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RJ85 / Vehicle, Gothenburg Sweden, 2011

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Summary
On 8 September 2011, a Brussels Airlines Avro RJ85 on the take off roll at Gothenburg came close to collision with a vehicle which the subsequent investigation found had been issued with clearance to enter the same runway as a result of controller error in the context of non-essential conversation. The vehicle saw the approaching aircraft just before entering the runway and stopped just clear of the runway approximately 40 metres ahead of the point at which it became airborne.
Event Details
When September 2011
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BAE SYSTEMS AVRO RJ-85
Operator Brussels Airlines
Domicile Belgium
Type of Flight Public Transport (Passenger)
Origin Gothenburg City
Intended Destination Brussels Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Take Off
TOF
Location - Airport
Airport Gothenburg City
General
Tag(s) ATC Training,
Inadequate ATC Procedures
HF
Tag(s) ATC clearance error,
Distraction
RI
Tag(s) ATC error,
Incursion pre Take off
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Air Traffic Management
Safety Recommendation(s)
Group(s) Air Traffic Management
Investigation Type
Type Independent

Description

On 8 September 2011, an Avro RJ85 being operated by Brussels Airlines on a scheduled passenger flight from Gothenburg to Brussels with 85 occupants was taking off from runway 21 at Gothenburg in normal day visibility when a vehicle almost entered the same runway near to the airborne point. The vehicle stopped immediately upon seeing the aircraft and the aircraft crew reported having been unaware of it.

Investigation

An Investigation was carried out by the Swedish AIA. It was found that two positions were being manned in the VCR at the time, a TWR controller position with responsibility for the runway and aircraft departing from and arriving on it and a GND controller position with responsibility for vehicle movements, aircraft departure clearances and taxiing aircraft.

It was found that three vehicles had been waiting to enter the runway, two near the downwind end of the runway and the other at an intermediate position. Once the RJ85 aircraft had been given take off clearance and had begun to roll, it was found that the runway controller had given the GND controller permission to clear all three vehicles onto the runway “in one and the same sentence” without specifying the vehicles individually.

As he approached the runway, the vehicle driver reported having “perceived a light from the left at the same time as he heard a rumbling noise”. He had then spotted the aircraft which was taking off and stopped immediately at a distance subsequently determined to have been 50 metres from the centreline of the 45 metre wide runway.

It was found that a few minutes prior to the issue of this take off clearance, the GND controller position had been handed over from an OJTI paring to a qualified controller. During this handover, the trainee had advised the controller taking over the GND position that the vehicle which subsequently came close to the departing aircraft was waiting for runway occupancy in a position different to its actual position - at the upwind end of the runway rather than in the mid point area. This error had increased the risk of collision which had been created by the subsequent vehicle clearance error.

Whilst it was noted by the Investigation that “there are no regulations concerning conversations of a private nature while performing air traffic services”, it was considered that non-operational conversations may have led to a failure to both properly ascertain and pass on the position of the vehicle:

“…conversations of a non-operative nature between the personnel (in the control room) may have contributed to both the instructor and the trainee being distracted from (comprehending) the position given by (the vehicle driver) as well to the trainee neither asking the driver of the vehicle to repeat his position nor himself making a note of the stated position on the strip. Also, the (OJT) instructor's ability to follow up on what occurred may have been limited by the private conversations that were going on.”

The Investigation concluded “that the introduction of a sterile concept for air traffic controllers during certain phases while in an operative position would contribute to increased aviation safety”. It was noted that “air traffic controllers would thereby work under conditions which correspond to the sterile concept already applied within commercial aviation (flight decks)” and observed that “it cannot be considered reasonable for only one party in a situation with two-way radio communication to apply the sterile concept”.

Two Safety Recommendations were issued as a result of the Investigation:

  • that the LFV [the Swedish ANSP] develop and establish clear guidelines within the scope of its safety culture work, for conversations of a private nature during the course of operative work, in order to introduce a sterile concept for air traffic controllers during certain phases when in an operative position. [RL 2012:16 R1]
  • that the Swedish Transport Agency take measures to ensure the use of a sterile concept for air traffic controllers during certain phases when in an operative position. [RL 2012:16 R2]

The Final Report of the Investigation Final report RL 2012: 16 was published on 27 August 2012.

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