Germania B737 at Las Palmas on Jan 7th 2016, cleared for takeoff on closed runway and rejected takeoff

Last Update: January 17, 2017 / 16:15:49 GMT/Zulu time

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Incident Facts

Date of incident
Jan 7, 2016

Classification
Incident

Airline
Germania

Flight number
ST-6129

Departure
Las Palmas, Spain

Destination
Friedrichshafen, Germany

Aircraft Registration
D-ABLB

Aircraft Type
Boeing 737-700

ICAO Type Designator
B737

A Germania Boeing 737-700, registration D-ABLB performing flight ST-6129 from Las Palmas,CI (Spain) to Friedrichshafen (Germany) with 135 passengers and 5 crew, was cleared for takeoff from Las Palmas' Gran Canaria Airport's runway 03R at about 14:48Z and began acceleration, when ATC realized the runway was closed for work in progress and instructed the aircraft to reject takeoff. The crew rejected takeoff at low speed, then backtracked the runway to the threshold, subsequently lined up runway 03L and departed from runway 03L without further incident about 5 minutes later. The aircraft landed safely in Friedrichshafen about 4 hours later.

On Feb 9th 2016 Spain's CIAIAC reported an investigation has been opened into the occurrence.

On Nov 21st 2016 the CIAIAC released their final report in Spanish concluding the probable causes of the incident were:

- the controller did not detect his error although several visual measures were implemented to identify the runway was closed. The controller neither detected the physical presence of the car on the side of runway (which did not have anti-collision beacons on), nor did the controller detect the presence of the flight strip indicating a car was on the runway.

- the controller partially heard a transmission from the aircraft querying the stop bar lights being on, but did not request to repeat that transmission and instructed the aircraft again to line up and wait on runway 03R.

- the crew taxied past the active stop bar lights without requesting those lights to be turned off or receive contingency information why the stop bars could not be turned off. The respective instructions in the manuals may have contributed being unclear and not specific.

- the crew commenced the takeoff roll despite having visual contact with the car on the side of the runway.

- a mitigating measure to place cones near the runway threshold to indicate the temporary closure of the runway was not approved by the local runway safety committee although the measure had been proposed to the committee

On Jan 17th 2017 the CIAIAC released their English version of the final report writing following conclusion (the original AVH translation of the Spanish conclusions unmodified above):

The incident was caused by the controller’s loss of situational awareness, as he instructed the crew of GMI6129 to enter and then take off from runway 03R, despite knowing that it was closed.

Contributing to the incident was a series of factors that bypassed the safety barriers that could have prevented its occurrence:

- The controller did not detect his mistake despite the presence of visual aids in the tower indicating that the runway was closed. He also did not see the car in the runway 03R strip, though this may have been caused, as per the statement from the crew and the controller, by the fact that the car did not have its flashing lights on.

- The controller only partially heard a report from the crew notifying that the stop bar was illuminated, but he did not ask for the message to be repeated and again instructed the crew to line up and wait.

- The crew crossed an illuminated stop bar without having information regarding contingency measures in place to speciically allow this. Contributing to this is the fact that the regulation on stop bars and the applicable manuals are not clear or specific.

- The aircraft’s crew started the takeoff run despite being in visual contact with the car that was stopped on the runway strip.

- The mitigation measure of placing cones at the threshold of the temporarily closed runway was not in effect, since the minutes of the Local Runway Safety Committee meeting, where this measure had been proposed, were not yet approved.

The investigation released two safety recommendations as result.

The CIAIAC reported that the closure of runway 03R had been NOTAMed. Both the tower controller as well as the crew knew, runway 03R was closed.

The tower controller correctly instructed a preceding departure to line up runway 03L and cleared the flight for takeoff from runway 03L. However, when a couple of minutes later the Germania taxied for departure, tower instructed the aircraft to cross runway 03L, line up and wait runway 03R. The crew taxied the aircraft across runway 03L, noticed the active stop bars ahead of runway 03R and queried tower, tower however repeated the instruction to line up runway 03R. The crew thus taxied across the active stop bar lights and lined up runway 03R. About two minutes later tower cleared the flight for takeoff from runway 03R, however, cancelled the takeoff clearance after the aircraft had rolled about 270 meters/900 feet.

The CIAIAC reported the captain of the flight (36, ATPL) had accumulated 6,550 hours total, 6,030 hours on type, the first officer (26, CPL) had accumulated 1000 hours total with 650 hours on type.

The tower controller (38) had acquired his controller's license in 2008 and had been controlling at Las Palmas since 2010. In 2013 he became supervisor and became instructor in 2014.

At the time of the occurrence visual meteorologic conditions prevailed with good visibility, scattered cloud ceiling was at 2500 feet.

