If you wish to contribute or participate in the discussions about articles you are invited to join SKYbrary as a registered user

 Actions

Accident and Serious Incident Reports: RI

From SKYbrary Wiki

Article Information
Category: Runway Incursion Runway Incursion
Content source: SKYbrary About SKYbrary
Content control: EUROCONTROL EUROCONTROL

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

  • A319 / B737, Zurich Switzerland, 2002 (On 23 November 2002, an A319, landing on Rwy16 at Zurich Switzerland, narrowly missed collision with a B737-600 cleared for take off on an intersecting runway.)
  • A320 / AT76, Yangon Myanmar, 2017 (On 18 September 2017, a departing Airbus A320 was instructed to line up and wait at Yangon but not given takeoff clearance until an ATR72 was less than a minute from touchdown and the prevailing runway traffic separation standard was consequently breached. The Investigation found that the TWR controller had been a temporarily unsupervised trainee who, despite good daylight visibility, had instructed the A320 to line up and wait and then forgotten about it. When the A320 crew, aware of the approaching ATR72, reminded her, she “did not know what to do” and the trainee APP controller had to intervene.)
  • A320 / B738 Barcelona Spain, 2012 (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.)
  • A320 / CRJ2, Port Elizabeth South Africa, 2014 (On 10 July 2014, the crew of a Bombardier CRJ200 on a visual go around from an approach to runway 26 at Port Elizabeth took visual avoiding action overhead of the aerodrome to ensure safe separation from an Airbus A320 which had just taken off. Both aircraft also received TCAS RAs. Minimum achieved separation from radar was 370 metres laterally and 263 feet vertically. The Investigation noted that the go around resulted from the TWR controller, who was supervising a student controller, clearing the A320 to enter the runway and take off when the CRJ200 was on short final to land.)
  • A320 / SW4, Calgary AB Canada, 2016 (On 2 December 2016, the crew of an Airbus A320 passing 100 knots on takeoff at Calgary saw another aircraft crossing an intersection ahead but continued because they considered that, as the other aircraft was already more than half way across, it would be clear before they reached that point. The Investigation found that the GND Controller had cleared the other aircraft to cross after forgetting that the runway was active and under TWR control. It was concluded that the response of the ANSP SMS process to a history of identical controller errors and related reports had been inadequate.)
  • A320 / Vehicle, London Gatwick UK, 2018 (On 3 February 2018, a runway inspection vehicle was cleared onto the active runway at London Gatwick ahead of an aircraft which had just touched down and driven towards it having been cleared to do so because the aircraft crew’s confirmation that they would clear the runway before reaching the vehicle was considered by the controller as a clearance limit. The Investigation found that the associated runway inspection procedure had not been adequately risk-assessed and noted that many issues raised by it had still not been addressed by the time it was completed eighteen months later.)
  • A320/B734, vicinity London Gatwick UK, 2012 (On 4 August 2012 an Easyjet Airbus A320 on approach to London Gatwick was given landing clearance in IMC for a runway occupied by a Boeing 737-400 waiting for take off which heard this transmission. Despite normal ground visibility and an unrestricted view of the runway, ATC failed to recognise their error and, after two unsuccessful attempts to advise them of it, the commander of the 737 instructed the A320 to go around which it did. Only upon hearing this did the controller realise what had happened.)
  • A321 / B734, Barcelona Spain, 2015 (On 25 November 2015, an Airbus A321 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 737 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. On reaching the lit stop bar protecting the runway, the crew queried their clearance and were told to hold position. Noting that the event had occurred at the time of a routine twice-daily runway configuration change and two previous very similar events in 2012 and 2014, further safety recommendations on risk management of runway configuration change were made.)
  • A343 / B763, Barcelona Spain, 2014 (On 5 July 2014, an Airbus A340-300 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 767 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. Sighting by both aircraft resulted in an accelerated crossing and a very low go around. The Investigation noted the twice-daily runway configuration change made due to noise abatement reasons was imminent. It was also noted that airport procedure involved use of stop bars even on inactive runways and that their operation was then the responsibility of ground controllers.)
  • B722 / BE10, Atlanta GA USA, 1990 (On 18 January 1990, a Boeing 727-200 landing at Atlanta at night and in good visibility in accordance with an unconditional clearance failed to see that a Beechcraft King Air, which had landed ahead of it, had yet to clear the runway. The 727 was unable to avoid a collision after a late sighting. The 727 sustained substantial damage and the King Air was destroyed. The Investigation attributed the collision to a combination of the failure of the runway controller to detect the lack of separation resulting from their issue of multiple landing clearances and the inadequacy of relevant ATC procedures.)
  • B732 / A321, Manchester UK, 2004 (On 29 February 2004, a Boeing 737-200 crossed an active runway in normal daylight visibility ahead of a departing Airbus A321, the crew of which made a high speed rejected take off upon sighting the other aircraft after hearing its crossing clearance being confirmed. Both aircraft were found to have been operating in accordance with their acknowledged ATC clearances issued by the same controller. An alert was generated by the TWR conflict detection system but it was only visually annunciated and had not been noticed. Related ATC procedures were subsequently reviewed and improved.)
  • B733 / B744, Chicago IL USA, 2006 (On 23 July 2006, a Boeing B737-300 operated by United Airlines executed an early rotation during a night take off when a Boeing 747 operated by Atlas Air was observed on a landing roll on an intersecting runway at Chicago O’Hare Airport. The occurrence is attributed to ATC error.)

