Cobham B712 at Perth on Jul 26th 2014, cleared to land despite vehicle on runway, go around after touch down avoids collision
Last Update: February 26, 2015 / 15:37:55 GMT/Zulu time
Incident Facts
Date of incident
Jul 26, 2014
Classification
Report
Airline
Cobham Aviation/QantasLink
Flight number
QF-1921
Departure
Karratha, Australia
Destination
Perth, Australia
Aircraft Registration
VH-NXL
Aircraft Type
Boeing 717-200
ICAO Type Designator
B712
However, tower had cleared a maintenance vehicle onto the runway previously, the vehicle had become stationary on the runway center line about 1180 meters from the runway threshold facing towards the runway end. The driver heard the landing clearance but did not hear the runway numbers and assumed the aircraft would land on runway 21.
The aircraft continued for a touchdown on runway about 380 meters past the runway threshold, immediately after touchdown the first officer, pilot monitoring, saw flashing lights on the runway and called "go-around, car on the runway", the captain, pilot flying, immediately balked the landing, the aircraft became airborne about 740 meters past the runway threshold and passed the vehicle at about 150 feet AGL.
Only when the aircraft overflew his vehicle, the driver became aware of the aircraft assigned to runway 24.
Australia's TSB (ATSB) released their brief final report releasing following safety message:
With experience comes the ability to fuse conscious control with largely automated actions. Instead of conscious focus on individual tasks, experts develop the ability to join separate movements and words together into packages or sequences. This automation of mental performance can improve efficiency and free up attentional resources for other tasks. However, the penalty for mental automation can be absent-mindedness or a lack of attention to a specific task.
The ATSB reported that the tower controller returned to duty from a 30 minute break about 5 minutes prior to the occurrence. About a minute later the first officer of QF-1921 contacted tower on approach to runway 24. The controller found, that the flight strip showed runway 21 assigned to the aircraft, the aircraft however clearly was on approach to runway 24 and amended the flight strip.
About 45 seconds later the controller cleared another aircraft to land on runway 21.
A short time later the airport vehicle, bright yellow and fitted with a rotating orange beacon carrying an aerodrome safety officer, call sign Safety Two, reported on tower frequency requesting to enter runway 24 for a runway inspection. The controller cleared the vehicle to enter runway 24, hold short of runway 21 and then wrote "S2" onto the console runway strip to indicate runway 24 was occupied.
At that point VH-NXL was about 7.5nm before the runway threshold on final approach in instrument meteorological conditions. Neither flight crew recalled hearing the vehicle being cleared onto the runway.
The other aircraft cleared to land on runway 21 landed and vacated the runway, a Fokker 100 was cleared for takeoff from runway 21, the controller followed the movement of the Fokker and once the Fokker had crossed runway 24 moved the flight strip of QF-1921 into the console runway bay without noticing the "S2" strip already placed there, scanned the runway without seeing the vehicle and cleared QF-1921 to land on runway 24, which at that point was descending through about 1000 feet AGL about 1.5nm before the runway threshold still in cloud, the first officer became visual with the runway when the aircraft descended through 700 feet AGL.
Just as the aircraft touched down the first officer noticed the rotating beacon on the runway and called the go-around then reported on tower frequency "Going around, car on the runway". The safety officer queried tower "what happened?". The controller completed the hand off of the departing Fokker, coordinated the go-around with the departure controller, instructed the vehicle to vacate the runway and handed the Boeing 717 off to departure, then handed the tower position over to a relief controller.
The ATSB wrote while summarzing the controller's comments: "The controller had a single runway bay on the Tower console where flight progress strips for aircraft using either of the two runways in use were placed. The runway assigned to the aircraft was written on the aircraft’s strip. The vehicle strip (red with a white centre) was in the console runway bay at the time of the incident. There were two possible reasons the controller may have missed it: the process of placing the aircraft strip without reconciling with the vehicle strip already there was a muscle memory or automatic process rather than a conscious one; or, the combination of picking up the strip, talking and scanning all at once when issuing a landing clearance meant that the controller was looking outside at the runway, talking and moving the strip without looking at the bay to reconcile the strips."
The ATSB summarized the captain's statement commending the first officer: "It was a split second decision to go around. If they had commenced the reverse thrust action, they would have been committed to landing. The aircraft had landing lights, navigation lights, beacon and high intensity lighting on at the time of the incident. The first officer was highly experienced which may have assisted in sighting the vehicle and reacting quickly. The incident provided a very good example of the value of flight crew knowing their role as pilot flying or pilot monitoring explicitly and maintaining a good awareness of their environment."
Air Services Australia, Air Traffic Control Provider, took a number of safety actions, for example introduction of Advanced surface movement guidance control system (ASMGCS) or ground radar, as result of the occurrence as did the aerodrome operator for example requiring safety officers to turn off the company frequency (chit-chat) while doing runway inspections and to perform runway inspections reciprocal (facing towards the arriving traffic).
Incident Facts
Date of incident
Jul 26, 2014
Classification
Report
Airline
Cobham Aviation/QantasLink
Flight number
QF-1921
Departure
Karratha, Australia
Destination
Perth, Australia
Aircraft Registration
VH-NXL
Aircraft Type
Boeing 717-200
ICAO Type Designator
B712
This article is published under license from Avherald.com. © of text by Avherald.com.
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