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 2 July 2022, a Boeing 737-800 taxiing for departure from runway 24L at Barcelona under GND control using a route which crossed the runway 24R extended centreline almost immediately following the runway end was abruptly stopped by the controller on the centreline and almost immediately, an Airbus A330-300 departing 24R overflew the 737 at about 700 feet. The 737 should have been stopped at an earlier unlit stopbar position before the A330 was given takeoff clearance. An inadequate lighting control and indicating system was assessed as contributing to procedural failure. Both controllers involved were correctly qualified but very inexperienced.

On 10 June 2021, an Embraer 170-200LR was cleared to line up and wait on runway 27 at San Diego with a Boeing 737-800 already cleared to land on the same runway. The occupied runway led to ASDE-X activation which prompted a controller go-around instruction to the 737 when it was less than a mile from the runway displaced threshold but this was blocked by an undetected simultaneous transmission from the E170 which had just been instructed to exit the runway. The 737 manoeuvred around the E170 as it attempted to exit the runway, before touching down beyond it.

On 13 November 2018, a Boeing 737-800 on approach to Hong Kong at night received a late landing clearance for runway 07L in good visibility. The aircraft touched down without the crew seeing that a Bombardier Global 5000 that had just landed ahead of them had not cleared the runway. Minimum on-runway separation was just over 1000 metres. It was found that the controller had not recognised that the runway was still engaged, but noted that the business jet had taken significantly longer than normal to clear the runway after landing.

On 18 October 2022, an Airbus A321 on approach to Venice in thick fog was observed on TCAS by a Boeing 737-800 crew awaiting takeoff clearance from the same runway after a lineup and wait instruction. When no takeoff clearance followed, the 737 crew transmitted, advising its position without any response. The crew then transmitted on 121.5, instructing the A321 to go around, and they received no response. They were about to vacate the runway when the controller instructed the A321 to go around, which only  occurred as it approached 100 feet AGL. The controller involved had failed to plug in his headset properly.

On 3 June 2022, an Airport Rescue and Fire Fighting Service utility vehicle inadvertently entered an active runway at night when intending to drive along its parallel taxiway after becoming confused about their routing. On reaching the clearly identified runway holding point but requesting permission to access the intended taxiway, the controller turned off the illuminated stop bar and the vehicle was briefly driven onto the runway before the driver realised their error and made a U turn to exit. The incursion activated visual and aural warnings but these were both inexplicably missed by the controller and their supervisor.

Accepted ATC Clearance not followed

On 15 October 2022 an airport authority vehicle entered an active runway without clearance with a Boeing 737-8 on short final which was instructed to and completed a go around. The experienced driver involved had correctly read back a clearance to remain at the holding point on reaching it but failed to stop and it was concluded the insufficiently obvious nature of the installed signage was contributory. Drivers were found to have routinely ignored instructions to use the available perimeter road for years, preferring to cross active runways to save time without the airport authority taking any relevant safety action.

On 21 June 2022, a Boeing 737-9 cleared for a visual approach and landing on runway 28C at Pittsburgh landed on the adjacent runway 28L instead. The controller stated that having become aware that the aircraft was lined up with the wrong runway in the absence of any potential hazards, he had decided not to intervene. The crew said that a transient avionics fault on final approach had reduced their opportunity to ensure correct runway alignment but this fault was found to have cleared much earlier. It was noted that runway 28L had sequenced approach lighting whereas 28C had none.

On 18 November 2022, the crew of an Airbus A320neo about to become airborne as it departed Lima were unable to avoid a high-speed collision with an airport fire appliance, which unexpectedly entered the runway. The impact wrecked the vehicle, killing two of its three occupants, and a resultant fuel-fed fire severely damaged the aircraft, although with no fatalities amongst its 107 occupants. The vehicle was found to have entered the runway without clearance primarily as a consequence of inadequate briefing for an exercise to validate emergency access times from a newly relocated airport fire station.

