An Alitalia Airbus A320-200, registration EI-DTJ performing flight AZ-1344 from Bologna to Catania (Italy) with 91 passengers and 6 crew, was cleared for takeoff from Bologna's runway 30, the airport was operating according to low visibility requirements. The aircraft rotated and climbed out, upon contacting departure the crew complained "Ehh, there was a Panda at the left edge of the runway" (identifying a vehicle rather than an animal).
Italy's ANSV released their final report concluding the probable cause of the serious incident was:
an untimely handover from one tower controller to the next during which key information about two vehicles cleared onto the runway was omitted.
The ANSV reported tower had cleared two vehicles, one for bird control and another one for a runway inspection (called "Safety"), onto the runway, the airport was operating according to low visibility procedures. These inspections were taken at regular intervals, the vehicles had been cleared onto and withdrawn from the runway several times within 30 minutes prior to the occurrence. In the meantime AZ-1344 obtained start up and push back clearance.
About two minutes after AZ-1344 received push back clearance (on ground frequency) tower cleared the two vehicles back onto the runway, the runway inspection car entered the runway at taxiway A (at the threshold of runway 12 tracking towards the threshold of runway 30), the bird control vehicle entered the runway via taxiway H (at the displaced threshold runway 30). The tower controller however did not activate the runway occupied indication.
Ground subsequently cleared AZ-1344 to taxi to the holding point K2 at the beginning of runway 30. Tower controller advised the two vehicles of the aircraft taxiing on taxiway T. As runway occupation and all runway clearances depended solely on him, the tower controller still did not activate the runway occupied indication, but placed the flight strip of AZ-1344 onto his stack of active flights on his multifunction displays.
In the next minute the next tower controller, arriving late for his shift, showed up for duties. The outgoing controller briefed the incoming controller on Ei-DTJ taxiing on taxiway T but forgot to mention the presence of two vehicles on the runway. The handover was carried out very quickly in the belief nothing important had to be conveyed. The incoming controller did a brief scan of the situation but was mainly attracted by EI-DTJ taxiing towards holding point K2.
About one minute after the hand over ground handed EI-DTJ off to tower. When the aircraft reported on tower frequency, the incoming controller made his first actual transmission "Alitalia 1344, good afternoon, runway t(h)ree zero, line up and cleared for takeoff, wind calm."
About 75 seconds after that transmission EI-DTJ had lined up and began the takeoff run, the two vehicles had reached about mid point of the runway each and were near the exit onto a service road.
The outgoing controller, who was still in the back of the control room, made an impassioned call to his collegue that the runway was occupied.
The first who reacted was the ground controller who grabbed the tower microphone and called "Safety immediately vacate to Alpha" prompting the driver of the bird control vehicle to speed off the runway via the service road and report his callsign was "bird control" while the safety car did not report. The ground controller, who had not been involved with the operation of the two vehicles and did not fully understand the situaiton, did not see another less prominent target on the ground radar screen, which was shown on the runway for the safety vehicle which was moving between intersections with taxiways E and F. The driver of the safety vehicle, still driving towards the threshold of runway 30 in opposite direction, however noticed lights moving ahead and sped off to the right beyond the edge of the runway onto the shoulder and stopped about 8 seconds later, the aircraft at that point was 287 meters from the vehicle and passed the vehicle about 4 seconds later at a speed of about 120 knots, the horizontal distance between the tip of the left wing and the vehicle reduced to 10 meters.
After the aircraft rotated and contacted departure the crew compained "Ehh, there was a Panda at the left edge of the runway".
The investigation released two safety recommendations arguing that even if the controller is operating entirely alone this does not absolve him from operating the runway occupation indications as required by procedures in order to ensure, that a sudden replacement can immediately recognize the present scenario.
fonte: avherald.com
Italy's ANSV released their final report concluding the probable cause of the serious incident was:
an untimely handover from one tower controller to the next during which key information about two vehicles cleared onto the runway was omitted.
The ANSV reported tower had cleared two vehicles, one for bird control and another one for a runway inspection (called "Safety"), onto the runway, the airport was operating according to low visibility procedures. These inspections were taken at regular intervals, the vehicles had been cleared onto and withdrawn from the runway several times within 30 minutes prior to the occurrence. In the meantime AZ-1344 obtained start up and push back clearance.
About two minutes after AZ-1344 received push back clearance (on ground frequency) tower cleared the two vehicles back onto the runway, the runway inspection car entered the runway at taxiway A (at the threshold of runway 12 tracking towards the threshold of runway 30), the bird control vehicle entered the runway via taxiway H (at the displaced threshold runway 30). The tower controller however did not activate the runway occupied indication.
Ground subsequently cleared AZ-1344 to taxi to the holding point K2 at the beginning of runway 30. Tower controller advised the two vehicles of the aircraft taxiing on taxiway T. As runway occupation and all runway clearances depended solely on him, the tower controller still did not activate the runway occupied indication, but placed the flight strip of AZ-1344 onto his stack of active flights on his multifunction displays.
In the next minute the next tower controller, arriving late for his shift, showed up for duties. The outgoing controller briefed the incoming controller on Ei-DTJ taxiing on taxiway T but forgot to mention the presence of two vehicles on the runway. The handover was carried out very quickly in the belief nothing important had to be conveyed. The incoming controller did a brief scan of the situation but was mainly attracted by EI-DTJ taxiing towards holding point K2.
About one minute after the hand over ground handed EI-DTJ off to tower. When the aircraft reported on tower frequency, the incoming controller made his first actual transmission "Alitalia 1344, good afternoon, runway t(h)ree zero, line up and cleared for takeoff, wind calm."
About 75 seconds after that transmission EI-DTJ had lined up and began the takeoff run, the two vehicles had reached about mid point of the runway each and were near the exit onto a service road.
The outgoing controller, who was still in the back of the control room, made an impassioned call to his collegue that the runway was occupied.
The first who reacted was the ground controller who grabbed the tower microphone and called "Safety immediately vacate to Alpha" prompting the driver of the bird control vehicle to speed off the runway via the service road and report his callsign was "bird control" while the safety car did not report. The ground controller, who had not been involved with the operation of the two vehicles and did not fully understand the situaiton, did not see another less prominent target on the ground radar screen, which was shown on the runway for the safety vehicle which was moving between intersections with taxiways E and F. The driver of the safety vehicle, still driving towards the threshold of runway 30 in opposite direction, however noticed lights moving ahead and sped off to the right beyond the edge of the runway onto the shoulder and stopped about 8 seconds later, the aircraft at that point was 287 meters from the vehicle and passed the vehicle about 4 seconds later at a speed of about 120 knots, the horizontal distance between the tip of the left wing and the vehicle reduced to 10 meters.
After the aircraft rotated and contacted departure the crew compained "Ehh, there was a Panda at the left edge of the runway".
The investigation released two safety recommendations arguing that even if the controller is operating entirely alone this does not absolve him from operating the runway occupation indications as required by procedures in order to ensure, that a sudden replacement can immediately recognize the present scenario.
fonte: avherald.com
