Runway Incursions

Runways and their environs are high risk areas for everyone, whether in the air or on the ground.

The Lakenheath Incident

Look ahead and land, said the Ground Controlled Approach (GCA) controller and I looked up from the instruments and transferred my attention to the enormous Runway 24 (2743m by 46m) at USAF Lakenheath. It was more or less where it should be and my practice instrument approach in a Vampire FB5 had gone very nicely so far. However, the view ahead was somewhat marred by the presence of an enormous fuel bowser on the peritrack straddling the runway threshold. The obstruction seemed unlikely to disappear in the near future as the driver was to be seen sprinting away from the threshold as fast as his considerable corpulence would allow. How all this incident had developed from the viewpoint of the ex driver I cannot say but no doubt harsh words were subsequently exchanged between various Lakenheath personnel. As I was never asked to contribute to these exchanges I presume that, unlike today’s practice of recording, examining and trying to learn lessons from any Occurrence, the matter was soon dismissed as Just One of Those Things. The driver probably regaled many listeners in the future with an account of his close shave, just as I am now doing with you, dear Reader.

From my point of view this particular shave was a good way from being even slightly close. I had never intended to land at Lakenheath as we just used their equipment and personnel for practice GCAs and always overshot. So I was mentally already well into the overshoot when I first espied the monster bowser. While jet engines of the 1950s, and even today to some extent, took an interminable, and sometimes frightening, time to spool up from idle I had the engine already at well over half power and had no difficulty in clearing the bowser by some 150 ft. However, just suppose I had been in one of those new six engine B47s that the Yanks were beginning to operate, and suppose that I had inadvertently got myself too low and too slow, with little chance of piling on much thrust in the next few seconds, the collision between the Stratojet and the big bowser would have occasioned quite some funeral pyre. In those days military aviation accidents were so frequent that the loss of a single jet was worth only two or three column inches in a middle page but, assuming that some quick witted person got a photo of at least the smoke column, this would have made the national front pages.

Even if nobody other than myself and probably the bowser driver learned anything from this incident it certainly did impress on my sub conscious how suddenly aircraft and/or vehicle operations on or close to a runway can very quickly develop into disaster. It has taken me many hours and much pain to learn other great truths of aviation but the area of experience nowadays called Runway Incursions has been with me ever since that day.

Most of us already know full well that the Air Traffic Zone around an airfield is a great deal more dangerous, so far as mid air collision is concerned, than is the rest of airspace but we all tend to think that the ground is a much safer environment than the air. Consequently we are wont to drive around airfields often lost in conversation with passengers or in admiration of some lovely aircraft swooping in or out. While taxying out in an aircraft we conscientiously check instruments, adjust GPS sets and avionics, examine SID or other charts and prepare ourselves for the flight to come. There is nearly always one taxying accident, sometimes two or three, in every AAIB monthly bulletin and you will usually find not looking where they were going because of the distraction of carrying out some cockpit task at the root of many of the accidents. So push as much of the cockpit work to before or after taxying as you can: you never know – you might even taxy on to the active while your head is in the office.

Alternatively we relax after our invariably faultless landing and taxi in, switching things off while in motion with half our minds on the plans for the evening. When your instructor tells you that the flight is not over until the propeller has stopped turning he or she is speaking words of wisdom. Indeed, in my experience the flight is not over until you have entered the crew room or driven off in your car. Too many flat batteries from forgetting to turn off the Master remind me of this truth and a ding-ed wing tip while pushing her back into the hangar add to this lesson. Aren’t those wingtip strobe lights expensive!

Tenerife

The granddaddy of them all and still, I believe, the aviation accident with the greatest loss of life is of course the Tenerife disaster, involving as it did the loss of two B747 jumbo jets with 583 fatalities. To quote from Wikipedia:

“A terrorist incident at Gran Canaria Airport had caused many flights to be diverted to Los Rodeos, including the two accident aircraft. The airport quickly became congested with parked aircraft blocking the only taxiway and forcing departing aircraft to taxi on the runway instead. Patches of thick fog were also drifting across the airfield, preventing aircraft and control tower from seeing each other.

The collision occurred when KLM 4805 initiated its takeoff run while Pan Am 1736, shrouded in fog, was still on the runway and about to turn off onto the taxiway. The impact and ensuing fire killed everyone on board the KLM jet and most of the occupants of the Pan Am, leaving only 61 survivors from the aircraft’s front section.

The subsequent investigation by Spanish authorities concluded that the primary cause of the accident was the KLM captain’s decision to take off in the mistaken belief that a takeoff clearance from air traffic control (ATC) had been issued. Dutch investigators placed a greater emphasis on mutual mis- understanding in radio communications between the KLM crew and ATC but ultimately, KLM admitted their crew was responsible for the accident and the airline agreed to compensate the victims’ relatives.

The disaster had a lasting influence on the industry. An increased emphasis was placed on the importance of using standardized phraseology in radio communications. Cockpit procedures were also reviewed, contributing to the establishment of crew resource management as a fundamental part of airline pilots’ training.”

