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C551 / B738, Oslo Gardermoen Norway, 2006

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Summary
On 7 September 2006, a Cessna 551 Citation, in normal visibility conditions entered the active runway at Oslo Gardermoen Airport, Norway without a valid ATC clearance. As result of the runway incursion, the ATC instructed a Boeing 737-800 to reject its take off thereby removing the risk of collision.
Event Details
When September 2006
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft CESSNA 551 Citation II SP
Operator Triple Alpha Luftfahrtgesellschaft
Domicile Germany
Type of Flight Public Transport (Passenger)
Origin Oslo/Gardermoen Airport
Intended Destination Billund
Take off Commenced No
Flight Airborne No
Flight Phase Taxi
TXI
Flight Details
Aircraft BOEING 737-800
Operator Sterling Airlines
Domicile Denmark
Type of Flight Public Transport (Passenger)
Origin Oslo/Gardermoen Airport
Intended Destination Alicante-Elche Airport
Take off Commenced Yes
Flight Airborne No
Flight Phase Take Off
TOF
Location - Airport
Airport Oslo/Gardermoen Airport
General
Tag(s) Aircraft-aircraft near miss
HF
Tag(s) Distraction,
Ineffective Monitoring,
Procedural non compliance
RI
Tag(s) Accepted ATC Clearance not followed
Safety Net Mitigations
Malfunction of Relevant Safety Net No
A-SMGCS Available but ineffective
Outcome
Damage or injury No
Aircraft damage None"None" is not in the list (Minor, Major, Hull loss) of allowed values for the "Aircraft damage" property.
Injuries None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Injuries" property.
Fatalities None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Fatalities" property. ()
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 7 September 2006, a Cessna 551 Citation, operated by Triple Alpha Luftfahrtgesellschaft, in normal visibility conditions entered the active runway at Oslo Gardermoen Airport, Norway without a valid ATC clearance. As result of the runway incursion, the ATC instructed a Boeing 737-800 to reject its take off thereby removing the risk of collision.

Synopsis

The following extract is from the official Report by the Aircraft Investigation Board Norway (AIBN) on the Serious Incident:

"[…] CLU8000 (C551) was cleared to holding position C1 for RWY 01L.

SNB611T (B738) was given line-up clearance for RWY 01L at 07:47:25, and take-off clearance at 07:48:19. As SNB611T commenced the take-off roll, the air traffic controller observed that CLU8000 had passed beyond holding position C1 and was about to enter RWY 01L. The air traffic controller immediately instructed SNB611T to abort the take-off, which was complied with."

The Investigation

According to the report, the commander of C551 states that there were three factors which contributed to the aircraft proceeding beyond the clearance limit of holding position C1.

  • "The visibility from the cockpit was “not good”, as the aircraft was taxiing into a rising sun.
  • Checks of the “thrust reversers” (TR) on C500 Series aircraft are required to be performed while the aircraft is taxiing into a head wind in order to avoid exhaust gases entering the cabin. The distance from the General Aviation area to holding position C1 is relatively short. Thus only a limited time was available in which to perform the required checks. The first officer, due to limited experience, had problems performing the thrust reversers checks.
  • The commander’s attention was being diverted to other tasks.

The AIBN makes the following comments in the Report:

"The AIBN shares the understanding of the CLU8000 commander regarding elements which may have contributed to the aircraft passing the C1 holding position. The attention of the commander of CLU8000 would seem to have been fixated on the first officer’s problems with the checks of the thrust reversers.

When a pilot-in-command (PIC) is aware that the distance to the runway in use is short, and he also knows that the checklist to complete before take-off is extensive, or if other events demand extra attention, it is the responsibility of the PIC to adjust the taxiing to ensure that the runway in use is not entered before the checklist is completed. Having flown 3 000 hours on the type, it is reasonable to consider the PIC of CLU8000 is experienced.

The accident investigation board has not made inquiries about the Triple Alpha Luftfartgesellschaft regarding training programmes or operating procedures, and can therefore not assess whether any deficiencies in these elements exist with the company. Neither the cockpit CRM (Company Resource Management) on the day in question nor the company culture have been evaluated, and there is no reason to assume that human factors apart from those already mentioned, have contributed to the evolving situation. Nevertheless, the AIBN wishes to give a reminder of the importance of good CRM, together with training programmes and procedures which improve air safety.

There has been done a lot of work internationally to prevent runway incursions. The AIBN believes that it would be possible to reduce the number of incidents of the type described in this report if operators carry out training and produce operational procedures in accordance with the recommendations made by Eurocontrol and other equivalent organisations. (See, EUROCONTROL’s European Action Plan for the Prevention of Runway Incursions and ERSI in Related Articles )

The AIBN considers that the flight crew of SNB611T acted in a prompt and correct manner upon being instructed to abort the take-off run. Their action was a contribution in preventing the incident developing into a situation with a potentially far more serious outcome."

Apart from the AIBN comments, no Safety Recommendations are made in the Report.

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