... further results

Accepted ATC Clearance not followed

  • A139 / A30B, Ottawa Canada, 2014 (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.)
  • A319 / UNKN, Stockholm Arlanda Sweden, 2011 (On 5 February 2011, an Airbus A319-100 being operated by Air Berlin on a passenger flight departing Stockholm inadvertently proceeded beyond the given clearance limit for runway 19R and although it subsequently stopped before runway entry had occurred, it was by then closer to high speed departing traffic than it should have been. There was no abrupt stop and none of the 103 occupants were injured.)
  • A320 / B739, Yogyakarta Indonesia, 2013 (On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.)
  • A320 / B789 / A343, San Francisco CA USA, 2017 (On 7 July 2017 the crew of an Airbus A320, cleared for an approach and landing on runway 28R at San Francisco in night VMC, lined up for the visual approach for which it had been cleared on the occupied parallel taxiway instead of the runway extended centreline and only commenced a go-around at the very last minute, having descended to about 60 feet agl whilst flying over two of the four aircraft on the taxiway. The Investigation determined that the sole direct cause of the event was the poor performance of the A320 flight crew.)
  • A320 / CRJ2, Sofia Bulgaria, 2007 (On 13 April 2007 in day VMC, an Air France A320 departing Sofia lined up contrary to an ATC Instruction to remain at the holding point and be ready immediate. The controller did not immediately notice and after subsequently giving a landing clearance for the same runway, was obliged to cancel it send the approaching aircraft around. An Investigation attributed the incursion to both the incorrect terminology used by TWR and the failure to challenge the incomplete clearance read back by the A320 crew.)
  • A320, vicinity Rapid City SD USA, 2016 (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.)
  • A320, vicinity Tokyo Haneda Japan, 2016 (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.)
  • A320/B773, Dubai UAE, 2012 (On March 20 2012 a Ural Airlines Airbus A320 failed to taxi as instructed after vacating the landing runway 12L at Dubai and crossed the lit stop bar of an intersection access to runway 12R before stopping just in time to prevent a collision with a Boeing 777-300ER about to pass the intersection at very high speed on take off. Taxi clearance had been correctly given and acknowledged. The aircraft commander had extensive aircraft type experience but the inexperienced First Officer appeared to be undergoing early stage line training with a Safety Pilot present. The Investigation is continuing.)
  • A321 / B738, Dublin Ireland, 2011 (On 21 May 2011, a Monarch Airlines A321 taxiing for departure at Dublin inadvertently taxied onto an active runway after failing to follow its taxi clearance. The incursion was not noticed by ATC but the crew of a Boeing 737 taking off from the same runway did see the other aircraft and initiated a very high speed rejected take off stopping 360 metres from it. The incursion occurred in a complex manoeuvring area to a crew unfamiliar with the airport at a location which was not a designated hot spot. Various mitigations against incursions at this position have since been implemented.)
  • A333 / A333, Narita International Japan, 2017 (On 14 February 2017, an Airbus A330-300 preparing to depart Narita entered the active runway at night without clearance as another Airbus A330-300 was approaching the same runway with a landing clearance. ATC observed the conflict after an alert was activated on the surface display system and instructed the approaching aircraft, which was passing approximately 400 feet and had not observed the incursion, to go around. The Investigation attributed the departing aircraft crew’s failure to comply with their clearance to distraction and noted that the stop bar lighting system was not in use because procedures restricted its use to low visibility conditions.)
  • AS32 / B734, Aberdeen UK, 2000 (For reasons that were not established, a Super Puma helicopter being air tested and in the hover at about 30 feet agl near the active runway at Aberdeen assumed that the departure clearance given by GND was a take off clearance and moved into the hover over the opposite end of the runway at the same time as a Boeing 737 was taking off. The 737 saw the helicopter ahead and made a high speed rejected take off, stopping approximately 100 metres before reaching the position of the helicopter which had by then moved off the runway still hovering.)
  • AT45 / B733, Munich Germany, 2004 (During the hours of darkness at Munich on 3 May 2004, an ATR42-500 was given a conditional line up clearance for Runway 08R but contrary to this clearance then taxied onto that runway as a Boeing 737-300 was landing on it. The landing aircraft missed the right wingtip of the ATR-42, which continued taxing onto the runway as it approached, by “a few metres”.)

... further results

Incursion pre Take off

  • A139 / A30B, Ottawa Canada, 2014 (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.)
  • A319 / A320, Naha Okinawa Japan, 2012 (On 5 July 2012, an Airbus A319 entered its departure runway at Naha without clearance ahead of an A320 already cleared to land on the same runway. The A320 was sent around. The Investigation concluded that the A319 crew - three pilots including one with sole responsibility for radio communications and a commander supervising a trainee Captain occupying the left seat - had misunderstood their clearance and their incorrect readback had not been detected by the TWR controller. It was concluded that the controller's non-use of a headset had contributed to failure to detect the incorrect readback.)
  • A319 / A320, Paris CDG France, 2014 (On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.)
  • A319 / B737, Zurich Switzerland, 2002 (On 23 November 2002, an A319, landing on Rwy16 at Zurich Switzerland, narrowly missed collision with a B737-600 cleared for take off on an intersecting runway.)
  • A319 / UNKN, Stockholm Arlanda Sweden, 2011 (On 5 February 2011, an Airbus A319-100 being operated by Air Berlin on a passenger flight departing Stockholm inadvertently proceeded beyond the given clearance limit for runway 19R and although it subsequently stopped before runway entry had occurred, it was by then closer to high speed departing traffic than it should have been. There was no abrupt stop and none of the 103 occupants were injured.)
  • A320 / B738 Barcelona Spain, 2012 (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.)
  • A320 / B739, Yogyakarta Indonesia, 2013 (On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.)
  • A320 / CRJ2, Sofia Bulgaria, 2007 (On 13 April 2007 in day VMC, an Air France A320 departing Sofia lined up contrary to an ATC Instruction to remain at the holding point and be ready immediate. The controller did not immediately notice and after subsequently giving a landing clearance for the same runway, was obliged to cancel it send the approaching aircraft around. An Investigation attributed the incursion to both the incorrect terminology used by TWR and the failure to challenge the incomplete clearance read back by the A320 crew.)
  • A320 / SW4, Calgary AB Canada, 2016 (On 2 December 2016, the crew of an Airbus A320 passing 100 knots on takeoff at Calgary saw another aircraft crossing an intersection ahead but continued because they considered that, as the other aircraft was already more than half way across, it would be clear before they reached that point. The Investigation found that the GND Controller had cleared the other aircraft to cross after forgetting that the runway was active and under TWR control. It was concluded that the response of the ANSP SMS process to a history of identical controller errors and related reports had been inadequate.)
  • A320/B734, vicinity London Gatwick UK, 2012 (On 4 August 2012 an Easyjet Airbus A320 on approach to London Gatwick was given landing clearance in IMC for a runway occupied by a Boeing 737-400 waiting for take off which heard this transmission. Despite normal ground visibility and an unrestricted view of the runway, ATC failed to recognise their error and, after two unsuccessful attempts to advise them of it, the commander of the 737 instructed the A320 to go around which it did. Only upon hearing this did the controller realise what had happened.)
  • A321 / B734, Barcelona Spain, 2015 (On 25 November 2015, an Airbus A321 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 737 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. On reaching the lit stop bar protecting the runway, the crew queried their clearance and were told to hold position. Noting that the event had occurred at the time of a routine twice-daily runway configuration change and two previous very similar events in 2012 and 2014, further safety recommendations on risk management of runway configuration change were made.)
  • A321 / B738, Dublin Ireland, 2011 (On 21 May 2011, a Monarch Airlines A321 taxiing for departure at Dublin inadvertently taxied onto an active runway after failing to follow its taxi clearance. The incursion was not noticed by ATC but the crew of a Boeing 737 taking off from the same runway did see the other aircraft and initiated a very high speed rejected take off stopping 360 metres from it. The incursion occurred in a complex manoeuvring area to a crew unfamiliar with the airport at a location which was not a designated hot spot. Various mitigations against incursions at this position have since been implemented.)

