Vehicle / E190 / E121, Jersey Channel Islands, 2010
From SKYbrary Wiki
|On 1 June 2010, an Airport RFFS bird scaring vehicle entered the active runway at Jersey in LVP without clearance and remained there for approximately three minutes until ATC became aware. The subsequent Investigation found that the incursion had fortuitously occurred just after an ERJ 190 had landed and had been terminated just as another aircraft had commenced a go around after failure to acquire the prescribed visual reference required to continue to a landing. The context for the failure of the vehicle driver to follow existing procedures was found to be their inadequacy and appropriate changes were implemented.|
|Actual or Potential
|Ground Operations, Human Factors, Runway Incursion|
|Flight Conditions||On Ground - Low Visibility|
|Aircraft||EMBRAER ERJ 190-100|
|Type of Flight||Public Transport (Passenger)|
|Intended Destination||Jersey Airport|
|Take off Commenced||Yes|
|Operator||French Air Force|
|Type of Flight||Not Recorded|
|Intended Destination||Jersey Airport|
|Take off Commenced||Yes|
|Flight Phase||Missed Approach|
|Location - Airport|
Plan Continuation Bias,
Procedural non compliance
|Tag(s)||Aircraft / Vehicle conflict|
|Tag(s)||Accepted ATC Clearance not followed,|
Incursion after Landing,
|Damage or injury||No|
|Causal Factor Group(s)|
On 1 June 2010, with LVP in force and the active runway not visible to ATC, a daylight runway incursion onto the active runway by a bird scaring vehicle was found to have occurred. Just as the discovery was made, an approaching aircraft reported commencing a go around after being unable to acquire the necessary visual reference to continue to a landing. ATC deduced that the incursion had probably been initiated whilst a previously landed aircraft was in the process of exiting the runway.
An Investigation was carried out by the UK AAIB assisted by recorded radio communications for both GND and TWR and radar data for aircraft on final approach to runway 27. A Meteorological Terminal Air Report (METAR)/SPECI sequence around the time of the incursion was found to indicate that there had been fog with rain and/or drizzle throughout, with visibility varying between 200 and 800 metres and Runway Visual Range (RVR) varying between 550 metres and 800 metres.
It was noted unless it is very busy, ATC control of traffic at and in the immediate vicinity of the airport is normally achieved using a TWR controller who also looks after ground movement. If the additionally-available GND frequency is in use, this information is included in the Automatic Terminal Information Service (ATIS) broadcast. On the morning of the investigated event, the GND frequency was in use “principally for the purpose of Controller training”.
It was established that a bird scaring vehicle operated by the airport Rescue and Fire Fighting Services had been cleared to holding point ‘A1’ just south of the downwind end of runway 27 by GND (see the airport diagram below taken from the official report) and instructed to contact TWR for permission to enter the runway. Two minutes later, the Investigation found that there had been a carrier wave transmission on the TWR frequency which had been immediately followed by an ATC instruction to a Flybe-operated ERJ190 which had just landed on runway 27 to “Report Vacated”. It was established that the bird scaring vehicle had then entered the runway and had begun to drive along it, stopping for a time on the northern side, opposite Taxiway F, where the driver had observed some birds. The birds dispersed and the vehicle continued along the runway. At about the same time, the TWR controller changed to facilitate a routine break and the handover included the information that the bird scaring vehicle was holding at A1 but had not yet checked in on the TWR frequency. The replacement controller attempted to call the vehicle to confirm his position but when there was no reply, he asked GND to attempt contact and after receiving reply he reminded the driver that he needed to contact TWR before entering the runway. The response was considered “hesitant” and led GND to ask for confirmation that the vehicle was still at A1. The driver replied “Negative, um I’m leaving the runway at B” which is at the opposite end of the runway to the holding point where the vehicle was understood to be. After a further exchange with GND, it became apparent that the vehicle had entered and driven the full length of the runway without permission. TWR, aware of this exchange, was about to instruct an Embraer 121 aircraft on short final to go-around but the aircraft declared a go around due to lack of visual reference first. When it proved impossible to make further contact with the bird scaring vehicle, ATC took action to safeguard the runway and manoeuvring areas until it had been confirmed that the vehicle had returned to the fire station, after which normal operations were resumed.
The Investigation found that the vehicle involved, which was a general purpose one normally used for bird scaring was fitted with a radio and that the driver would usually also carry a separate portable radio. The portable radio was intended to be used as a back up in the event of radio failure or if the driver needs to temporarily leave the vehicle. However, it became apparent that some drivers habitually used the portable radios for normal communications when the GND frequency was in operation and that a significant number of RFFS personnel did not properly understand the correct radio communication procedures.
The vehicle driver stated after the incursion that it was his second bird dispersal patrol of the day and that he had been aware that LVPs were in force and that both ATC frequencies were in use. He said that because he understood that it was necessary to monitor both frequencies, he had tuned the vehicle radio to GND and the portable radio to TWR. He stated that upon exiting the fire station, he had established contact with GND at Holding Point H and been cleared to proceed to Holding Point A1 and to contact Tower. Upon arrival there, he reported having contacted TWR using the portable radio and received a clearance to enter the runway and to report vacated.
Safety Action by Jersey Airport as a result of the event was based on a comprehensive internal investigation which made a number of safety recommendations, including one to review driving procedures on the airport. Subsequently, Safety Notices were issued requiring aeronautical radios installed in vehicles to be tuned to the active frequency or the frequency instructed by ATC and for portable radios to be used only for emergency backup and when drivers were out of the vehicle on the manoeuvring area for purposes such as marshalling or inspection.
The Final Report of the Investigation was published on in March 2011. No Safety Recommendations were made.