What happened
On 19 July 2020, at 20:51 UTC, a Boeing 737-800, registration EI-EFJ, operated by Ryanair, was cleared for takeoff from runway 24R at Palma de Mallorca Airport. At the time of the clearance, an airport lighting maintenance vehicle, identified as ‘Balizamiento 3’, was positioned on the same runway.
The vehicle had been cleared by the ground movement controller to perform maintenance work. During the sequence, the vehicle driver contacted the local controller to report his position at holding point H5, but mistakenly requested permission to enter the south runway. The local controller approved this request. The driver then requested to cross illuminated stop bars, and the controller instructed the vehicle to proceed.
When the Boeing 737-800 established contact on the local frequency and reported readiness for departure, the controller cleared the aircraft for takeoff. Upon hearing the takeoff clearance, the driver of the maintenance vehicle realized the conflict and notified the tower of his presence. The controller immediately instructed the aircraft to abort the takeoff, and the crew successfully stopped the aircraft shortly after the takeoff run had commenced. The minimum distance between the aircraft and the vehicle was recorded at 1.6 NM. There were no injuries to the 151 persons on board or the vehicle driver, and no damage was sustained by the aircraft.
The investigation
나The CIAIAC investigation examined the communications between the ground movement controller, the local controller, the aircraft crew, and the vehicle driver. The investigation focused on the sequence of instructions regarding the maintenance vehicle's entry onto the runway and the controller's failure to verify the vehicle's actual position. The investigators also reviewed the use of standard phraseology and the adherence to the airport's Operating Manual and Spanish Air Traffic Regulations.
Findings
- The local controller failed to detect a spatial error in the vehicle driver's communication, where the driver requested access to a runway that was not accessible from his actual position at H5.
- The local controller failed to perform visual scanning or utilize the surface movement radar (A-SMGCS) to verify the position of the maintenance vehicle.
- The controller authorized the vehicle to cross illuminated stop bars without any operational justification.
- The controller used incorrect phraseology when notifying the aircraft of the incursion and when canceling the takeoff clearance.
- The vehicle driver used non-standard phraseology by failing to use the proper runway designator.
Safety action
- REC 20/21: It is recommended that ENAIRE reinforce training for tower controllers regarding visual observation and the use of surface radar at Palma de Mallorca Airport.
- REC 21/21: It is recommended that AENA reinforce training for airside drivers regarding the use of standard phraseology for communications at Palma de Mallorca Airport.