... further results

Incursion after Landing

  • A319 / A320, Paris CDG France, 2014 (On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.)
  • A319 / B737, Zurich Switzerland, 2002 (On 23 November 2002, an A319, landing on Rwy16 at Zurich Switzerland, narrowly missed collision with a B737-600 cleared for take off on an intersecting runway.)
  • A320 / B739, Yogyakarta Indonesia, 2013 (On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.)
  • A320 / F50, Adelaide Australia, 2016 (On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.)
  • A320 / Vehicle, London Gatwick UK, 2018 (On 3 February 2018, a runway inspection vehicle was cleared onto the active runway at London Gatwick ahead of an aircraft which had just touched down and driven towards it having been cleared to do so because the aircraft crew’s confirmation that they would clear the runway before reaching the vehicle was considered by the controller as a clearance limit. The Investigation found that the associated runway inspection procedure had not been adequately risk-assessed and noted that many issues raised by it had still not been addressed by the time it was completed eighteen months later.)
  • A320/B773, Dubai UAE, 2012 (On March 20 2012 a Ural Airlines Airbus A320 failed to taxi as instructed after vacating the landing runway 12L at Dubai and crossed the lit stop bar of an intersection access to runway 12R before stopping just in time to prevent a collision with a Boeing 777-300ER about to pass the intersection at very high speed on take off. Taxi clearance had been correctly given and acknowledged. The aircraft commander had extensive aircraft type experience but the inexperienced First Officer appeared to be undergoing early stage line training with a Safety Pilot present. The Investigation is continuing.)
  • B190 / BE9L, Quincy IL USA, 1996 (On 19 November 1996, a Beech 1900C which had just landed and a Beech King Air A90 which was taking off collided at the intersection of two runways at the non-Towered Quincy Municipal Airport. Both aircraft were destroyed by impact forces and fire and all occupants of both aircraft were killed. The Investigation found that the King Air pilots had failed to monitor the CTAF or properly scan visually for traffic. The loss of life of the Beech 1900 occupants, who had probably survived the impact, was attributed largely to inability to open the main door of the aircraft.)
  • B722 / BE10, Atlanta GA USA, 1990 (On 18 January 1990, a Boeing 727-200 landing at Atlanta at night and in good visibility in accordance with an unconditional clearance failed to see that a Beechcraft King Air, which had landed ahead of it, had yet to clear the runway. The 727 was unable to avoid a collision after a late sighting. The 727 sustained substantial damage and the King Air was destroyed. The Investigation attributed the collision to a combination of the failure of the runway controller to detect the lack of separation resulting from their issue of multiple landing clearances and the inadequacy of relevant ATC procedures.)
  • B733 / B744, Chicago IL USA, 2006 (On 23 July 2006, a Boeing B737-300 operated by United Airlines executed an early rotation during a night take off when a Boeing 747 operated by Atlas Air was observed on a landing roll on an intersecting runway at Chicago O’Hare Airport. The occurrence is attributed to ATC error.)
  • B735/B733, Dallas-Fort Worth TX USA, 2001 (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.)
  • B737 / A320, Los Angeles CA USA, 2007 (On 16 August 2007, a Westjet Boeing 737-700 which had just landed began to cross a runway in normal daylight visibility from which an Airbus A320 was taking off because the crew had received a clearance to do so after an ambiguous position report given following a non-instructed frequency change. When the other aircraft was seen, the 737 was stopped partly on the runway and the A320 passed close by at high speed with an 11 metre clearance. The AMASS activated, but not until it was too late to inform a useful controller response.)
  • B737 / A332, Seatle-Tacoma WA USA, 2008 (On 2 July 2008, an Air Tran Airways B737-700 which had just landed at night on runway 34C at Sea-Tac failed to hold clear of runway 34R during taxi as instructed and passed almost directly underneath a North West Airlines A330-200 which had just become airborne from Runway 32R. The Investigation found that the 737 crew had been unaware of their incursion and that the alert provided by ASDE-X had not provided an opportunity for ATC to usefully intervene to stop prevent the potential conflict)

... further results

Runway Crossing

  • A319 / A320, Paris CDG France, 2014 (On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.)
  • A320 / B738 Barcelona Spain, 2012 (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.)
  • A320 / F50, Adelaide Australia, 2016 (On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.)
  • A320 / SW4, Calgary AB Canada, 2016 (On 2 December 2016, the crew of an Airbus A320 passing 100 knots on takeoff at Calgary saw another aircraft crossing an intersection ahead but continued because they considered that, as the other aircraft was already more than half way across, it would be clear before they reached that point. The Investigation found that the GND Controller had cleared the other aircraft to cross after forgetting that the runway was active and under TWR control. It was concluded that the response of the ANSP SMS process to a history of identical controller errors and related reports had been inadequate.)
  • A321 / B734, Barcelona Spain, 2015 (On 25 November 2015, an Airbus A321 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 737 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. On reaching the lit stop bar protecting the runway, the crew queried their clearance and were told to hold position. Noting that the event had occurred at the time of a routine twice-daily runway configuration change and two previous very similar events in 2012 and 2014, further safety recommendations on risk management of runway configuration change were made.)
  • A343 / B763, Barcelona Spain, 2014 (On 5 July 2014, an Airbus A340-300 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 767 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. Sighting by both aircraft resulted in an accelerated crossing and a very low go around. The Investigation noted the twice-daily runway configuration change made due to noise abatement reasons was imminent. It was also noted that airport procedure involved use of stop bars even on inactive runways and that their operation was then the responsibility of ground controllers.)
  • B190 / B737, Calgary Canada, 2014 (On 29 March 2014, a Beech 1900D being taxied by maintenance personnel at Calgary entered the active runway without clearance in good visibility at night as a Boeing 737-700 was taking off. The 737 passed safely overhead. The Investigation found that the taxiing aircraft had taken a route completely contrary to the accepted clearance and that the engineer on control of the aircraft had not received any relevant training. Although the airport had ASDE in operation, a transponder code was not issued to the taxiing aircraft as required and stop bar crossing detection was not enabled at the time.)
  • B732 / A321, Manchester UK, 2004 (On 29 February 2004, a Boeing 737-200 crossed an active runway in normal daylight visibility ahead of a departing Airbus A321, the crew of which made a high speed rejected take off upon sighting the other aircraft after hearing its crossing clearance being confirmed. Both aircraft were found to have been operating in accordance with their acknowledged ATC clearances issued by the same controller. An alert was generated by the TWR conflict detection system but it was only visually annunciated and had not been noticed. Related ATC procedures were subsequently reviewed and improved.)
  • B735/B733, Dallas-Fort Worth TX USA, 2001 (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.)
  • B737 / A320, Los Angeles CA USA, 2007 (On 16 August 2007, a Westjet Boeing 737-700 which had just landed began to cross a runway in normal daylight visibility from which an Airbus A320 was taking off because the crew had received a clearance to do so after an ambiguous position report given following a non-instructed frequency change. When the other aircraft was seen, the 737 was stopped partly on the runway and the A320 passed close by at high speed with an 11 metre clearance. The AMASS activated, but not until it was too late to inform a useful controller response.)
  • B737 / A332, Seatle-Tacoma WA USA, 2008 (On 2 July 2008, an Air Tran Airways B737-700 which had just landed at night on runway 34C at Sea-Tac failed to hold clear of runway 34R during taxi as instructed and passed almost directly underneath a North West Airlines A330-200 which had just become airborne from Runway 32R. The Investigation found that the 737 crew had been unaware of their incursion and that the alert provided by ASDE-X had not provided an opportunity for ATC to usefully intervene to stop prevent the potential conflict)
  • B737/LJ45, Chicago Midway, USA 2011 (On 1 December 2011 a Southwest Boeing 737-700 was cleared to taxi in after landing on a route which included crossing another active runway before contacting GND and the controller who had issued that clearance then inadvertently issued a take off clearance to a Gama Charters Learjet 45 for the runway to be crossed. One of the 737 pilots saw the approaching Learjet and warned the PF to stop as the runway crossing was about to begin. The departing aircraft then overflew the stationary 737 by 62 feet after rotating shortly before the crossing point without seeing it.)

