Incident Description
On 19 June 2016, a towing operation involving a De Havilland Canada Dash 8 (400) aircraft at Warsaw Chopin Airport (EPWA) resulted in an unauthorized runway incursion. After completing an engine test, the towing team—comprising a tug driver and two mechanics—received instructions from air traffic control to proceed to taxiway D4 via taxiway C and hold short of runway 11. The tug driver failed to comply with the instructions and did not stop before the holding line at the edge of runway 11, causing the aircraft to enter the runway without authorization. This created a conflict with a departing aircraft on runway 29, leading to a temporary halt of departures. The tug driver subsequently received new instructions to tow the aircraft to the hangar.
Cause
The accident investigation determined the cause to be human error: the tug driver failed to follow the air traffic controller's instructions and commands, which led to a dangerous situation.
Preventive Measures
In response to the incident, several preventive measures were implemented:
- The tug driver's authorization to operate vehicles in the maneuvering area was revoked, and he received a reprimand along with relevant training.
- Incident materials were provided to the Technical Personnel Training Section for use in human factors and aircraft type training.
- Materials were cascaded to area managers to inform maintenance staff.
- Supervisory and management personnel were instructed to monitor and prevent such irregularities; before each towing operation, the shift manager must brief the assigned towing team.
- Maintenance personnel were ordered to strictly adhere to airport operational procedures and manuals concerning aircraft towing.
- The tug driver underwent retraining at the airport operator's facility, including a course to regain authorization to drive in the maneuvering area, which he passed.
- The driver was referred for additional periodic medical examinations.
- Topics addressing such incidents were included in the periodic human factors training program.
- The incident was recorded in the technical maintenance organization's event database and will be included in safety performance indicators.
The investigation commission did not issue any safety recommendations.