What happened
On June 19, 2016, an incident occurred at Warsaw Chopin Airport (EPWA) involving a DE HAVILLAND CANADA, Dash 8 (400). Following the completion of an engine run-up, a towing team—consisting of a tractor driver and two mechanics—was instructed by Air Traffic Control (ATC) to taxi via taxiway D4 from taxiway C and wait before the holding point of runway 11.
During the maneuver, the tractor driver failed to follow the ATC instructions and did not stop at the designated holding line before the edge of runway 11. This unauthorized entry onto the runway created a potential collision risk with an aircraft that was departing from runway 29 at that time. As a result of the incursion, departures from runway 29 were temporarily suspended, and the driver was subsequently instructed to tow the aircraft to a hangar.
The investigation
The investigation, conducted by the maintenance organization, established that the driver failed to adhere to the specific instructions provided by the controller. During the inquiry, the driver attributed the error to fatigue, citing high ambient temperatures and the high volume of towing operations performed throughout the day.
Findings
- The primary cause of the incident was human error, specifically the failure of the towing driver to comply with ATC instructions.
- Environmental factors and workload, including heat-related fatigue and repetitive operations, contributed to the driver's failure to observe the holding line.