... further results

Intersecting Runways

  • A319 / B737, Zurich Switzerland, 2002 (On 23 November 2002, an A319, landing on Rwy16 at Zurich Switzerland, narrowly missed collision with a B737-600 cleared for take off on an intersecting runway.)
  • A320 / F50, Adelaide Australia, 2016 (On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.)
  • AT43/A346, Zurich Switzerland, 2010 (On 18 June 2010, an ATR 42 began a daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began take off from intersecting runway 16 with an ATC clearance. ATC were unaware of this until alerted to the situation by the crew of another aircraft which was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so prior to the runway intersection whilst the A340 continued departure on runway 16 .)
  • B190 / BE9L, Quincy IL USA, 1996 (On 19 November 1996, a Beech 1900C which had just landed and a Beech King Air A90 which was taking off collided at the intersection of two runways at the non-Towered Quincy Municipal Airport. Both aircraft were destroyed by impact forces and fire and all occupants of both aircraft were killed. The Investigation found that the King Air pilots had failed to monitor the CTAF or properly scan visually for traffic. The loss of life of the Beech 1900 occupants, who had probably survived the impact, was attributed largely to inability to open the main door of the aircraft.)
  • B463 / PA38 Birmingham UK, 1999 (On 28 April 1999, a BAe 146-300 departing Birmingham began its daylight take off from Runway 33 without ATC clearance just prior to the touchdown of a PA38 on the intersecting runway 06. Collision was very narrowly avoided after the Controller intervened and the BAe 146 rejected its take off, just missing the PA38 which had stopped just off the runway 33 centreline. The Investigation noted the 146 pilots belief that a take off clearance had been issued but also that no attempt appeared to have been made to read it back or confirm it with the First Officer.)
  • B733 / B744, Chicago IL USA, 2006 (On 23 July 2006, a Boeing B737-300 operated by United Airlines executed an early rotation during a night take off when a Boeing 747 operated by Atlas Air was observed on a landing roll on an intersecting runway at Chicago O’Hare Airport. The occurrence is attributed to ATC error.)
  • B737 / A332, Seatle-Tacoma WA USA, 2008 (On 2 July 2008, an Air Tran Airways B737-700 which had just landed at night on runway 34C at Sea-Tac failed to hold clear of runway 34R during taxi as instructed and passed almost directly underneath a North West Airlines A330-200 which had just become airborne from Runway 32R. The Investigation found that the 737 crew had been unaware of their incursion and that the alert provided by ASDE-X had not provided an opportunity for ATC to usefully intervene to stop prevent the potential conflict)
  • B738, Perth Western Australia, 2010 (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.)
  • B752/B722, Providence RI USA, 1999 (On December 6, 1999, United Airlines Boeing 757 failed to follow its taxi-in clearance after landing at night in thick fog at Providence RI and ended up at the edge of the runway it had just the landed on as a departing FedEx Boeing 727 passed very close by. The TWR controller, without surface radar available, then made unjustified presumptions about the 757s position and twice cleared a 737 to take off whilst the runway was still obstructed. Fortunately, the crew of that aircraft declined until safety was positively assured by the eventual arrival of the 757 at the terminal.)
  • CRJ1 / A320, Baltimore MD USA, 2007 (On 2 December 2007, at Baltimore/Washington International Thurgood Marshall Airport, after controller error, a CRJ-100 operated by Comair with a valid take-off clearance missed by 400 ft vertically and 400 ft horizontally an Airbus A320, which just landed with also valid clearance on an intersecting runway.)
  • DH8B / BN2P, Horn Island QLD Australia, 2016 (On 12 October 2016, a BN2 Islander and a Bombardier DHC8-200 were involved in a near miss after the DHC8 took off from a runway which intersected with the runway on which the BN2 was about to land. The BN2 broke off its approach just before touchdown when the DHC8 was observed accelerating towards the runway intersection on its take-off roll. The Investigation noted that the aerodrome involved relied on visual separation and use of a CTAF and found that although both aircraft were aware of each other, the DHC8 crew failed to fully utilise visual lookout.)
  • E145, Dayton OH USA, 2011 (On 31 January 2011, an Embraer 145LR being operated by Expressjet Airlines on a scheduled passenger flight from Cleveland OH to Dayton left landing runway 06R during a night landing in normal ground visibility and light winds and ended up on intersecting active runway 36. None of the 32 occupants were injured and only minor damage was caused to ground installations and the aircraft. No conflict with other aircraft resulted from the incursion onto runway 36 and after establishing that there was no major damage to the aircraft and after the taxiway route had been ‘sanded’ the aircraft was taxied in to the gate for passenger disembarkation.)

