Accident and Serious Incident Reports: RI
Accident and Serious Incident Reports: RI
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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 24 October 2021, a Shorts SD360 intending to land at the international airport serving Ndola did so at the recently closed old international airport after visually navigating there in hazy conditions whilst unknowingly in contact with ATC at the very recently opened new airport which had taken the same name and radio frequencies as the old one. The Investigation found multiple aspects of the airport changeover and re-designation had been mismanaged, particularly but not only failure to publish new flight procedures for both airports and ensure that NOTAM communication of the changes internationally had been effective.
On 11 October 2016, an Airbus A320 crew accelerating for takeoff and already at high speed observed an Airbus A330-300 beginning to cross the runway ahead. Unsure of whether they would be able to reject the takeoff and stop before reaching it, an early rotation was commenced. The A330 continued to cross and the A320 passed over its vertical stabiliser with what was subsequently calculated as a 19 metre clearance. The Investigation found that the same runway controller had initially cleared the just-landed A330 to cross the runway but forgot this and then cleared the A320 to take off.
On 18 March 2019, a Bombardier Challenger 300 had just touched down at Subang when it collided with an unseen and apparently unlit vehicle destroying it and critically injuring its occupant. Significant left wing leading edge damage was then found. The destroyed vehicle and another one had been cleared onto the runway by ATC for routine runway maintenance purposes by a single controller who then failed to tell another colleague taking over that the runway was occupied. Use of single controller position manning was non-standard and airside vehicle and aircraft communications were routinely using different communication channels preventing situational awareness.
On 27 April 2021, a Boeing 737-400 commenced a night takeoff at Porto in good visibility without seeing a runway inspection vehicle heading in the opposite direction on the same runway. On querying sight of an opposite direction aircraft on a discrete frequency the driver was told to quickly vacate the runway. The aircraft became airborne 300 metres before reaching the vehicle and passed over and abeam it. Both vehicle and aircraft were following the controller’s clearances. The detailed Investigation confirmed controller error in a context of multiple systemic deficiencies in the delivery of runway operational safety at the airport.
On 14 November 2019, a Boeing 737 was instructed was instructed to stop its night takeoff from Lyon at a low speed when the controller saw snow clearance vehicles entering the runway ahead. This vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the runway controller and only the monitoring of surface movement radar and visual external scanning had removed the risk of a more serious consequence arising from the permitted incursion. The airport operator’s snow response plan was found not be specific to their airport and consequently of limited practical value.
Accepted ATC Clearance not followed
On 24 October 2021, a Shorts SD360 intending to land at the international airport serving Ndola did so at the recently closed old international airport after visually navigating there in hazy conditions whilst unknowingly in contact with ATC at the very recently opened new airport which had taken the same name and radio frequencies as the old one. The Investigation found multiple aspects of the airport changeover and re-designation had been mismanaged, particularly but not only failure to publish new flight procedures for both airports and ensure that NOTAM communication of the changes internationally had been effective.
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.
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 of 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’ absence of situational awareness and noted 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 occurred 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.
Incursion pre Take off
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.
On 11 October 2016, an Airbus A320 crew accelerating for takeoff and already at high speed observed an Airbus A330-300 beginning to cross the runway ahead. Unsure of whether they would be able to reject the takeoff and stop before reaching it, an early rotation was commenced. The A330 continued to cross and the A320 passed over its vertical stabiliser with what was subsequently calculated as a 19 metre clearance. The Investigation found that the same runway controller had initially cleared the just-landed A330 to cross the runway but forgot this and then cleared the A320 to take off.
On 18 March 2016, at Cheongju in thick fog at night with visibility just above the minimum permitted for landing, an Airbus A319 began to enter the departure runway as a Boeing 737-800 was landing on it as cleared. Only when the 737 crew saw the other aircraft ahead when still at high speed were they able to initiate a lateral deviation and thereby avoid a collision by creating a 3 metre separation between their aircraft and the A319.The Investigation found that the A319 had exceeded the taxi clearance given by Ground Control but noted that this used poor phraseology.
On 27 April 2021, a Boeing 737-400 commenced a night takeoff at Porto in good visibility without seeing a runway inspection vehicle heading in the opposite direction on the same runway. On querying sight of an opposite direction aircraft on a discrete frequency the driver was told to quickly vacate the runway. The aircraft became airborne 300 metres before reaching the vehicle and passed over and abeam it. Both vehicle and aircraft were following the controller’s clearances. The detailed Investigation confirmed controller error in a context of multiple systemic deficiencies in the delivery of runway operational safety at the airport.