On 24 October 2021, a Bombardier DHC8-400 inbound to Belagavi initially advised to expect a non-precision approach to runway 08 was subsequently cleared for an equivalent approach to runway 26. An approach to runway 08 was then flown without ATC intervention or pilot error recognition, but with no actual consequences. The error was attributed to pilot expectation bias and distraction and controller failure to order a go-around after eventually realising what was happening. The context that had facilitated the errors was considered to be procedure and performance inadequacy at both the aircraft operator and ATC.

On 27 February 2023, an Embraer 190 was flaring for an imminent night touchdown on runway 04R at Boston in normal visibility when a Learjet 60 began takeoff from intersecting runway 09. As the Embraer descended through 30 feet AGL, the Learjet entered runway 04R, taking two seconds to cross it. The incursion had triggered an ATC alert and just after the crossing, the Embraer was instructed to go around and did so from around 10 feet AGL. The Investigation found that the Learjet crew correctly read back their line up and wait clearance but then took off without clearance.

Incursion pre Take off

On 2 July 2022, a Boeing 737-800 taxiing for departure from runway 24L at Barcelona under GND control using a route which crossed the runway 24R extended centreline almost immediately following the runway end was abruptly stopped by the controller on the centreline and almost immediately, an Airbus A330-300 departing 24R overflew the 737 at about 700 feet. The 737 should have been stopped at an earlier unlit stopbar position before the A330 was given takeoff clearance. An inadequate lighting control and indicating system was assessed as contributing to procedural failure. Both controllers involved were correctly qualified but very inexperienced.

On 10 June 2021, an Embraer 170-200LR was cleared to line up and wait on runway 27 at San Diego with a Boeing 737-800 already cleared to land on the same runway. The occupied runway led to ASDE-X activation which prompted a controller go-around instruction to the 737 when it was less than a mile from the runway displaced threshold but this was blocked by an undetected simultaneous transmission from the E170 which had just been instructed to exit the runway. The 737 manoeuvred around the E170 as it attempted to exit the runway, before touching down beyond it.

On 18 November 2022, the crew of an Airbus A320neo about to become airborne as it departed Lima were unable to avoid a high-speed collision with an airport fire appliance, which unexpectedly entered the runway. The impact wrecked the vehicle, killing two of its three occupants, and a resultant fuel-fed fire severely damaged the aircraft, although with no fatalities amongst its 107 occupants. The vehicle was found to have entered the runway without clearance primarily as a consequence of inadequate briefing for an exercise to validate emergency access times from a newly relocated airport fire station.

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 at Shanghai Hongqiao and already at high speed observed an Airbus A330-300 crossing 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.

Incursion after Landing

On 13 November 2018, a Boeing 737-800 on approach to Hong Kong at night received a late landing clearance for runway 07L in good visibility. The aircraft touched down without the crew seeing that a Bombardier Global 5000 that had just landed ahead of them had not cleared the runway. Minimum on-runway separation was just over 1000 metres. It was found that the controller had not recognised that the runway was still engaged, but noted that the business jet had taken significantly longer than normal to clear the runway after landing.

On 18 March 2016 at night and with visibility just above the minimum permitted for landing with thick fog patches present, an Airbus A319 entered the runway at Cheongju contrary to its clearance 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 an immediate lateral deviation and avoid a collision by creating a 3 metre separation between the two aircraft. The Investigation found that the A319 had exceeded its clearance and remained on the Ground frequency but noted poor controller 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.

Runway Crossing

On 2 July 2022, a Boeing 737-800 taxiing for departure from runway 24L at Barcelona under GND control using a route which crossed the runway 24R extended centreline almost immediately following the runway end was abruptly stopped by the controller on the centreline and almost immediately, an Airbus A330-300 departing 24R overflew the 737 at about 700 feet. The 737 should have been stopped at an earlier unlit stopbar position before the A330 was given takeoff clearance. An inadequate lighting control and indicating system was assessed as contributing to procedural failure. Both controllers involved were correctly qualified but very inexperienced.

On 15 October 2022 an airport authority vehicle entered an active runway without clearance with a Boeing 737-8 on short final which was instructed to and completed a go around. The experienced driver involved had correctly read back a clearance to remain at the holding point on reaching it but failed to stop and it was concluded the insufficiently obvious nature of the installed signage was contributory. Drivers were found to have routinely ignored instructions to use the available perimeter road for years, preferring to cross active runways to save time without the airport authority taking any relevant safety action.

