What happened
On August 31, 2021, at approximately 14:35 UTC, a runway incursion occurred on runway 13L at El Dorado International Airport in Bogotá, Colombia. The incident involved a Cessna C208, registration HK3200G, operating under general aviation flight rules, and an ATR 75, registration HK5293.
During ground operations, the North Surface controller informed the crew of the Cessna C208 that they were number eight for departure and suggested they taxi to the Alfa 4 intersection to expedite their departure. While the crew acknowledged the instruction, they failed to correctly read back the specific holding instruction. Instead of stopping at the Alfa 4 taxiway holding point, the crew continued taxiing and entered the active runway.
Simultably, the controller authorized the ATR 75 to begin its takeoff roll from runway 13L. As the ATR 75 accelerated, the crew observed the Cessna C208 on the runway and immediately aborted the takeoff, coming to a stop approximately 400 meters down the runway. No injuries were reported among the occupants of either aircraft, and no damage was sustained.
The investigation
The GRIAA investigation examined several elements, including flight plans, ATC logs, controller reports, and pilot statements. Investigators also analyzed airport security camera footage and radio frequency recordings. The investigation focused on the communication between the North Surface controller and the aircraft, as well as the physical positioning of the ATC personnel.
Findings
- The primary cause of the incident was a loss of situational awareness by the crew of the Cessna C208, which led them to enter the runway without authorization.
- The crew failed to correctly read back the controller's instruction to hold at the Alfa 4 intersection, demonstrating a deviation from standardized aeronautical phraseology.
- The North Surface controller was unable to visually verify the unauthorized runway entry because their workstation was oriented toward the south runway.
- The controller was managing a high volume of traffic, as two different frequencies had been merged into a single workstation, increasing the workload.
- The aircraft operator lacked established Standard Operating Procedures (SOPs) for operations at El Dorado and had not implemented a Safety Management System (SMS).