What happened
On 22 July 2009, a Boeing 737-8AS, registration EI-EBE, was cleared for takeoff from Runway 17 at Cork Airport. During the aircraft's takeoff roll, the pilot noticed an airport operations vehicle, identified as Police 1, moving across the intersecting runway. The vehicle, a white saloon car, was in the process of vacating Runway 17 to enter Runway 07. At the time the conflict was resolved, the aircraft and the vehicle were estimated to be approximately 700 meters apart. There were no injuries and no damage to the aircraft or the vehicle.
The investigation
The investigation examined the air traffic control (ATC) environment and the movements of various airport entities. At the time of the incident, the Air Movements Controller (AMC) was managing both Tower and Ground duties because the Surface Movements Controller (SMC) had stepped away for a relief break. The investigation found that while the AMC had performed a visual scan of the runway, the Police 1 vehicle was difficult to detect due to its low profile, white color, and the presence of rain on the tower windows and runway surface.
Furthermore, the investigation looked into the communication gap between the aircraft and the vehicle. The aircraft was communicating on the Tower frequency, while the vehicle was monitoring the Ground frequency. The investigation also reviewed the use of the flight progress board, specifically the removal of the 'Runway Occupied' strip.
Findings
- The primary cause of the incident was that takeoff clearance was issued to the Boeing 737-8AS while an operations vehicle was still occupying the runway at the intersection of Runway 17 and 25.
- The 'Runway Occupied' strip was removed from the flight progress board in error when a previous vehicle, Electrician 1, vacated the runway, even though the Police 1 vehicle was still present.
- The AMC's situational awareness was compromised by the increased workload of managing two controller positions simultaneously.
- The Police 1 vehicle was not easily visible due to the combination of wet weather, the vehicle's color, and physical obstructions like tower pillars.
- A lack of frequency synchronization meant the vehicle driver could not hear the takeoff clearance issued on the Tower frequency.