurred just after an ERJ 190 had landed and had been terminated just as another aircraft had commenced a go around after failure to acquire the prescribed visual reference required to continue to a landing. The context for the failure of the vehicle driver to follow existing procedures was found to be their inadequacy and appropriate changes were implemented.

Whilst a light aircraft was lined up for departure, a vehicle made an incorrect assumption about the nature of an ambiguously-phrased ATC TWR instruction and proceeded to enter the same runway. There was no actual risk of conflict since, although LVP were still in force after earlier fog, the TWR controller was able to see the vehicle incursion and therefore withhold the imminent take off clearance. The subsequent Investigation noted that it was imperative that clearance read backs about which there is doubt are not made speculatively in the expectation that they will elicit confirmation or correction.

Visual Response to Conflict

On 22 August 2019, a Boeing 737-800 positioning visually from downwind after accepting clearance to make an approach to and landing on runway 03L at Hyakuri instead lined up on temporarily closed runway 03R and did not commence a go around until around 100 feet agl after seeing a vehicle on the runway and the painted runway threshold identification. The Investigation concluded that the event occured due to the captain not thoroughly performing the visual recognition of runway, and the FO not adequately monitoring the flight status of the aircraft thus failing to correct the runway misidentification made by the Captain.

On 22 September 2017, a Boeing 747-400F taxiing in after landing requested and received further taxi instructions from GND on reaching its clearance limit when the controller assumed it had already crossed the active runway ahead. An Airbus A330-300 crew beginning takeoff saw the 747 beginning to cross, rejected the takeoff and stopped well clear of the other aircraft. The Investigation found that the GND controller had failed to check which side of the runway the 747 was on before issuing his clearance and noted that the controllable red stop bar system was not active or required to be.

On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a small aircraft which had just landed on the same runway until it appeared in the landing lights with rotation imminent. After immediately setting maximum thrust and rotating abruptly, the 737 just cleared the other aircraft, an Embraer 110 whose occupants were aware of a large aircraft passing very low overhead whilst their aircraft was still on the runway. The Investigation attributed the conflict primarily to controller use of non-standard phraseology and the absence of unobstructed runway visibility from the TWR.

On 12 December 2018, the flight crew of a Beechcraft 1900 landing at the uncontrolled airport at Trail after an into- sun offset visual approach failed to see a runway inspection vehicle coming towards them until after touchdown. Maximum reverse and braking and an increased vehicle speed to exit combined to prevent collision by 4 seconds. The Investigation found that the mandatory airport safety management system was dysfunctional with relevant driver procedures either not followed or nonexistent and noted that two other recent runway incursions had been deemed unrelated to airport operations so that no risk review was carried out.

On 9 August 2019, a Bombardier CRJ-200LR about to depart Toronto which had read back and actioned a clearance to line up on the departure runway then began its takeoff without clearance and only commenced a high speed rejected takeoff when a Boeing 777-300 came into view crossing the runway ahead. A high speed rejected takeoff was completed from a maximum speed of around 100 knots. The Investigation concluded that an increased crew workload, an expectation that a takeoff clearance would be received without delay and misinterpretation of the line up instructions led to the premature initiation of a takeoff.

On 2 February 2019, a Bombardier CRJ200 narrowly avoided collision with part of a convoy of snowplough vehicles which had entered the landing runway without clearance less than 10 seconds before touchdown and begun to position on the centreline. The Investigation found that despite the prompt initiation of a go-around on sighting the vehicles, the aircraft was likely to have cleared them by less than 100 feet. A number of opportunities for improved ground vehicle movement procedures were identified and the incursion was seen as indicative of a general need to more effectively address this risk at Canadian airports.

On 27 July 2018, Amsterdam ATC cleared a Boeing 737-800 to line up for departure from an intermediate taxiway but the 737 crew then heard the controller issue a takeoff clearance to an Embraer ERJ190 from the full length of the same runway. Having stopped past the holding point but clear of the actual runway and reported on the runway, they were then given a takeoff clearance, too, but held position. The 190 crew heard the 737 takeoff clearance and rejected their own takeoff, passing clear of the 737 at high speed. The Investigation suggested a review of intersection takeoffs.

