Executive summary
On 29 May 2007, a Saab SF340A aircraft that was holding on an angled taxiway at Auckland International Airport was inadvertently cleared to line up in front of a landing Raytheon 1900D. The aerodrome controller transmitted an amended clearance, but the transmission crossed with that of the Saab crew reading back the line-up clearance. The pilots of both aircraft took action to avoid a collision and stopped on the runway without any damage or injury.
Contributory factors were the local procedure for the handling of flight progress strips for departing traffic; the use of multiple taxiways, including angled taxiways, for runway entry; and the captain of the aircraft entering the runway not seeing the landing traffic.
On 1 August 2007, the crew of a Raytheon 1900D aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Raytheon 1900D aircraft that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.
Contributory factors were the non-adherence to standard procedures for radiotelephony (RTF) use and the issue of an air traffic clearance, the use of an angled taxiway for runway entry, and the captain of the aircraft entering the runway not seeing the aircraft already lined up on the runway.
The Civil Aviation Authority of New Zealand (CAA) had not previously assessed the nature and scale of the runway incursion problem in New Zealand and had not defined “runway incursion”, and aerodrome and airspace incidents that were probably runway incursions had not been recorded or investigated in a consistent manner.
The restricted vision from the cockpit of some aircraft types when holding on an angled taxiway drew attention to the procedures for the issue and acceptance of conditional clearances for runway entry.
Related Recommendations
Require Airways New Zealand to enhance its procedure for handling flight progress strips with the aim of increasing the time given to aerodrome controllers to assimilate the details of departing traffic.
Encourage operators of aerodromes to apply suitable technological measures to complement procedural defences against runway incursions.
Require Airways New Zealand to improve its method of promulgation to controllers of safety-related information and to demonstrate that the content was understood and applied by controllers.
Require operators of aerodromes where an air traffic service is provided and that have more than one taxiway available for entry to any runway to prescribe the procedures and conditions, including the environmental conditions, under which multiple taxiways may be used to enter the runway.
Investigate, in conjunction with Airways New Zealand, whether aerodrome controllers, before issuing a conditional clearance, should obtain confirmation from the pilot concerned that the subject traffic has been positively identified.
Adopt the ICAO definition of runway incursion and the ICAO Runway Incursion Severity Classification model, use a consistent process to investigate runway incursions and ensure that other involved parties are promptly advised of an incursion notified by any one of them, and calculate annual runway incursion rates for certified aerodromes.
Remind pilots that a conditional clearance cannot be accepted unless the conflicting traffic that is the subject of the clearance has been positively identified.
Remind pilots that an active listen-out and lookout are critical requirements around the runway environment.
Remind pilots and air traffic controllers to comply strictly with the rules for phonetic pronunciation, particularly of numerals, and to seek immediate clarification of any clearance or read-back affected by a crossed transmission.
Require operators of aerodromes that have taxiways joining a runway at an oblique angle to prescribe the procedures and conditions, including the environmenatal conditions, under which the taxiways may be used to enter the runway.