What happened
On June 19, 2016, a runway incursion occurred at Warsaw Chopin Airport (EPWA) during daylight hours under CAVOK weather conditions. While taxiing for departure, the pilot of a Cirrus SR2 overlap requested full runway length for takeoff from Runway 29. Air Traffic Control instructed the aircraft to enter Runway 29 via Taxiway E3.
During the maneuver, the aircraft entered Runway 29 via Taxiway N3. In doing so, the crew crossed an active stop bar (set to level 3) and failed to comply with both vertical and horizontal "NO ENTRY" markings. Following the incursion, the pilot reported a need to delay the takeoff, an action that may have impacted the crew's situational awareness at the intersection of Taxiway N3 and E3.
The investigation
The investigation focused on the crew's movement through the taxiway intersection and the communication protocols used by ground controllers. The investigation established that the crew members on board did not observe the stop bar or the "NO ENTRY" signs. Furthermore, an analysis of audio recordings revealed that the air traffic controller did not proactively report the runway incursion to relevant parties for preventative purposes.
Findings
- The primary cause of the incident was human error, specifically a loss of situational awareness and lack of orientation by the flight crew.
- The crew failed to notice the active stop bar and the specific runway entry restrictions.
- There was a failure in the communication chain, as the runway incursion was not reported by the controller immediately following the event.
Safety action
Following the investigation, several preventative measures were identified:
- Reminding controllers of their obligation to report runway incursions.
- Reviewing AIP entries regarding the prohibition of crossing active stop bars.
- Reconfiguring the taxiway access to the threshold of Runway 29 to address the double-entry issue.
- Implementing Advanced-Surface Movement Guidance and Control Systems (A-SMGCS).