... further results

Intersecting extended centrelines

  • A320, vicinity Rapid City SD USA, 2016 (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

  • B738 / AT46, Jakarta Halim Indonesia, 2016 (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.)
  • B762 / A310, Toronto Canada, 2001 (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.)
  • B763 / B744, Amsterdam Netherlands, 1998 (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.)

Near Miss

  • A139 / A30B, Ottawa Canada, 2014 (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.)
  • A319 / B737, Zurich Switzerland, 2002 (On 23 November 2002, an A319, landing on Rwy16 at Zurich Switzerland, narrowly missed collision with a B737-600 cleared for take off on an intersecting runway.)
  • A320 / B739, Yogyakarta Indonesia, 2013 (On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.)
  • A320 / CRJ2, Port Elizabeth South Africa, 2014 (On 10 July 2014, the crew of a Bombardier CRJ200 on a visual go around from an approach to runway 26 at Port Elizabeth took visual avoiding action overhead of the aerodrome to ensure safe separation from an Airbus A320 which had just taken off. Both aircraft also received TCAS RAs. Minimum achieved separation from radar was 370 metres laterally and 263 feet vertically. The Investigation noted that the go around resulted from the TWR controller, who was supervising a student controller, clearing the A320 to enter the runway and take off when the CRJ200 was on short final to land.)
  • A320/B773, Dubai UAE, 2012 (On March 20 2012 a Ural Airlines Airbus A320 failed to taxi as instructed after vacating the landing runway 12L at Dubai and crossed the lit stop bar of an intersection access to runway 12R before stopping just in time to prevent a collision with a Boeing 777-300ER about to pass the intersection at very high speed on take off. Taxi clearance had been correctly given and acknowledged. The aircraft commander had extensive aircraft type experience but the inexperienced First Officer appeared to be undergoing early stage line training with a Safety Pilot present. The Investigation is continuing.)
  • AS32 / B734, Aberdeen UK, 2000 (For reasons that were not established, a Super Puma helicopter being air tested and in the hover at about 30 feet agl near the active runway at Aberdeen assumed that the departure clearance given by GND was a take off clearance and moved into the hover over the opposite end of the runway at the same time as a Boeing 737 was taking off. The 737 saw the helicopter ahead and made a high speed rejected take off, stopping approximately 100 metres before reaching the position of the helicopter which had by then moved off the runway still hovering.)
  • AT43/A346, Zurich Switzerland, 2010 (On 18 June 2010, an ATR 42 began a daylight take off on runway 28 at Zurich without ATC clearance at the same time as an A340 began take off from intersecting runway 16 with an ATC clearance. ATC were unaware of this until alerted to the situation by the crew of another aircraft which was waiting to take off from runway 28, after which the ATR 42 was immediately instructed to stop and did so prior to the runway intersection whilst the A340 continued departure on runway 16 .)
  • AT45 / B733, Munich Germany, 2004 (During the hours of darkness at Munich on 3 May 2004, an ATR42-500 was given a conditional line up clearance for Runway 08R but contrary to this clearance then taxied onto that runway as a Boeing 737-300 was landing on it. The landing aircraft missed the right wingtip of the ATR-42, which continued taxing onto the runway as it approached, by “a few metres”.)
  • B190 / B190, Auckland NZ, 2007 (On 1 August 2007, the crew of a Beech 1900 aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Beech 1900 that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.)
  • B190 / B737, Calgary Canada, 2014 (On 29 March 2014, a Beech 1900D being taxied by maintenance personnel at Calgary entered the active runway without clearance in good visibility at night as a Boeing 737-700 was taking off. The 737 passed safely overhead. The Investigation found that the taxiing aircraft had taken a route completely contrary to the accepted clearance and that the engineer on control of the aircraft had not received any relevant training. Although the airport had ASDE in operation, a transponder code was not issued to the taxiing aircraft as required and stop bar crossing detection was not enabled at the time.)
  • B463 / PA38 Birmingham UK, 1999 (On 28 April 1999, a BAe 146-300 departing Birmingham began its daylight take off from Runway 33 without ATC clearance just prior to the touchdown of a PA38 on the intersecting runway 06. Collision was very narrowly avoided after the Controller intervened and the BAe 146 rejected its take off, just missing the PA38 which had stopped just off the runway 33 centreline. The Investigation noted the 146 pilots belief that a take off clearance had been issued but also that no attempt appeared to have been made to read it back or confirm it with the First Officer.)
  • B732 / A321, Manchester UK, 2004 (On 29 February 2004, a Boeing 737-200 crossed an active runway in normal daylight visibility ahead of a departing Airbus A321, the crew of which made a high speed rejected take off upon sighting the other aircraft after hearing its crossing clearance being confirmed. Both aircraft were found to have been operating in accordance with their acknowledged ATC clearances issued by the same controller. An alert was generated by the TWR conflict detection system but it was only visually annunciated and had not been noticed. Related ATC procedures were subsequently reviewed and improved.)

