Iberia A319 at Madrid on Sep 22nd 2013, cleared to land and landed with runway occupied
Last Update: February 3, 2016 / 21:29:39 GMT/Zulu time
Spain's CIAIAC reported on Aug 21st 2014 that the vehicle had been cleared to perform a runway inspection due to the presence of birds. The tower controller attempted to raise the driver several times on radio to instruct the vehicle to leave the runway, but repeated contact attempts failed. Tower had cleared the aircraft to land anticipating the vehicle would have vacated the runway at touch down. The investigation is continuing focussing on aspects of radio coverage at the aerodrome and questions why the vehicle driver could not be contacted. (Editorial note: The CIAIAC statement does not contain indication that the investigation is trying to clarify why the landing clearance was issued and why no go-around instruction was issued).
On Feb 3rd 2016 the CIAIAC released their final report in Spanish concluding the probable cause of the incident was:
Erroneous time planning by Tower to ensure completion of a secure runway inspection and the lack of proper operating procedures with respect to runway inspection at Tower. In addition the loss of communication between vehicle and Tower prevented the coordination between the two.
The CIAIAC reported tower had requested a runway inspection after the preceding landing traffic had encountered a bird strike in the area of the touch down zone of the runway. Tower therefore cleared an operations vehicle to enter runway 18L at the end of the runway, taxiway Y1 (IB-3471 was about 6nm before touchdown), the vehicle drove up the runway in opposite direction to the landing traffic. When IB-3471 reported on tower frequency, tower advised the aircraft of the vehicle on the runway and advised to expect a late landing clearance or accept clearance to land long on own discretion. About a minute later, IB-3471 now 3.9nm out, tower attempted to contact the operations vehicle for a first time with no response, followed by seven more attempts to raise the driver and instruct the vehicle to vacate the runway immediately without response. Tower stopped traffic on runway 14R in anticipation of a possible go-around. The vehicle crossed the runway threshold 18L just when the aircraft was 0.7nm before the threshold, the driver subsequently turned off ahead of the runway threshold onto taxiway Y7. Just when the driver radioed that he was clear of the runway the aircraft touched down. The minimum distance, with the vehicle still within the runway protected area, between aircraft and vehicle was 0.1nm horizontally and 200 feet vertically.
The CIAIAC reported that the aircraft encountered no communication problems with tower. Daily operations did not notice any issue communicating with tower at any point. The routine test, last performed on Sep 8th 2013, had not shown any issue. The test was repeated on Sep 26th 2013 but also showed no significant problem preventing communication between vehicle and tower, the test just noted an increased background noise between taxiways Y5 and Y7 but without loss of audio signal strength.
The report about the communication continued, that the conditions at the time of the occurrence were reproduced, the flood lights of the vehicle were turned on as during the runway inspection. The result was that transmissions became nearly unreadable in the vehicle especially if the lamps were not halogen type lights. (Editorial note: this point raised in the factual part of the report, first paragraph on page 8, was not followed up in analysis, findings, conclusions or safety recommendations causing quite some concern with this editor of possibly misinterpreting this paragraph).
A check of the tower transmitter showed no anomalies, no alarms were active.
The test then mapped the entire aerodrome using tower north and tower south positions and frequencies. The weakest point of signal was found at the most northern points of runway 18L and 18R (before the displaced thresholds of both runways), the signal strength however was still 6 times the minimum signal needed for the minimum equipment receiver (requiring the strongest signal to work).
The CIAIAC reported that prior to the occurrence the tower manual provided following guidelines for performing runway inspections:
- runway inspections must be done with vehicles equipped with speed limiters
- the inspection vehicle drives along the runway in opposite direction to landing and departing traffic at about 60kph (except last inspection of the day which is performed in both directions)
- tower must provide a gap of about 4-5 minutes to complete the runway inspection
Following the event the guidelines were amended in December 2014 introducting a distinction between routine runway inspections, the framework of which remained the same as so far with an additional requirement to provide approach control with the information of the pending runway inspection about 15 minutes prior to the inspection - so that the needed gap in approach traffic can be coordinated -, and ad hoc inspections, that are needed after e.g. tail strike, bird strike, engine failure, tyre damage, pilot request, heavy rain, other weather phenomena or presence of foreign objects. In this case the runway has to be closed, assuming the presence of foreign objects on the runway, until the runway inspection has been completed, approach is to be kept advised.
The CIAIAC analysed that the time given to the vehicle to inspect the runway was insufficient, the CIAIAC reasoned that the vehicle would have needed to drive along the runway at 184kph in order to vacate the runway in time to ensure proper separation, which however would completely invalidate the runway inspection giving the driver no chance to notice any anomalies. The CIAIAC further analysed that given the actual timeline during the event it is clear that the average speed of the vehicle, from entering at Y1 and being clear of the runway at Y7 was above 90 kph, it seemed unreasonable that the driver was doing the entire length at that speed. The CIAIAC assumed that the driver performed the runway inspection at 60kph during the first 2000 meters then sped up. The remaining 1200 meters of runway to the threshold and further on to taxiway Y7 the vehicle must have driven in excess of 120kph, therefore the runway inspection was not according to requirements and the aircraft operated on the runway without full assurance of safety as required (the inspection did not ensure that the runway was clear of debris).
Th CIAIAC further analysed that the driver of the vehicle sped up so much, that a departure from the paved surface would likely have resulted in the vehicle overturning.
The CIAIAC analysed that the precaution to stop traffic on runway 14R in anticipation of a possible of a go around was insufficient, it was also not appropriate to leave the discretion to continue the landing or go around with the crew as the only one with the full knowledge of the traffic situation was the tower controller, while the crew would not have that full situation awareness.
The CIAIAC analysed that in general the radio communication is ensured throughout the aerodrome although between taxiways Y5 and Y7 there is considerable background noise (with normal audio signal levels). It was not possible to identify the source of the background noise however.
No safety recommendations were released as result of the investigation reasoning that all safety actions had already been taken.
This article is published under license from Avherald.com. © of text by Avherald.com.
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