On 17 March 2017, a Bombardier CRJ 700 which had just landed on runway 35R at Lyon Saint-Exupéry was about to cross runway 35L as cleared when its crew saw the departing Airbus A319 on runway 35L accelerating towards their intended crossing position and braked to a stop before entering the runway. The Investigation found that both aircraft had complied with all instructions issued by the TWR controller and concluded that safety management processes at the airport were not commensurate with the incursion risk involved and had been unchanged since an almost identical incident a year previously.

On 29 March 2010, a Raytheon 390 operating a passenger charter flight failed to follow acknowledged taxi instructions in normal visibility at night and entered the departure runway at an intermediate intersection and turned to backtrack against an opposite direction CRJ200 which had just started its take off roll. There was no ATC intervention but the CRJ crew saw the aircraft ahead and were able to stop before reaching it. The Raytheon flight crew stated that they had “encountered considerable difficulties finding out where they were while taxiing” and ended up on the departure runway “without realising it”.

On 21 April 2006, a Boeing 737-800 cleared to take off from Brisbane began to do so whilst a vehicle was crossing the same runway in accordance with an ATC clearance issued on a different frequency. The aircraft crew saw the vehicle as they accelerated but decided that it would be clear by the time they reached its position. The vehicle driver reported that he was still within the runway strip when the aircraft passed. Since the occurrence, the adoption at Brisbane of the ICAO recommended procedure of using one frequency for all runway occupancy is being “actively considered”.

R/T Response to Conflict

On 28 November 2020, a Boeing 737-300F taxiing for an early morning departure at Singapore Changi crossed an illuminated red stop bar in daylight and entered the active runway triggering an alert which enabled the controller to instruct the aircraft to immediately exit the runway and allow another aircraft already on approach to land. The Investigation found that the flight was the final one of a sequence of six carried out largely overnight as an extended duty predicated on an augmented crew. The context for the crew error was identified as a poorly managed operator subject to insufficient regulatory oversight.

On 7 June 2018, a Boeing 737-800 operated by a non-Spanish speaking crew was given takeoff clearance at Alicante after the same supervised student controller had previously cleared two vehicles to begin a full-length opposite-direction runway inspection in Spanish. The controller error was only recognised when the vehicles were able to transmit that they were still on the runway, the aircraft crew being unaware of the conflict until then told to reject the takeoff. The maximum speed reached by the aircraft was 88 knots and minimum separation between the aircraft and the closest vehicle was never less than 1000 metres.

On 7 January 2016, a Boeing 737-700 was inadvertently cleared by ATC to take off on a closed runway. The take-off was commenced with a vehicle visible ahead at the runway edge. When ATC realised the situation, a 'stop' instruction was issued and the aircraft did so after travelling approximately 740 metres. Investigation attributed the controller error to lost situational awareness. It also noted prior pilot and controller awareness that the runway used was closed and that the pilots had, on the basis of the take-off clearance crossed a lit red stop bar to enter the runway without explicit permission.

On 31 March 2014, a Geneva TWR controller believed it was possible to clear a light aircraft for an intersection take off ahead of a Fokker 100 already lining up on the same runway at full length and gave that clearance with a Boeing 737-800 6nm from touchdown on the same runway. Concluding that intervention was not necessary despite the activation of loss of separation alerts, the controller allowed the 737 to continue, issuing a landing clearance whilst the F100 was still on the runway. Sixteen seconds later, the 737 touched down three seconds after the F100 had become airborne.