... further results

Ground Collision

  • AT75 / B739, Medan Indonesia, 2017 (On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.)
  • B190 / BE9L, Quincy IL USA, 1996 (On 19 November 1996, a Beech 1900C which had just landed and a Beech King Air A90 which was taking off collided at the intersection of two runways at the non-Towered Quincy Municipal Airport. Both aircraft were destroyed by impact forces and fire and all occupants of both aircraft were killed. The Investigation found that the King Air pilots had failed to monitor the CTAF or properly scan visually for traffic. The loss of life of the Beech 1900 occupants, who had probably survived the impact, was attributed largely to inability to open the main door of the aircraft.)
  • B722 / BE10, Atlanta GA USA, 1990 (On 18 January 1990, a Boeing 727-200 landing at Atlanta at night and in good visibility in accordance with an unconditional clearance failed to see that a Beechcraft King Air, which had landed ahead of it, had yet to clear the runway. The 727 was unable to avoid a collision after a late sighting. The 727 sustained substantial damage and the King Air was destroyed. The Investigation attributed the collision to a combination of the failure of the runway controller to detect the lack of separation resulting from their issue of multiple landing clearances and the inadequacy of relevant ATC procedures.)
  • B733 / SW4, Los Angeles CA USA, 1991 (On 1 February 1991, a Boeing 737-300 had just made a normal visibility night touchdown on Los Angeles runway 24L in accordance with its clearance when its crew saw another aircraft stationary ahead of them on the same runway. Avoidance was impossible in the time available and a high speed collision and post-impact fire destroyed both aircraft and killed 34 of their 101 occupants and injured 30 others. The other aircraft was subsequently found to have been a Fairchild Metroliner cleared to line up and wait by the same controller who had then cleared the 737 to land.)
  • B738 / AT46, Jakarta Halim Indonesia, 2016 (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.)
  • B742 / B741, Tenerife Canary Islands Spain, 1977 (On 27 March 1977, a KLM Boeing 747-200 began its low visibility take-off at Tenerife without requesting or receiving take-off clearance and a collision with a Boeing 747-100 backtracking the same runway subsequently occurred. Both aircraft were destroyed by the impact and consequential fire and 583 people died. The Investigation attributed the crash primarily to the actions and inactions of the KLM Captain, who was the Operator's Chief Flying Instructor. Safety Recommendations made emphasised the importance of standard phraseology in all normal radio communications and avoidance of the phrase "take-off" in ATC Departure Clearances.)
  • B744 / Vehicle, Luxembourg Airport, Luxembourg 2010 (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.)
  • DC91 / B722, Detroit MI USA, 1990 (On 3 December 1990 a Douglas DC9-10 flight crew taxiing for departure at Detroit in thick fog got lost and ended up stopped to one side of an active runway where, shortly after reporting their position, their aircraft was hit by a departing Boeing 727-200 and destroyed by the impact and subsequent fire. The Investigation concluded that the DC9 crew had failed to communicate positional uncertainty quickly enough but that their difficulties had been compounded by deficiencies in both the standard of air traffic service and airport surface markings, signage and lighting undetected by safety regulator oversight.)
  • DC93 / B722, Madrid Spain, 1983 (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.)
  • FA50 / Vehicle, Moscow Vnukovo Russia, 2014 (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.)
  • MD82 / C441, Lambert-St Louis MI USA, 1994 (On 22 November 1994 a McDonnell Douglas MD 82 flight crew taking off from Lambert- St. Louis at night in excellent visibility suddenly became aware of a stationary Cessna 441 on the runway ahead and was unable to avoid a high speed collision. The collision destroyed the Cessna but allowed the MD82 to be brought to a controlled stop without occupant injury. The Investigation found that the Cessna 441 pilot had mistakenly believed his departure would be from the runway he had recently landed on and had entered that runway without clearance whilst still on GND frequency.)
  • MD87 / C525, Milan Linate, 2001 (On 8th October 2001, an SAS MD-87 taking off as cleared from Milan Linate in thick fog collided at high speed with a German-operated Cessna Citation which had failed to follow its taxi clearance and unknown to ATC had eventually crossed a lit red stop bar and entered the active runway just as the MD-87 was reaching the same point. After the collision, the MD-87 continued along the ground until it impacted, still at high speed, a ground handling building. Both aircraft caught fire and were destroyed. The 114 occupants of both aircraft and 4 ground personnel were killed.)

... further results

Phraseology

  • A139 / A30B, Ottawa Canada, 2014 (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.)
  • A319 / A320, Paris CDG France, 2014 (On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.)
  • A320 / B739, Yogyakarta Indonesia, 2013 (On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.)
  • A320 / CRJ2, Sofia Bulgaria, 2007 (On 13 April 2007 in day VMC, an Air France A320 departing Sofia lined up contrary to an ATC Instruction to remain at the holding point and be ready immediate. The controller did not immediately notice and after subsequently giving a landing clearance for the same runway, was obliged to cancel it send the approaching aircraft around. An Investigation attributed the incursion to both the incorrect terminology used by TWR and the failure to challenge the incomplete clearance read back by the A320 crew.)
  • A320 / F50, Adelaide Australia, 2016 (On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.)
  • A320 / Vehicle, London Gatwick UK, 2018 (On 3 February 2018, a runway inspection vehicle was cleared onto the active runway at London Gatwick ahead of an aircraft which had just touched down and driven towards it having been cleared to do so because the aircraft crew’s confirmation that they would clear the runway before reaching the vehicle was considered by the controller as a clearance limit. The Investigation found that the associated runway inspection procedure had not been adequately risk-assessed and noted that many issues raised by it had still not been addressed by the time it was completed eighteen months later.)
  • AT75 / B739, Medan Indonesia, 2017 (On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.)
  • B190 / B190, Auckland NZ, 2007 (On 1 August 2007, the crew of a Beech 1900 aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Beech 1900 that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.)
  • B737 / A320, Los Angeles CA USA, 2007 (On 16 August 2007, a Westjet Boeing 737-700 which had just landed began to cross a runway in normal daylight visibility from which an Airbus A320 was taking off because the crew had received a clearance to do so after an ambiguous position report given following a non-instructed frequency change. When the other aircraft was seen, the 737 was stopped partly on the runway and the A320 passed close by at high speed with an 11 metre clearance. The AMASS activated, but not until it was too late to inform a useful controller response.)
  • B738 / AT46, Jakarta Halim Indonesia, 2016 (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.)
  • B742 / B741, Tenerife Canary Islands Spain, 1977 (On 27 March 1977, a KLM Boeing 747-200 began its low visibility take-off at Tenerife without requesting or receiving take-off clearance and a collision with a Boeing 747-100 backtracking the same runway subsequently occurred. Both aircraft were destroyed by the impact and consequential fire and 583 people died. The Investigation attributed the crash primarily to the actions and inactions of the KLM Captain, who was the Operator's Chief Flying Instructor. Safety Recommendations made emphasised the importance of standard phraseology in all normal radio communications and avoidance of the phrase "take-off" in ATC Departure Clearances.)
  • B744 / MD90, New Chitose Japan, 2008 (On 16 February 2008, during daylight and in poor visibility, a Boeing 747-400, operated by Japan Airlines, was holding on a taxiway next to runway 01R of New Chitose Airport, Japan. A Douglas MD-90-30 operated by the same airline landed on the same runway and was still on the runway when the B747 was cleared to line up and wait. Shortly after lineup the B747 began its takeoff roll without receiving such clearance and subsequently was instructed to abort the takeoff. The crew of the B747 successfully rejected the takeoff.)

