Thai AirAsia A320 at Macau on Nov 12th 2018, departed despite vehicle on runway

Last Update: July 22, 2019 / 13:33:56 GMT/Zulu time

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Photo of Thai AirAsia HS-BBO, Airbus A320 — Thai AirAsia HS-BBO, Airbus A320 (Photo credit: Rawipad C.KKU / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Nov 12, 2018

Classification
Incident

Airline
Thai AirAsia

Flight number
FD-763

Departure
Macau, Macau

Destination
Bangkok Don Muang, Thailand

Aircraft Registration
HS-BBO

Aircraft Type
Airbus A320

ICAO Type Designator
A320

Airport
Macau International Airport, Taipa

Airport ICAO Code
VMMC

A Thai AirAsia Airbus A320-200, registration HS-BBO performing flight FD-763 from Macau (Macau) to Bangkok Don Muang (Thailand), was taxiing for departure when tower cleared a follow me vehicle onto runway 34 for a runway inspection. The A320 subsequently reported ready for departure from runway 34, tower issued "the departure clearance" (editorial note: exact wording used by Macau's Civil Aviation Authority, hence unclear whether this was a takeoff clearance or not although the context suggests this was a takeoff clearance) to the flight at 14:35L (06:35Z), although the follow me was still on the runway and the surface movement radar showed an amber alert indicating the vehicle was on the runway. The aircraft lined up for departure and commenced their takeoff run at 14:36L (06:36Z). At this time the audio alarm of the surface movement radar activated, tower realized the vehicle was still on the runway and radioed the vehicle to immediately vacate the runway. The Follow Me, which had just reached the end of runway 34, vacated the runway, the aircraft became airborne shortly afterwards at about 14:37L (06:37Z), climbed out and continued to destination for a safe landing without further incident.

Macau's Civil Aviation Authority opened an investigation into the occurrence labelled "Aircraft Took-off from Engaged Runway" and reported according to surface movement radar data: "the estimated nearest distance between both moving objects was about 1480 metres or 0.8 nautical miles."

On Jul 22nd 2019 Macau's Civil Aviation Authority (AACM) released their final report concluding the probable causes of the incident were:

The tower controller momentarily forgot about the Follow-me 5 vehicle was on the runway when issuing clearance to flight AIQ763 / FD763.

Both the tower controller and ATC supervisor considered that traffic volume and complexity during the incident were light to moderate. The tower controller was thinking of the training she would delivered on the day after the incident.

The tower controller did not check the flight progress strip before giving clearance to flight AIQ763 / FD763.

During the occurrence, the ATC supervisor was not present at the working position in the visual control room.

The flight strip management system in Macau International Airport had no active monitoring function.

The SMR (Surface Movement Radar) in Macau International Airport had been unserviceable for over six months. Until October 2018, the SMR was resumed operations under the condition of monitoring by technicians. At the time of the occurrence, false alert was found presenting at the holding position even the vehicle has left the area. Moreover, the SMR display was being placed a bit far from controller working position. All these situations of the SMR would had affected the intention of the controllers in utilizing the SMR as supplement safety measure.

The AACM analysed:

Tower controller issued take off clearance to AIQ763 / FD763 when Followme 5 was on the runway, refer to Figure 3. The status of Follow-me 5 was indicated on the SMR display and flight progress board. Follow-me 5 and AIQ763 / FD763 were moving in the same direction on runway after AIQ763/ FD763 entered runway. The closest distance between Follow-me 5 and AIQ763 / FD763 before airborne was 1,480 meters, refer to Figure 4. According to ICAO Runway Incursion Severity Calculator, the runway incursion is rated as Severity Category C.

The tower controller stated that she forgot the vehicle on runway when she issued take-off clearance to AIQ763 / FD763. She checked neither the flight progress board nor the SMR display before issued the take-off clearance.

The ATC supervisor stated that when he heard the audible alarm of the SMR system, he approached the tower controller working position and noticed that AIQ763 / FD763 got airborne at about mid runway. He also noticed that the sequence of FPS showed that the runway was occupied by Follow-me 5 but not sure where was Follow-me 5 at that time. The tower controller stated that she told the ATC supervisor that she forgot that Follow-me 5 was still on the runway before she was alerted by the audible alarm of SMR.

Metars:
VMMC 120800Z 03005KT 350V060 9999 FEW025 28/21 Q1012 NOSIG=
VMMC 120730Z 03005KT 300V070 9000 FEW025 28/21 Q1012 NOSIG=
VMMC 120700Z 03007KT 360V060 4800 HZ FEW025 27/22 Q1011 NOSIG=
VMMC 120630Z 04008KT 3300 HZ FEW025 28/22 Q1012 TEMPO 2800 HZ=
VMMC 120600Z 04009KT 3200 HZ FEW025 27/22 Q1012 NOSIG=
VMMC 120530Z 03007KT 360V060 4800 HZ FEW025 28/22 Q1013 NOSIG=
VMMC 120516Z 03007KT 360V060 4400 HZ FEW025 27/22 Q1013 NOSIG=
VMMC 120500Z 03006KT 350V070 2500 HZ FEW025 27/23 Q1013 NOSIG=
VMMC 120430Z 03005KT 350V050 2600 HZ FEW025 27/23 Q1013 NOSIG=
VMMC 120409Z 03005KT 360V070 2800 HZ FEW025 27/22 Q1014 NOSIG=
VMMC 120400Z 03005KT 350V060 4000 HZ FEW020 26/22 Q1014 NOSIG=