On 5 June 2014, an AW139 about to depart from its Ottawa home base on a positioning flight exceeded its clearance limit and began to hover taxi towards the main runway as an A300 was about to touch down on it. The TWR controller immediately instructed the helicopter to stop which it did, just clear of the runway. The A300 reached taxi speed just prior to the intersection. The Investigation attributed the error to a combination of distraction and expectancy and noted that the AW139 pilot had not checked actual or imminent runway occupancy prior to passing his clearance limit.

On 25 November 2015, an Airbus A321 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 737 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. On reaching the lit stop bar protecting the runway, the crew queried their clearance and were told to hold position. Noting that the event had occurred at the time of a routine twice-daily runway configuration change and two previous very similar events in 2012 and 2014, further safety recommendations on risk management of runway configuration change were made.

On 3 October 2013, a vehicle entered an active runway without clearance after partial readback of a potentially confusing clearance was not challenged by the controller. A different controller then cleared a Boeing 777-300 to land without taking all available action to ensure that the runway was clear. The aircraft crew saw the vehicle near the edge of the runway after touchdown and manoeuvred their aircraft away from it, although the aircraft wing still passed over it. At the time of the incident, vehicles with clearance were permitted to cross red stop bars, a policy which has since been changed.

On 13 April 2007 in day VMC, an Air France A320 departing Sofia lined up contrary to an ATC Instruction to remain at the holding point and be ready immediate. The controller did not immediately notice and after subsequently giving a landing clearance for the same runway, was obliged to cancel it send the approaching aircraft around. An Investigation attributed the incursion to both the incorrect terminology used by TWR and the failure to challenge the incomplete clearance read back by the A320 crew.

No Single Runway Occupancy Frequency

On 14 November 2019, a Boeing 737 was instructed to stop its takeoff whilst still at low speed when the controller saw snow clearance vehicles entering the runway ahead. The Investigation found that the vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the tower controller and that only the monitoring of surface movement radar and the external environment visually had removed the risk of a more serious consequence arising from the incursion. The airport operator’s snow response plan was not specific to their airport and consequently of limited practical value.

On 21 April 2006, a Boeing 737-800 cleared to take off from Brisbane began to do so whilst a vehicle was crossing the same runway in accordance with an ATC clearance issued on a different frequency. The aircraft crew saw the vehicle as they accelerated but decided that it would be clear by the time they reached its position. The vehicle driver reported that he was still within the runway strip when the aircraft passed. Since the occurrence, the adoption at Brisbane of the ICAO recommended procedure of using one frequency for all runway occupancy is being “actively considered”.

On 11 January 2018, a privately-operated Cessna 525A Citation with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within less than a metre of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated. The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking. It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.

On 2 March 2017, a DHC8-200 took off from Kangerlussuaq in normal day visibility without clearance and almost immediately overflew three snow clearance vehicles on the runway. The Investigation identified a number of likely contributory factors including a one hour departure delay which the crew were keen to reduce in order to remain within their maximum allowable duty period and their inability to initially see the vehicles because of the runway down slope. No evidence of crew fatigue was found; it was noted that the vehicles involved had been in contact with TWR on a separate frequency using the local language.

On 4 April 2016, a Boeing 737-800 crew taking off in normal night visibility from Jakarta Halim were unable to avoid an ATR 42-600 under tow which had entered their runway after ambiguity in its clearance. Both aircraft sustained substantial damage and caught fire but all those involved escaped uninjured. The Investigation concluded that contributory to the accident had been failure to use a single runway occupancy frequency, towing of a poorly lit aircraft, the potential effect on pilot detection of an obstruction of embedded approach lighting ahead of the displaced landing threshold and issues affecting controller traffic monitoring effectiveness.

On 29 May 2009, a Boeing 757-200 being operated by UK Airline Thomson Airways on a passenger charter flight from Sharm-el-Sheikh, Egypt to Dublin and having just landed on runway 10 at destination at night in poor visibility overtook a small ride-on grass mower moving along the right hand side of the runway in approximate line with the aircraft’s right hand wing tip. The driver of the mower was unaware of the arriving aircraft until he heard it on the runway behind him. Prior to the landing, ATC had been informed that all grass-cutting equipment previously working on and around the runway had cleared it.