On 3 June 2022, an Airport Rescue and Fire Fighting Service utility vehicle inadvertently entered an active runway at night when intending to drive along its parallel taxiway after becoming confused about their routing. On reaching the clearly identified runway holding point but requesting permission to access the intended taxiway, the controller turned off the illuminated stop bar and the vehicle was briefly driven onto the runway before the driver realised their error and made a U turn to exit. The incursion activated visual and aural warnings but these were both inexplicably missed by the controller and their supervisor.

On 30 November 2019, as an Airbus A320 was about to touchdown in normal night visibility at Toyko Haneda, a runway maintenance contractor’s small car began to cross the same runway without obtaining the required clearance as the driver believed this was not necessary. Separation reduced to 1,417 metres shortly before the A320 began to clear the 3,000 metre runway. Planning for overnight work on the intersecting runway was found to have been inadequate and multiple related training requirements and procedures were enhanced by both the aviation regulator and the airport operator. The incursion was assessed as ICAO Category ‘C’.

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.

Intersecting Runways

On 27 February 2023, an Embraer 190 was flaring for an imminent night touchdown on runway 04R at Boston in normal visibility when a Learjet 60 began takeoff from intersecting runway 09. As the Embraer descended through 30 feet AGL, the Learjet entered runway 04R, taking two seconds to cross it. The incursion had triggered an ATC alert and just after the crossing, the Embraer was instructed to go around and did so from around 10 feet AGL. The Investigation found that the Learjet crew correctly read back their line up and wait clearance but then took off without clearance.

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.

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 27 February 2023, an Embraer 190 was flaring for an imminent night touchdown on runway 04R at Boston in normal visibility when a Learjet 60 began takeoff from intersecting runway 09. As the Embraer descended through 30 feet AGL, the Learjet entered runway 04R, taking two seconds to cross it. The incursion had triggered an ATC alert and just after the crossing, the Embraer was instructed to go around and did so from around 10 feet AGL. The Investigation found that the Learjet crew correctly read back their line up and wait clearance but then took off without clearance.

On 11 October 2016, an Airbus A320 crew accelerating for takeoff at Shanghai Hongqiao and already at high speed observed an Airbus A330-300 crossing 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 night and with visibility just above the minimum permitted for landing with thick fog patches present, an Airbus A319 entered the runway at Cheongju contrary to its clearance 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 an immediate lateral deviation and avoid a collision by creating a 3 metre separation between the two aircraft. The Investigation found that the A319 had exceeded its clearance and remained on the Ground frequency but noted poor controller 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.

Ground Collision

On 18 November 2022, the crew of an Airbus A320neo about to become airborne as it departed Lima were unable to avoid a high-speed collision with an airport fire appliance, which unexpectedly entered the runway. The impact wrecked the vehicle, killing two of its three occupants, and a resultant fuel-fed fire severely damaged the aircraft, although with no fatalities amongst its 107 occupants. The vehicle was found to have entered the runway without clearance primarily as a consequence of inadequate briefing for an exercise to validate emergency access times from a newly relocated airport fire station.

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 did not 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.

Phraseology

On 18 November 2022, the crew of an Airbus A320neo about to become airborne as it departed Lima were unable to avoid a high-speed collision with an airport fire appliance, which unexpectedly entered the runway. The impact wrecked the vehicle, killing two of its three occupants, and a resultant fuel-fed fire severely damaged the aircraft, although with no fatalities amongst its 107 occupants. The vehicle was found to have entered the runway without clearance primarily as a consequence of inadequate briefing for an exercise to validate emergency access times from a newly relocated airport fire station.

On 24 October 2021, a Bombardier DHC8-400 inbound to Belagavi initially advised to expect a non-precision approach to runway 08 was subsequently cleared for an equivalent approach to runway 26. An approach to runway 08 was then flown without ATC intervention or pilot error recognition, but with no actual consequences. The error was attributed to pilot expectation bias and distraction and controller failure to order a go-around after eventually realising what was happening. The context that had facilitated the errors was considered to be procedure and performance inadequacy at both the aircraft operator and ATC.