Whole books have been written on this seminal disaster and there is so much to learn from it but to my mind the outstanding lessons are:

1 Poor visibility – night or any restriction in daytime visibility that limits your ability to see the whole airfield and its approaches – greatly enhances the risk of a serious mistake.

2 You should always be conscientious about fully understanding ATC’s instructions and seeking clarification when unsure, especially when in the circuit or on the ground. At least when on the ground you can hold your position while seeking clarification and it is usually sensible to do so.


BAe 146-300 and PA-38
Birmingham 1999


“On 28 April 1999, a BAe 146-300 being operated by Aer Lingus on a scheduled passenger flight from Birmingham to Dublin began its take off from Runway 33 in normal daylight visibility without ATC clearance just prior to the touchdown of a Piper PA-38 Tomahawk on the intersecting runway 06. Collision was very narrowly avoided after the Controller intervened and the BAe 146 rejected its take off but was unable to stop before the intersection where the now stationary PA38 was positioned off the runway 33 centreline. As the BAe 146 stopped, the aircraft commander transmitted ‘did we hit him’ to which a negative reply was given by the Controller.”

The AAIB report observed that the BAe 146 had begun the take off without a clearance and noted that “As with the majority of incidents, this occurrence was the result of an accumulation of factors”, the most significant of which was the unexplained perception of the BAe146 aircraft commander that a take-off clearance had actually been given, despite the fact that it was not included in his read back of the departure instruction.

The lesson here, as I see it, is that you must accept that no one, even your good self, is infallible and mistakes occur all the time. Usually matters are put right before they get out of hand but expecting the unexpected is always sound advice. So, if you think that you are cleared for take off - are you quite sure? And if ATC clears you to land, it’s still a good idea to check carefully the runway and its environs for yourself.

Bombardier CRJ-700 and Cessna 172, 
Allentown, PA USA, 
2008


“On 19 September 2008, CRJ-700 being operated by Mesa Airlines on a United Express scheduled passenger service from Allentown PA to Chicago O’Hare IL made a high speed rejected take off on runway 06 upon seeing a light aircraft on the runway ahead at night in normal visibility. By veering to the left around it whilst decelerating, a collision was avoided.”

This was an error by ATC who cleared the Bombardier regional airliner to take off without first ensuring that the Cessna had cleared the runway. Watch out for mistakes by others as well as yourself – especially at night. 

UK GA Runway Incursions

It is a disappointing fact that Occurrence Reports relating to UK GA are fairly sparse and not very accessible. There is no Mandatory Reporting requirement and I imagine that the problem stems from the cost of managing such a system, including
monitoring and analysing it if it is to be of much practical value. The British Gliding Association does an excellent job in this respect and it would be good to see other flying organisations finding the resources to do the same within their own sectors. Meanwhile most of the rest of UK GA is left with no more than AAIB reports and these have to go through the filter of the occurrence leading to serious injury or damage if it is to be reported. Necessarily a close encounter on or near a runway which avoids actual contact will be unlikely to be reported to the GA community, unless it becomes the subject of an airprox, If you accept the general proposition that there are about 30 ‘Occurrences’ to every ‘Accident’ then we are all missing important information 29 times out of 30 and if only we had it we should be in a better position to make improvements. I have
selected runway incursions for most of the Occurrence Reports in this issue.

Here are a two recent AAIB reports that involved runway incursions.

Piper L-18C Super Cub, ATPL 61 years, 19,162 hours (30 on type and 22 in past 28 days) Shoreham Airfield.
During takeoff the aircraft encountered a wake vortex system from a helicopter which had hover-taxied across the runway approximately two minutes earlier. The pilot was unable to correct the roll, induced by the vortex system, before the aircraft struck the ground. The aircraft was destroyed and the pilot suffered minor injuries. 

Christen Eagle II, PPL, 2,500 hours (0 on type, 13 in past 28 days). Seething Airfield, Norfolk. Ref EW/C2008/10/94 

While making an approach to land, the aircraft collided with an agricultural vehicle that was spraying crops in a field adjacent to the runway threshold. The aircraft was destroyed in the impact and post-crash fire. Both occupants suffered fatal injuries. The investigation concluded that the aircraft’s final approach was flown such that its occupants were unable to ensure that the flight path ahead was clear of obstacles. As a result, they were unaware of the vehicle’s proximity to the runway. 

Conclusion

Runway incursions, whether in your aircraft or your vehicle, are potentially disastrous and you need to keep yourself in a high state of awareness, especially in poor visibility or if you are under time pressure, as was the KLM Jumbo Captain at Tenerife. So take great care out there and, if ATC clears you to line up and there are flashing red lights across or next to the threshold, don’t move. You might be trying to line up on the wrong runway (check your compass) or they might have made a mistake. Either way, everyone will be a whole lot safer if you stay put behind those red lights until the situation has become clear.