... further results

Intentional Premature Rotation

  • B735/B733, Dallas-Fort Worth TX USA, 2001 (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.)
  • B742 / B744, Chicago O'Hare IL USA, 1999 (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

  • A320 / Vehicle, London Gatwick UK, 2018 (On 3 February 2018, a runway inspection vehicle was cleared onto the active runway at London Gatwick ahead of an aircraft which had just touched down and driven towards it having been cleared to do so because the aircraft crew’s confirmation that they would clear the runway before reaching the vehicle was considered by the controller as a clearance limit. The Investigation found that the associated runway inspection procedure had not been adequately risk-assessed and noted that many issues raised by it had still not been addressed by the time it was completed eighteen months later.)
  • A332 / Vehicle, Madrid Spain, 2014 (On 17 October 2014, an Airbus A330-200 crew taking off from Madrid at night detected non-runway lights ahead as they accelerated through approximately 90 knots. ATC were unaware what they might be and the lights subsequently disappeared, and the crew continued the takeoff. A reportedly unlit vehicle at the side of the runway was subsequently passed just before rotation. The Investigation found that the driver of an external contractor's vehicle had failed to correctly route to the parallel runway which was closed overnight for maintenance but had not realised this until he saw the lights of an approaching aircraft.)
  • B733 / vehicle, Amsterdam Netherlands, 2010 (On 18 December 2010, the ATC Runway Controller responsible for runway 24 at Amsterdam gave a daylight take off clearance in normal visibility to a Norwegian Boeing 737-300 whilst a bird control vehicle which they had earlier given clearance to enter the runway was still on it. The departing aircraft overflew the vehicle without noticing it. The subsequent investigation highlighted significant differences between the procedures for active runway access at Amsterdam and corresponding international practice as well as finding that integrated safety investigation and overall safety management at the airport were systemically ineffective.)
  • B744 / Vehicle, Luxembourg Airport, Luxembourg 2010 (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.)
  • B763, Addis Ababa Ethiopia, 2014 (On 12 October 2014, a Boeing 767-300 commenced take-off at Addis Ababa in accordance with its clearance but rejected take-off at 135 knots when the crew saw an obstruction ahead in the centre of the runway and it stopped approximately 100 metres from a vehicle. The Investigation found that the GND controller had cleared the vehicle to enter the runway, the TWR controller had given take-off clearance without first checking that that the runway was clear. It could not be established whether the GND controller had obtained TWR controller permission to grant the vehicle runway access.)
  • FA50 / Vehicle, Moscow Vnukovo Russia, 2014 (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.)
  • SW4 / Vehicle, Dunedin New Zealand, 2010 (On 25 May 2010 an Airwork SA227 Metroliner operating a cargo flight narrowly missed colliding with a vehicle on the runway during its night landing at Dunedin in normal visibility. The vehicle was subsequently found to have been on the runway without the appropriate authority in order to carry out a security inspection and the vehicle only co-incidentally at the side of the runway as its driver was unaware of the aircraft. It was noted such access had become a matter of custom and practice for which the context was inadequate procedures for control of airside vehicular access.)
  • Vehicle / B712, Perth Western Australia, 2014 (On 26 July 2014, the crew of a Boeing 717 which had just touched down on the destination landing runway at Perth in normal day visibility as a heavy shower cleared the airport area after previously receiving and acknowledging a landing clearance saw the rear of a stationary vehicle on the runway centreline approximately 1180 metres from the landing threshold. An immediate go around was called and made and the aircraft cleared the vehicle by about 150 feet. The same experienced controller who had issued the landing clearance was found to have earlier given runway occupancy clearance to the vehicle.)
  • Vehicle / B738, Brisbane Australia, 2006 (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”.)
  • Vehicle / B752, Dublin Ireland, 2009 (On 29 May 2009, a Boeing 757-200 being operated by UK Airline Thomson Airways on a passenger charter flight from Sharm-el-Sheikh, Egypt to Dublin and having just landed on runway 10 at destination at night in poor visibility overtook a small ride-on grass mower moving along the right hand side of the runway in approximate line with the aircraft’s right hand wing tip. The driver of the mower was unaware of the arriving aircraft until he heard it on the runway behind him. Prior to the landing, ATC had been informed that all grass-cutting equipment previously working on and around the runway had cleared it.)
  • Vehicle / B773, Singapore, 2013 (On 3 October 2013, a vehicle entered an active runway without clearance after partial readback of a potentially confusing clearance was not challenged by the controller. A different controller then cleared a Boeing 777-300 to land without taking all available action to ensure that the runway was clear. The aircraft crew saw the vehicle near the edge of the runway after touchdown and manoeuvred their aircraft away from it, although the aircraft wing still passed over it. At the time of the incident, vehicles with clearance were permitted to cross red stop bars, a policy which has since been changed.)
  • Vehicle / E190 / E121, Jersey Channel Islands, 2010 (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.)

... further results

Visual Response to Conflict

  • A319 / A320, Paris CDG France, 2014 (On 25 November 2014, the crew of an Airbus A320 taking off from Paris CDG and in the vicinity of V1 saw an A319 crossing the runway ahead of them and determined that the safest conflict resolution was to continue the takeoff. The A320 subsequently overflew the A319 as it passed an estimated 100 feet agl. The Investigation concluded that use of inappropriate phraseology by the TWR controller when issuing an instruction to the A319 crew had led to a breach of the intended clearance limit. It was also noted that an automated conflict alert had activated too late to intervene.)
  • A319, Mumbai India, 2013 (On 12 April 2013, an Airbus A319 landed without clearance on a runway temporarily closed for routine inspection after failing to check in with TWR following acceptance of the corresponding frequency change. Two vehicles on the runway saw the aircraft approaching on short final and successfully vacated. The Investigation concluded that the communication failure was attributable entirely to the Check Captain who was in command of the flight involved and was acting as 'Pilot Monitoring'. It was considered that the error was probably attributable to the effects of operating through the early hours during which human alertness is usually reduced.)
  • A320 / B739, Yogyakarta Indonesia, 2013 (On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.)
  • A320 / B789 / A343, San Francisco CA USA, 2017 (On 7 July 2017 the crew of an Airbus A320, cleared for an approach and landing on runway 28R at San Francisco in night VMC, lined up for the visual approach for which it had been cleared on the occupied parallel taxiway instead of the runway extended centreline and only commenced a go-around at the very last minute, having descended to about 60 feet agl whilst flying over two of the four aircraft on the taxiway. The Investigation determined that the sole direct cause of the event was the poor performance of the A320 flight crew.)
  • A320 / CRJ2, Port Elizabeth South Africa, 2014 (On 10 July 2014, the crew of a Bombardier CRJ200 on a visual go around from an approach to runway 26 at Port Elizabeth took visual avoiding action overhead of the aerodrome to ensure safe separation from an Airbus A320 which had just taken off. Both aircraft also received TCAS RAs. Minimum achieved separation from radar was 370 metres laterally and 263 feet vertically. The Investigation noted that the go around resulted from the TWR controller, who was supervising a student controller, clearing the A320 to enter the runway and take off when the CRJ200 was on short final to land.)
  • A320 / F50, Adelaide Australia, 2016 (On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.)
  • A321 / B734, Barcelona Spain, 2015 (On 25 November 2015, an Airbus A321 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 737 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. On reaching the lit stop bar protecting the runway, the crew queried their clearance and were told to hold position. Noting that the event had occurred at the time of a routine twice-daily runway configuration change and two previous very similar events in 2012 and 2014, further safety recommendations on risk management of runway configuration change were made.)
  • A332 / Vehicle, Madrid Spain, 2014 (On 17 October 2014, an Airbus A330-200 crew taking off from Madrid at night detected non-runway lights ahead as they accelerated through approximately 90 knots. ATC were unaware what they might be and the lights subsequently disappeared, and the crew continued the takeoff. A reportedly unlit vehicle at the side of the runway was subsequently passed just before rotation. The Investigation found that the driver of an external contractor's vehicle had failed to correctly route to the parallel runway which was closed overnight for maintenance but had not realised this until he saw the lights of an approaching aircraft.)
  • A343 / B763, Barcelona Spain, 2014 (On 5 July 2014, an Airbus A340-300 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 767 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. Sighting by both aircraft resulted in an accelerated crossing and a very low go around. The Investigation noted the twice-daily runway configuration change made due to noise abatement reasons was imminent. It was also noted that airport procedure involved use of stop bars even on inactive runways and that their operation was then the responsibility of ground controllers.)
  • AT75 / B739, Medan Indonesia, 2017 (On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.)
  • B722 / BE10, Atlanta GA USA, 1990 (On 18 January 1990, a Boeing 727-200 landing at Atlanta at night and in good visibility in accordance with an unconditional clearance failed to see that a Beechcraft King Air, which had landed ahead of it, had yet to clear the runway. The 727 was unable to avoid a collision after a late sighting. The 727 sustained substantial damage and the King Air was destroyed. The Investigation attributed the collision to a combination of the failure of the runway controller to detect the lack of separation resulting from their issue of multiple landing clearances and the inadequacy of relevant ATC procedures.)
  • B738 / AT46, Jakarta Halim Indonesia, 2016 (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.)