On 18 March 2016 at night and with visibility just above the minimum permitted for landing with thick fog patches present, an Airbus A319 entered the runway at Cheongju contrary to its clearance 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 an immediate lateral deviation and avoid a collision by creating a 3 metre separation between the two aircraft. The Investigation found that the A319 had exceeded its clearance and remained on the Ground frequency but noted poor controller 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.

Intentional Premature Rotation

On 11 October 2016, an Airbus A320 crew accelerating for takeoff at Shanghai Hongqiao and already at high speed observed an Airbus A330-300 crossing 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 15 October 2022 an airport authority vehicle entered an active runway without clearance with a Boeing 737-8 on short final which was instructed to and completed a go around. The experienced driver involved had correctly read back a clearance to remain at the holding point on reaching it but failed to stop and it was concluded the insufficiently obvious nature of the installed signage was contributory. Drivers were found to have routinely ignored instructions to use the available perimeter road for years, preferring to cross active runways to save time without the airport authority taking any relevant safety action.

On 18 November 2022, the crew of an Airbus A320neo about to become airborne as it departed Lima were unable to avoid a high-speed collision with an airport fire appliance, which unexpectedly entered the runway. The impact wrecked the vehicle, killing two of its three occupants, and a resultant fuel-fed fire severely damaged the aircraft, although with no fatalities amongst its 107 occupants. The vehicle was found to have entered the runway without clearance primarily as a consequence of inadequate briefing for an exercise to validate emergency access times from a newly relocated airport fire station.

On 3 June 2022, an Airport Rescue and Fire Fighting Service utility vehicle inadvertently entered an active runway at night when intending to drive along its parallel taxiway after becoming confused about their routing. On reaching the clearly identified runway holding point but requesting permission to access the intended taxiway, the controller turned off the illuminated stop bar and the vehicle was briefly driven onto the runway before the driver realised their error and made a U turn to exit. The incursion activated visual and aural warnings but these were both inexplicably missed by the controller and their supervisor.

On 30 November 2019, as an Airbus A320 was about to touchdown in normal night visibility at Toyko Haneda, a runway maintenance contractor’s small car began to cross the same runway without obtaining the required clearance as the driver believed this was not necessary. Separation reduced to 1,417 metres shortly before the A320 began to clear the 3,000 metre runway. Planning for overnight work on the intersecting runway was found to have been inadequate and multiple related training requirements and procedures were enhanced by both the aviation regulator and the airport operator. The incursion was assessed as ICAO Category ‘C’.

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.

Visual Response to Conflict

On 18 October 2022, an Airbus A321 on approach to Venice in thick fog was observed on TCAS by a Boeing 737-800 crew awaiting takeoff clearance from the same runway after a lineup and wait instruction. When no takeoff clearance followed, the 737 crew transmitted, advising its position without any response. The crew then transmitted on 121.5, instructing the A321 to go around, and they received no response. They were about to vacate the runway when the controller instructed the A321 to go around, which only  occurred as it approached 100 feet AGL. The controller involved had failed to plug in his headset properly.

On 3 June 2022, an Airport Rescue and Fire Fighting Service utility vehicle inadvertently entered an active runway at night when intending to drive along its parallel taxiway after becoming confused about their routing. On reaching the clearly identified runway holding point but requesting permission to access the intended taxiway, the controller turned off the illuminated stop bar and the vehicle was briefly driven onto the runway before the driver realised their error and made a U turn to exit. The incursion activated visual and aural warnings but these were both inexplicably missed by the controller and their supervisor.

On 11 October 2016, an Airbus A320 crew accelerating for takeoff at Shanghai Hongqiao and already at high speed observed an Airbus A330-300 crossing 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 night and with visibility just above the minimum permitted for landing with thick fog patches present, an Airbus A319 entered the runway at Cheongju contrary to its clearance 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 an immediate lateral deviation and avoid a collision by creating a 3 metre separation between the two aircraft. The Investigation found that the A319 had exceeded its clearance and remained on the Ground frequency but noted poor controller 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.

