ASN Wikibase Occurrence # 261785
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| Date: | Tuesday 27 April 2021 |
| Time: | 20:48 UTC |
| Type: |  Boeing 737-476 (SF) |
| Owner/operator: | ASL Airlines Belgium |
| Registration: | OE-IAJ |
| MSN: | 24440/2324 |
| Year of manufacture: | 1992 |
| Fatalities: | Fatalities: 0 / Occupants: 2 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Porto-Francisco Sá Carneiro Airport (OPO/LPPR) -
 Portugal
|
| Phase: | Take off |
| Nature: | Cargo |
| Departure airport: | Porto-Francisco Sá Carneiro Airport (OPO/LPPR) |
| Liège Airport (LGG/EBLG) | |
| Investigating agency: | GPIAAF |
| Confidence Rating: |  Accident investigation report completed and information captured |
ASL Airlines Belgium flight 4959, a Boeing 737-476(SF), was involved in a runway incursion incident when a follow me-vehicle was still on the active runway at Porto Airport during takeoff of the 737.
The controller gave permission to flight 4959 to take-off on runway 35 from intersection D. At that moment, the follow-me vehicle was still on the runway at the threshold of runway 17, heading south.
The operator of the follow-me noticed some strong lights on the runway centerline, in the area of taxiways C and D, lights that seemed to be in motion, and for that reason contacted the tower via radio, questioning if there were any aircraft lining-up on the runway. The controller confirmed an aircraft was rolling to take-off and requested the follow-me to immediate exit to the left edge of the runway. From the follow-me operator’s viewpoint and preliminary analysis of ground radar data, the distance between the aircraft and the vehicle was estimated at around 300 meters.
According to the description by the crew of flight 4959, after being authorised to take-off, they noticed white lights on the runway which, considering the night environment, became confused with the side runway lights. While during the climb, the crew questioned the controller about the vehicle on the runway and what happened, where the controller reported that it was a misunderstanding.
Probable cause:
The investigation determined as probable cause for the serious incident air traffic control’s issuance of a take-off clearance to the Boeing 737 despite having earlier authorised a Follow-Me vehicle onto the runway to perform a runway inspection.
Contributing factors:
• The provision of air traffic services with unified tower and approach positions, provided by a single controller without any supervision, working in continuous duty without interruptions for an extended
period of time, in a tedious and low-activity environment.
• Archaic memory aid system, ineffective and totally dependent on human action to prevent simultaneous use of the runway by vehicles and aircraft.
• An inactive RIMCAS system.
• Decision process on the application/inhibition of technological tools, in particular the inhibition of RIMCAS, without a risk analysis supported by facts or mitigation measures to allow such inhibition.
• The absence of advanced ATC surveillance systems, including multilateration and electronic flight strips which can offer additional protection when compared with traditional, entirely human-dependent systems.
• The absence of H24 stop bars procedure or other equivalent lighting systems at all runway holding positions, as recommended by EAPPRI for ANSPs.
• Absence of objective criteria set by the organisation for the tactical management of teams by supervisors, based on risk assessment in order to ensure that the required level of safety is not compromised.
• ANSP deficient organisational culture, resulting in misrepresentation of the position logs not in line with reality.
• NAV Portugal’s failure to oversee and detect operational, managerial and safety shortcomings over the different Units, namely at Porto and Ponta Delgada towers.
• Deficiencies in NAV Portugal’s safety management system, just culture and its compliance with the requirements of Part-ATS were not identified by the regulator.
• Regulator’s shortfall in properly supervising the Runway Safety Committees at Porto and Ponta Delgada airports, ensuring effectiveness of their activities and compliance with Regulation 8/2018.
• The lack of a single frequency for all aircraft and vehicle movements in the manoeuvring area (as recommended by EAPPRI, and others) which would allow both flight crew and ground vehicle drivers to be aware of any possible threats to safety.
• Unreliability of the radio scanners which were installed by the infrastructure management in the Follow-Me vehicles at Porto airport, which were not user friendly and for which no formal training had been given to the drivers on how to operate them.
• The Follow-Me driver’s decision not to actively monitor the aeronautical frequency even though it was not a mandatory requirement.
• The non-standardised manner of conducting the runway inspections which, in this case, resulted in a prolonged period of TETRA radio silence.
Accident investigation:
 |
|
Sources:
http://www.gpiaa.gov.pt/wwwbase/wwwinclude/ficheiro.aspx?tipo=0&id=10761&ambiente=WebSiteMenu
https://www.flightradar24.com/data/aircraft/oe-iaj#2789de5f
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 17-May-2021 17:42 | harro | Added |
| 17-May-2021 17:43 | harro | Updated [Location, Source] |
Corrections or additions? ... Edit this accident description
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