The CIAIAC analysed that on the day of the occurrence survey work was being conducted on the side strips of the runway requiring the closure of the runway. A car with a driver inside was performing the survey and was placed on the side strip of the runway. A flight strip indicating a vehicle on the runway had been placed onto the runway 03R stack on the controller's desk by the outgoing controller, the incoming controller was informed about the runway closure and started duties about 30 minutes prior to the occurrence initially correctly instructing aircraft onto runway 03L for a single runway operation.

The CIAIAC analysed that a new procedures for helicopters had come into effect and the controller was still paying full attention onto there very complex procedures requiring a lot of coordination. A helicopter thus required his full attention when the Germania reported ready for departure. The stress and concentration produced by the helicopter prevented the controller to pay full attention to the Boeing. After issuing the crossing clearance for runway 03L to the Germania the controller handed the previous departure off to departure twice, however did not receive a reply on both transmissions, then the Germania queried the stop bar lights. At that time the tower controller also monitored departure frequency to find out whether the previous departure had already contacted departure on their own, hence missed part of the transmission querying the stop bar lights, but did not request to repeat the transmission but repeated his instruction to line up runway 03R and wait without realizing why the crew had called in.

When the controller subsequently issued takeoff clearance he did not check the runway bay at his desk and thus did not notice the flight strip placed into there, nor did he spot the physical presence of the vehicle at the edge of the runway. The vehicle did not have anti-collision beacons activated, it's colour may have contributed to make the car difficult to spot on the runway surface. The controller suggested to place another marker for runway closure in front of the wind indicators as an immediate safety action, which was deemed sufficient by the investigation.

The controller finally spotted the vehicle on the runway only after the takeoff clearance had been transmitted and cancelled the takeoff clearance.

The CIAIAC analysed that the airport operator reported the car was equipped with anti-collision lights and that these lights had been operating at the time of the occurrence. The CIAIAC stated however that it was unlikely the collision lights were on given the controller as well as the crew did not see the vehicle before entering the runway.

The CIAIAC analysed that the crew was aware of the NOTAMs indicating the closure of runway 03R and was confused by the instruction to cross runway 03L and line up runway 03R but as the instruction was repeated decided to follow the instruction. Once approaching the hold short line of runway 03R they noticed the active stop bar and queried again, slowed and stopped the aircraft, but were again instructed to line up runway 03R which was also deemed clearance to cross the active stop bar lights. However, no crew is authorized to cross active stop bar lights except for receiving explicit clearance to cross the stop bar lights unless the lights are off.

The CIAIAC analysed that after line up the crew acquired visual contact with the vehicle but considered that there was no danger of collision with the vehicle when they received takeoff clearance and commenced takeoff. The runway strip is part of the runway used to reduce risks and damage for aircraft and occupants in case of runway excursions. The crew also did not know the intentions of the car driver being on a different frequency. After tower cancelled the takeoff clearance the crew complied with that instruction and stopped the aircraft.

The CIAIAC analysed that ICAO regulations stipulate that no aircraft is permitted to cross active stop bar lights. However, ICAO also defines contingency procedures to permit an aircraft past active stop bar lights. There is no standardized procedure however to make clear in communication that such a contingency procedure was being used, which could contribute to misunderstandings and confusions.

In a meeting of the local aerodrome's safety committee on Dec 1st 2015 the aerodrome proposed following a number of occurrences, that cones should be placed near the threshold of the runway to indicate the runway was closed. The measures should be implemented immediately. However, the safety committee did not adopt these measures until Jan 15th 2016. The cones could have established another safety barrier to prevent the occurrence.

Relevant NOTAM active on Jan 7th 2016:
B9738/15 NOTAMN
Q) GCCC/QMRLC/IV/NBO/A /000/999/2756N01523W005
A) GCLP B) 1601070800 C) 1601071820 EST
E) RWY 03R/21L CLSD EXC EMERG MIL

NOTAM in archive for Jan 7th 2016 but not active (and shown as cancelled however this NOTAM was highlighted as the only one):
B9736/15 NOTAMN
Q) GCCC/QMRLC/IV/NBO/A /000/999/2756N01523W005
A) GCLP B) 1601120800 C) 1601121820 EST
E) RWY 03L/21R CLSD EXCEPT SEGMENT A5
Incident Facts

Date of incident
Jan 7, 2016

Classification
Incident

Airline
Germania

Flight number
ST-6129

Departure
Las Palmas, Spain

Destination
Friedrichshafen, Germany

Aircraft Registration
D-ABLB

Aircraft Type
Boeing 737-700

ICAO Type Designator
B737

This article is published under license from Avherald.com. © of text by Avherald.com.
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