On 7 March 2020, an Embraer ERJ190 was taking off at Toronto when it struck a bird and commenced and reported a high speed rejected takeoff. This call was not heard by ATC who then cleared a Boeing 777-300 to line up and takeoff on the same runway. As the 777 accelerated, its crew saw the ERJ190 ahead and also commenced a high speed rejected takeoff, successfully avoiding a collision. The Investigation found that the air/ground status of both aircraft was configured in accordance with current design standards in a way which prevented activation of the ground collision prevention system.
Incursion after Landing
On 18 March 2016, at Cheongju in thick fog at night with visibility just above the minimum permitted for landing, an Airbus A319 began to enter the departure runway as a Boeing 737-800 was landing on it as cleared. Only when the 737 crew saw the other aircraft ahead when still at high speed were they able to initiate a lateral deviation and thereby avoid a collision by creating a 3 metre separation between their aircraft and the A319.The Investigation found that the A319 had exceeded the taxi clearance given by Ground Control but noted that this used poor phraseology.
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 smaller aircraft which had just landed on the same runway and was ahead 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.
Runway Crossing
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.
On 11 October 2016, an Airbus A320 crew accelerating for takeoff and already at high speed observed an Airbus A330-300 beginning to cross the runway ahead. Unsure of whether they would be able to reject the takeoff and stop before reaching it, an early rotation was commenced. The A330 continued to cross and the A320 passed over its vertical stabiliser with what was subsequently calculated as a 19 metre clearance. The Investigation found that the same runway controller had initially cleared the just-landed A330 to cross the runway but forgot this and then cleared the A320 to take off.
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.
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 uncontrolled 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.
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 11 October 2016, an Airbus A320 crew accelerating for takeoff and already at high speed observed an Airbus A330-300 beginning to cross the runway ahead. Unsure of whether they would be able to reject the takeoff and stop before reaching it, an early rotation was commenced. The A330 continued to cross and the A320 passed over its vertical stabiliser with what was subsequently calculated as a 19 metre clearance. The Investigation found that the same runway controller had initially cleared the just-landed A330 to cross the runway but forgot this and then cleared the A320 to take off.
On 18 March 2016, at Cheongju in thick fog at night with visibility just above the minimum permitted for landing, an Airbus A319 began to enter the departure runway as a Boeing 737-800 was landing on it as cleared. Only when the 737 crew saw the other aircraft ahead when still at high speed were they able to initiate a lateral deviation and thereby avoid a collision by creating a 3 metre separation between their aircraft and the A319.The Investigation found that the A319 had exceeded the taxi clearance given by Ground Control but noted that this used poor phraseology.
On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a smaller aircraft which had just landed on the same runway and was ahead 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.
Ground Collision
On 18 March 2019, a Bombardier Challenger 300 had just touched down at Subang when it collided with an unseen and apparently unlit vehicle destroying it and critically injuring its occupant. Significant left wing leading edge damage was then found. The destroyed vehicle and another one had been cleared onto the runway by ATC for routine runway maintenance purposes by a single controller who then failed to tell another colleague taking over that the runway was occupied. Use of single controller position manning was non-standard and airside vehicle and aircraft communications were routinely using different communication channels preventing situational awareness.
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 realised 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.
Phraseology
On 18 March 2016, at Cheongju in thick fog at night with visibility just above the minimum permitted for landing, an Airbus A319 began to enter the departure runway as a Boeing 737-800 was landing on it as cleared. Only when the 737 crew saw the other aircraft ahead when still at high speed were they able to initiate a lateral deviation and thereby avoid a collision by creating a 3 metre separation between their aircraft and the A319.The Investigation found that the A319 had exceeded the taxi clearance given by Ground Control but noted that this used poor phraseology.
On 19 July 2020, a Boeing 737-800 was instructed to reject its night 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 not adhered 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 smaller aircraft which had just landed on the same runway and was ahead 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.
