What happened
On 26 February 2019, an Airbus A300b4-622R(F), registration D-AEAD, was lined up at the threshold of runway 09R at London Heathrow Airport, having received clearance for takeoff. During the process, a maintenance vehicle entered the active runway, prompting air traffic control to immediately cancel the aircraft's departure clearance.
Two contractors were tasked with coning off several taxiways near the runway to prepare for overnight maintenance work. The work was to be supervised by a Senior Airfield Officer (SAO) driving an airport operations vehicle. Upon arrival at the work area, the SAO decided to park his vehicle to wait for a departing aircraft before proceeding. Crucially, the SAO had failed to activate the illuminated 'Follow Me' sign on his vehicle.
Unaware that the supervisor had stopped, the contractors continued with the task of placing cones and lights. When the supervisor's vehicle did not move to the next location, the contractors assumed they were permitted to proceed without direct supervision, as they had done previously. As they drove forward, they could not locate the expected Bolton barriers that would have marked the runway access point. This lack of visual landmarks caused the drivers to become disorientated, leading them to drive onto the active runway. The SAO attempted to chase the vehicle and alert the drivers using his horn, but the contractors did not notice him until they had already entered the runway area.
The investigation
The investigation examined the communication between the airport operations staff and the contractors, as well as the adequacy of airside driving training. It was noted that the contractors' driving permits did not require specific training regarding runway markings or lighting. Furthermore, while the contractors had been briefed on the work, the investigation highlighted that the driver's English proficiency may have impacted his comprehension of the safety documents.
The investigation also reviewed the airport's Airside Local Operating Procedures (ALOP). At the time of the incident, the procedures did not explicitly mandate that Bolton barriers be positioned before the commencement of coning-off work, though the supervisor had intended to do so.
Findings
- A lack of communication between the supervisor and the contractors led to conflicting expectations regarding the level of supervision required.
- The failure to activate the 'Follow Me' sign on the supervisor's vehicle contributed to the contractors' inability to track the supervisor's movements.
- The contractors became disorientated due to the absence of the expected physical barriers marking the runway entrance.
- Existing airside driving training for A Class permit holders did not sufficiently cover the recognition of runway entry points and associated safety markings.