... further results

R/T Response to Conflict

  • A139 / A30B, Ottawa Canada, 2014 (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.)
  • A320 / CRJ2, Sofia Bulgaria, 2007 (On 13 April 2007 in day VMC, an Air France A320 departing Sofia lined up contrary to an ATC Instruction to remain at the holding point and be ready immediate. The controller did not immediately notice and after subsequently giving a landing clearance for the same runway, was obliged to cancel it send the approaching aircraft around. An Investigation attributed the incursion to both the incorrect terminology used by TWR and the failure to challenge the incomplete clearance read back by the A320 crew.)
  • A321 / B734, Barcelona Spain, 2015 (On 25 November 2015, an Airbus A321 taxiing for departure at Barcelona was cleared across an active runway in front of an approaching Boeing 737 with landing clearance on the same runway by a Ground Controller unaware that the runway was active. On reaching the lit stop bar protecting the runway, the crew queried their clearance and were told to hold position. Noting that the event had occurred at the time of a routine twice-daily runway configuration change and two previous very similar events in 2012 and 2014, further safety recommendations on risk management of runway configuration change were made.)
  • B737, Gran Canaria Spain, 2016 (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.)
  • B738 / F100, Geneva Switzerland, 2014 (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.)
  • Vehicle / B773, Singapore, 2013 (On 3 October 2013, a vehicle entered an active runway without clearance after partial readback of a potentially confusing clearance was not challenged by the controller. A different controller then cleared a Boeing 777-300 to land without taking all available action to ensure that the runway was clear. The aircraft crew saw the vehicle near the edge of the runway after touchdown and manoeuvred their aircraft away from it, although the aircraft wing still passed over it. At the time of the incident, vehicles with clearance were permitted to cross red stop bars, a policy which has since been changed.)

No Single Runway Occupancy Frequency

  • B738 / AT46, Jakarta Halim Indonesia, 2016 (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.)
  • C25A / Vehicle, Reykjavik Iceland, 2018 (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.)
  • DH8B, Kangerlussuaq Greenland, 2017 (On 2 March 2017, a DHC8-200 took off from Kangerlussuaq in normal day visibility without clearance and almost immediately overflew three snow clearance vehicles on the runway. The Investigation identified a number of likely contributory factors including a one hour departure delay which the crew were keen to reduce in order to remain within their maximum allowable duty period and their inability to initially see the vehicles because of the runway down slope. No evidence of crew fatigue was found; it was noted that the vehicles involved had been in contact with TWR on a separate frequency using the local language.)
  • Vehicle / B738, Brisbane Australia, 2006 (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”.)
  • Vehicle / B752, Dublin Ireland, 2009 (On 29 May 2009, a Boeing 757-200 being operated by UK Airline Thomson Airways on a passenger charter flight from Sharm-el-Sheikh, Egypt to Dublin and having just landed on runway 10 at destination at night in poor visibility overtook a small ride-on grass mower moving along the right hand side of the runway in approximate line with the aircraft’s right hand wing tip. The driver of the mower was unaware of the arriving aircraft until he heard it on the runway behind him. Prior to the landing, ATC had been informed that all grass-cutting equipment previously working on and around the runway had cleared it.)

Change of Active Runway Configuration

  • A320 / B738 Barcelona Spain, 2012 (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.)
  • A320, vicinity Tokyo Haneda Japan, 2016 (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

  • AT75 / B739, Medan Indonesia, 2017 (On 3 August 2017, a Boeing 737-900ER landing at Medan was in wing-to-wing collision as it touched down with an ATR 72-500 which had entered the same runway to depart at an intermediate point. Substantial damage was caused but both aircraft could be taxied clear. The Investigation concluded that the ATR 72 had entered the runway at an opposite direction without clearance after its incomplete readback had gone unchallenged by ATC. Controllers appeared not to have realized that a collision had occurred despite warnings of runway debris and the runway was not closed until other aircraft also reported debris.)

Wrong Active Runway

  • A320, Ballykelly Northern Ireland UK, 2006 (On 29 March 2006, an Eirjet Airbus 320 was operating a scheduled passenger flight from Liverpool to Londonderry Airport in Northern Ireland for Ryanair in daylight. At 8nm from LDY, the operating crew reported that they were having problems with the ILS glideslope on approach to Runway 26. They judged that they were too high to carry out a safe landing from the ILS approach and requested permission from ATC to carry out a visual approach. The aircraft, with the commander as PF, then flew a right hand descending orbit followed by a visual circuit from which it landed. Upon landing, the crew were advised by Londonderry ATC, who had had the aircraft in sight when it called Finals and had then cleared it to land that they had, in fact, landed at Ballykelly airfield, a military helicopter base 5nm to the east-north-east of Londonderry.)