What happened
On November 20, 2011, an Airbus A320, registration EI-DTJ, operating as Alitalia flight AZA1344 from Bologna to Catania, was cleared for takeoff from runway 30 at Bologna Borgo Panigale Airport. At the time of the takeoff roll, two airport service vehicles—a bird control car (BCU) and a runway inspection vehicle (Safety)—were operating on the runway.
While the BCU vehicle successfully vacated the runway via taxiway A, the Safety vehicle was traveling in the opposite direction of the departing aircraft. As the Airbus A30 accelerated, the Safety vehicle driver noticed the approaching aircraft's lights and performed an emergency maneuver, pulling onto the runway shoulder between taxiways E and F. The aircraft passed the stationary vehicle at approximately 120 knots, passing within roughly 10 meters of the vehicle's left wingtip. The flight crew later reported the presence of a vehicle on the left side of the runway to the tower after completing the takeoff.
The investigation
The ANSV investigation focused on the sequence of events leading to the runway occupancy. The investigation established that the Tower controller (TWR) had recently undergone a shift change. The outgoing controller had authorized the two vehicles to enter the runway but failed to activate the visual runway occupancy alert system (video speaker) and did not use the manual "RWY ENGAGED" strip to signal the occupied status.
During the handover, the outgoing controller informed the incoming controller that the only moving aircraft was the EI-DTJ taxiing toward holding point K2, omitting the fact that the two service vehicles were still active on the runway. The incoming controller, relying on the handover and a brief scan of the radar, issued the takeoff clearance for the Airbus A320 without realizing the runway was still occupied by ground traffic.
Findings
- The primary cause was the improper handover of information between the outgoing and incoming air traffic controllers, which omitted the presence of vehicles on the runway.
- The outgoing controller failed to utilize the visual warning systems (video speaker and runway engaged strips) to indicate the runway was occupied.
- The incoming controller did not independently verify the runway status, relying instead on the information provided during the shift change.
- A lack of shared situational awareness was exacerbated by the fact that the service vehicles were communicating on a different radio frequency (UHF) than the aircraft and tower (VHF), preventing the Safety vehicle from hearing the takeoff clearance and potentially alerting the tower to its presence.
Safety action
- The ANSV recommended that ENAC and ENAV SpA implement procedures to ensure that controller handovers include a shared understanding of operational strategies, rather than just a transfer of information.
- The agency recommended that airport ground vehicles be equipped with radios capable of operating on the same VHF frequencies used by the Tower and AFIS to ensure all actors in the maneuvering area can communicate and maintain shared situational awareness.