Intentional Premature Rotation
On 11 October 2016, an Airbus A320 crew accelerating for takeoff and already at high speed observed an Airbus A330-300 beginning to cross the runway ahead. Unsure of whether they would be able to reject the takeoff and stop before reaching it, an early rotation was commenced. The A330 continued to cross and the A320 passed over its vertical stabiliser with what was subsequently calculated as a 19 metre clearance. The Investigation found that the same runway controller had initially cleared the just-landed A330 to cross the runway but forgot this and then cleared the A320 to take off.
On 10 April 2018, a Boeing 737-800 crew making a night takeoff from Brasilia did not see a smaller aircraft which had just landed on the same runway and was ahead 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 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 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.
On 27 April 2021, a Boeing 737-400 commenced a night takeoff at Porto in good visibility without seeing a runway inspection vehicle heading in the opposite direction on the same runway. On querying sight of an opposite direction aircraft on a discrete frequency the driver was told to quickly vacate the runway. The aircraft became airborne 300 metres before reaching the vehicle and passed over and abeam it. Both vehicle and aircraft were following the controller’s clearances. The detailed Investigation confirmed controller error in a context of multiple systemic deficiencies in the delivery of runway operational safety at the airport.
On 14 November 2019, a Boeing 737 was instructed was instructed to stop its night takeoff from Lyon at a low speed when the controller saw snow clearance vehicles entering the runway ahead. This vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the runway controller and only the monitoring of surface movement radar and visual external scanning had removed the risk of a more serious consequence arising from the permitted incursion. The airport operator’s snow response plan was found not be 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.
Visual Response to Conflict
On 11 October 2016, an Airbus A320 crew accelerating for takeoff and already at high speed observed an Airbus A330-300 beginning to cross the runway ahead. Unsure of whether they would be able to reject the takeoff and stop before reaching it, an early rotation was commenced. The A330 continued to cross and the A320 passed over its vertical stabiliser with what was subsequently calculated as a 19 metre clearance. The Investigation found that the same runway controller had initially cleared the just-landed A330 to cross the runway but forgot this and then cleared the A320 to take off.
On 18 March 2016, at Cheongju in thick fog at night with visibility just above the minimum permitted for landing, an Airbus A319 began to enter the departure runway as a Boeing 737-800 was landing on it as cleared. Only when the 737 crew saw the other aircraft ahead when still at high speed were they able to initiate a lateral deviation and thereby avoid a collision by creating a 3 metre separation between their aircraft and the A319.The Investigation found that the A319 had exceeded the taxi clearance given by Ground Control but noted that this used poor phraseology.
On 7 March 2020, an Embraer ERJ190 was taking off at Toronto when it struck a bird and commenced and reported a high speed rejected takeoff. This call was not heard by ATC who then cleared a Boeing 777-300 to line up and takeoff on the same runway. As the 777 accelerated, its crew saw the ERJ190 ahead and also commenced a high speed rejected takeoff, successfully avoiding a collision. The Investigation found that the air/ground status of both aircraft was configured in accordance with current design standards in a way which prevented activation of the ground collision prevention system.
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 occurred 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.
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.
No Single Runway Occupancy Frequency
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.
On 27 April 2021, a Boeing 737-400 commenced a night takeoff at Porto in good visibility without seeing a runway inspection vehicle heading in the opposite direction on the same runway. On querying sight of an opposite direction aircraft on a discrete frequency the driver was told to quickly vacate the runway. The aircraft became airborne 300 metres before reaching the vehicle and passed over and abeam it. Both vehicle and aircraft were following the controller’s clearances. The detailed Investigation confirmed controller error in a context of multiple systemic deficiencies in the delivery of runway operational safety at the airport.
On 14 November 2019, a Boeing 737 was instructed was instructed to stop its night takeoff from Lyon at a low speed when the controller saw snow clearance vehicles entering the runway ahead. This vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the runway controller and only the monitoring of surface movement radar and visual external scanning had removed the risk of a more serious consequence arising from the permitted incursion. The airport operator’s snow response plan was found not be 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.
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 realised 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 24 October 2021, a Shorts SD360 intending to land at the international airport serving Ndola did so at the recently closed old international airport after visually navigating there in hazy conditions whilst unknowingly in contact with ATC at the very recently opened new airport which had taken the same name and radio frequencies as the old one. The Investigation found multiple aspects of the airport changeover and re-designation had been mismanaged, particularly but not only failure to publish new flight procedures for both airports and ensure that NOTAM communication of the changes internationally had been effective.
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 of 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’ absence of situational awareness and noted 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 occurred 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.
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