Europa A332 at Madrid on Oct 17th 2014, takeoff despite vehicle on runway

Last Update: June 22, 2017 / 21:21:11 GMT/Zulu time

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Photo of Air Europa EC-LNH, Airbus A330-200 — Air Europa EC-LNH, Airbus A330-200 (Photo credit: airlines470 / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Oct 17, 2014

Classification
Incident

Airline
Air Europa

Flight number
UX-25

Departure
Madrid, Spain

Destination
Santa Cruz, Bolivia

Aircraft Registration
EC-LNH

Aircraft Type
Airbus A330-200

ICAO Type Designator
A332

An Air Europa Airbus A330-200, registration EC-LNH performing flight UX-25 (scheduled dep Oct 16th, actual dep Oct 17th) from Madrid,SP (Spain) to Santa Cruz (Bolivia) with 267 passengers and 12 crew, was accelerating for takeoff from Madrid's runway 36L at 00:37L (Oct 16th 23:37Z) when the crew noticed the presence of unusual lights. The crew inquired with tower about the origin of those lights, tower reported they were aware of the lights. When the aircraft went past the lights the crew noticed a vehicle at the left edge of the runway speeding off the paved area. The aircraft became safely airborne and continued for a safe landing in Santa Cruz.

Spain's CIAIAC reported on Dec 18th 2014 that an investigation was opened into the occurrence.

In an interim statement released on Oct 26th 2015 the CIAIAC reported that deviations from standard procedures regarding aerodrome maintenance were identified during the course of the investigation, which contributed to the presence of a vehicle on runway 36L. The airline took immediate safety action to instruct their crews to reject takeoff, provided the aircraft was still below V1, as soon as a possible threat to the safety of the aircraft is being identified. The investigation is continuing and assessing the performance of air traffic control with respect to the detection/non-detection of the vehicle on the runway.

On Jun 22nd 2017 Spain's CIAIAC released their final report in Spanish concluding the probable cause of the serious incident was:

The loss of situational awareness by the driver of the vehicle of an auxiliary company resulting in the vehicle transiting the runway in service at the same time when a takeoff occurred.

Contributing factors were:

- the driver's attention deficit at work
- the lack of adequate training and lack of promotion of safety culture at the auxiliary company
- Inaction by tower after the obstacle on the runway was identified
- Inconsistent reaction by the crew during the runway incursion
- Lack of reassessment of the operations safety surveillance plan in due periods of time as well as lack of verification of conduct of initial training by AENA Airports

The CIAIAC reported that flight UX-25 received takeoff clearance from runway 36L. At the same time a vehicle was on the runway about 2670 meters down the runway, and began to travel the runway in opposite direction (towards the threshold). Soon after the A330 crew noticed unusual lights and queried tower, who however did not know the origin of those lights. About 1875 meters past the runway threshold the aircraft crossed the vehicle, which had turned the lights off and was speeding off the paved surface of the runway to the left. The aircraft continued the takeoff, the vehicle left the runway without informing anyone.

A reconstruction company was contracted o carry out maintenance work in several areas of the aerodrome including runway 36R. The vehicle was dispatched to take supplies to runway 36R, the operator of the company was supposed to follow the service road around runway 36L to proceed onto runway 36R. After starting at point A (see map below) the vehicle followed the service road to point B, then turned right and followed taxiway ZW4 and after entering runway 18R/36L at point C turned left to the north (runway 36L), but about 2670 meters down runway 36L at point D turned around and now headed south in opposite direction to runway 36L coming to a stop and then speeding off the runway at point E, where the aircraft passed the vehicle. Just before the vehicle reached point D and turned around to drive the runway in opposite direction the aircraft began its takeoff roll.

The CIAIAC analysed that the vehicle was not carrying a transponder. When the controller issued the takeoff clearance to UX-25 he checked the ground radar. The vehicle at that time was still moving northwards and a primary target was not presented to the controller on the radar screen, probably due to filtering, attenuation or because of reflections. The controller, with the position of the control tower near the threshold runway 36L, only saw the rear lights of the vehicle more than 2000 meters away, in addition he did not expect a vehicle on the runway and thus did not consider the lights to be on the runway. However, when the crew queried the controller about the presence of unusual lights on the runway, the controller could see the headlights of the vehicle. The controller's reaction therefore could have been improved.

The CIAIAC analysed that the captain is responsible for the safe operation of his aircraft. When the crew spotted unusual lights and became unsure suspecting the presence of "something" on the runway, they should have rejected takeoff. At this time the aircraft was travelling at 89 KIAS, well below V1.

The vehicle was not supposed to operate on any of the maneouvering areas of the aerodrome, hence was not required to carry transponder, a rotating beacon or a radio. Runway 36R was closed and therefore was not part of the maneouvering area. The driver of the vehicle had actually not been on duty and was called in to replace a collegue, supposedly he improvised in order to achieve the work required. Training had not been included regarding the signage and beacons of the aerodrome, the beacons for runway 36R were operated in "Revision" mode while the beacons for runway 36L were operating normally, the lack of traffic on runway 36L at that time as well as uncertainty about the own position may have led the driver to enter active runway 36L instead of closed runway 36R. After he realized his mistake seeing the lights of the aircraft and sped off the runway to avoid a collision, he then drove away without telling anyone of his company or the airport, also showing lack of responsibility and lack of safety culture within his company.

As an immediate safety action the airline issued an urgent recommendation to their crews: "during takeoff phase, whenever doubts arise about a possible runway incursion regardless of vehicle, other aircraft or any other element, or when the slightest suspicion arises that the runway is not clear for takeoff, takeoff below V1 should be rejected". The CIAIAC considered this safety action adequate in view of the crew performance.