R/T Response to Conflict

On 2 July 2022, a Boeing 737-800 taxiing for departure from runway 24L at Barcelona under GND control using a route which crossed the runway 24R extended centreline almost immediately following the runway end was abruptly stopped by the controller on the centreline and almost immediately, an Airbus A330-300 departing 24R overflew the 737 at about 700 feet. The 737 should have been stopped at an earlier unlit stopbar position before the A330 was given takeoff clearance. An inadequate lighting control and indicating system was assessed as contributing to procedural failure. Both controllers involved were correctly qualified but very inexperienced.

On 15 October 2022 an airport authority vehicle entered an active runway without clearance with a Boeing 737-8 on short final which was instructed to and completed a go around. The experienced driver involved had correctly read back a clearance to remain at the holding point on reaching it but failed to stop and it was concluded the insufficiently obvious nature of the installed signage was contributory. Drivers were found to have routinely ignored instructions to use the available perimeter road for years, preferring to cross active runways to save time without the airport authority taking any relevant safety action.

On 10 June 2021, an Embraer 170-200LR was cleared to line up and wait on runway 27 at San Diego with a Boeing 737-800 already cleared to land on the same runway. The occupied runway led to ASDE-X activation which prompted a controller go-around instruction to the 737 when it was less than a mile from the runway displaced threshold but this was blocked by an undetected simultaneous transmission from the E170 which had just been instructed to exit the runway. The 737 manoeuvred around the E170 as it attempted to exit the runway, before touching down beyond it.

On 18 October 2022, an Airbus A321 on approach to Venice in thick fog was observed on TCAS by a Boeing 737-800 crew awaiting takeoff clearance from the same runway after a lineup and wait instruction. When no takeoff clearance followed, the 737 crew transmitted, advising its position without any response. The crew then transmitted on 121.5, instructing the A321 to go around, and they received no response. They were about to vacate the runway when the controller instructed the A321 to go around, which only  occurred as it approached 100 feet AGL. The controller involved had failed to plug in his headset properly.

On 20 July 2020, a Boeing 787-10 making an ILS approach to runway 09L at Paris CDG unexpectedly received landing clearance for runway 09R after transferring to TWR. The crew readback added explicit reference to the implied need to sidestep but elicited no further controller response and visual realignment to 09R followed. The controller then cleared a departing A320 to enter 09R but when its crew saw the 787 on very short final after crossing the holding point, they stopped, informed TWR and directly instructed the 787 to go-around. Investigation confirmed the controller’s error and noted their failure to monitor approaching traffic.

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 21 June 2022, a Boeing 737-9 cleared for a visual approach and landing on runway 28C at Pittsburgh landed on the adjacent runway 28L instead. The controller stated that having become aware that the aircraft was lined up with the wrong runway in the absence of any potential hazards, he had decided not to intervene. The crew said that a transient avionics fault on final approach had reduced their opportunity to ensure correct runway alignment but this fault was found to have cleared much earlier. It was noted that runway 28L had sequenced approach lighting whereas 28C had none.

On 24 October 2021, a Bombardier DHC8-400 inbound to Belagavi initially advised to expect a non-precision approach to runway 08 was subsequently cleared for an equivalent approach to runway 26. An approach to runway 08 was then flown without ATC intervention or pilot error recognition, but with no actual consequences. The error was attributed to pilot expectation bias and distraction and controller failure to order a go-around after eventually realising what was happening. The context that had facilitated the errors was considered to be procedure and performance inadequacy at both the aircraft operator and ATC.

On 8 June 2022, a Boeing 757-200 making a night visual approach to Tulsa inadvertently landed on runway 18R instead of 18L as briefed and cleared. ATC did not intervene. Neither pilot recognized the error until the captain realized there was less runway ahead than he had expected. He had planned to "roll long," expecting a the turnoff at the end of the much longer runway 18L. Although both pilots reported not being fatigued, it was concluded that lack of recognition of their error suggested otherwise, and probably facilitated plan continuation bias aided by inability to efficiently integrate available information.

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.

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