Change of Active Runway Configuration

On 27 May 2012, an Airbus A320 departing Barcelona was cleared by GND to taxi across an active runway on which a Boeing 737-800 was about to land. Whilst still moving but before entering the runway, the A320 crew, aware of the aircraft on approach, queried their crossing clearance but the instruction to stop was given too late to stop before crossing the unlit stop bar. The 737 was instructed to go around and there was no actual risk of collision. The Investigation attributed the controller error to lack of familiarisation with the routine runway configuration change in progress.

On 22 December 2016, an Airbus A320 cleared for a night approach to runway 16L at Haneda, which involved circling to the right from an initial VOR approach, instead turned left and began an approach to a closed but partially lit runway. ATC noticed and intervened to require a climb away for repositioning to the correct runway using radar vectors. The Investigation found that the context for the crew’s visual positioning error was their failure to adequately prepare for the approach before commencing it and that the new-on-type First Officer had not challenged the experienced Captain’s inappropriate actions and inactions.

Conditional Clearance

On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.

Wrong Active Runway

On 7 September 2019, the crew of a Boeing 737-800 completed a circling approach to runway 18R by making their final approach to and a landing on runway 18L contrary to their clearance. The Investigation found that during the turn onto final approach, the Captain flying the approach had not appropriately balanced aircraft control by reference to flight instruments with the essential visual reference despite familiarity with both the aircraft and the procedure involved.It was concluded that the monitoring of runway alignment provided by the relatively low experienced first officer had been inadequate and was considered indicative or insufficient CRM between the two pilots.

On 18 September 2018, an Airbus A320 crewed by a Training Captain and a trainee Second Officer departing Sharjah was cleared for an intersection takeoff on runway 30 but turned onto the 12 direction and commenced takeoff with less than 1000 metres of runway ahead. On eventually recognising the error the Training Captain took control, set maximum thrust and the aircraft became airborne beyond the end of the runway and completed its international flight. The Investigation attributed the event to the pilots’ total absence of situational awareness noting that after issuing takeoff clearance, the controller did not monitor the aircraft.

On 22 August 2019, a Boeing 737-800 positioning visually from downwind after accepting clearance to make an approach to and landing on runway 03L at Hyakuri instead lined up on temporarily closed runway 03R and did not commence a go around until around 100 feet agl after seeing a vehicle on the runway and the painted runway threshold identification. The Investigation concluded that the event occured due to the captain not thoroughly performing the visual recognition of runway, and the FO not adequately monitoring the flight status of the aircraft thus failing to correct the runway misidentification made by the Captain.

On 25 September 2019, an ATR 72-600 about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.

On 22 September 2018, a Saab 340B taking off in accordance with its clearance at Nassau came close to a midair collision over the main runway after a light aircraft began an almost simultaneous takeoff in the opposite direction of the same runway contrary to its received and correctly acknowledged non-conflicting takeoff clearance for a different runway without the TWR controller noticing. The light aircraft passed over the Saab 340 without either aircraft crew seeing the other aircraft. The Investigation noted that the light aircraft pilot had “forgotten” his clearance and unconsciously substituted an alternative.

On 29 March 2006, an Eirjet Airbus 320 was operating a scheduled passenger flight from Liverpool to Londonderry Airport in Northern Ireland for Ryanair in daylight. At 8nm from LDY, the operating crew reported that they were having problems with the ILS glideslope on approach to Runway 26. They judged that they were too high to carry out a safe landing from the ILS approach and requested permission from ATC to carry out a visual approach. The aircraft, with the commander as PF, then flew a right hand descending orbit followed by a visual circuit from which it landed. Upon landing, the crew were advised by Londonderry ATC, who had had the aircraft in sight when it called Finals and had then cleared it to land that they had, in fact, landed at Ballykelly airfield, a military helicopter base 5nm to the east-north-east of Londonderry.

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