What happened
On 29 December 2011, at 14:40 local time, a serious runway incursion occurred at Helsinki-Vantaa Airport. A SAAB 340A cargo aircraft, operating under the call sign NEF025, was taxiing toward the holding point for runway 22R. During the taxi, the crew of NEF025 contacted the approach controller rather than the tower controller responsible for the runway.
To prevent the aircraft from entering the active runway in front of an arriving plane, the tower controller activated the red stop bar. Shortly after, the crew of NEF025 established contact with the tower, at which point the controller provided information regarding an arriving aircraft. However, the crew of NEF025 proceeded to cross the illuminated stop bar and entered runway 22R without receiving a formal clearance.
Simultaneously, a Golden Air ATR72-212A aircraft, call sign BLF218, was on final approach to runway 22R with 67 passengers and 4 crew members on board. As the aircraft reached the final stage of its approach, the pilots observed that the runway was occupied. The controller subsequently issued a go-around instruction to BLF218 to avoid a collision.
The investigation
The investigation focused on the communication breakdown between the aircraft and air traffic control. Investigators examined the radio telephony logs, the functionality of the stop bar, and the cockpit procedures of the aircraft involved. The inquiry established that the crew of NEF025 misinterpreted the controller's traffic information as a clearance to enter the runway. The investigation also reviewed the controller's use of supplementary phraseology and the effectiveness of the stop bar as a visual warning.
Findings
- The primary cause of the incident was that the crew of NEF205 misinterpreted the traffic information provided by the controller, leading them to cross the illuminated stop bar and enter runway 22R without authorization.
- Inadequate multi-crew cooperation within the cockpit of NEF025 contributed to the error.
- The crew of NEF025 failed to correctly read back all instructions or failed to perform a readback entirely.
- The crew's ability to communicate and understand air traffic control instructions in English was limited.
- The controller used supplementary phraseology to provide traffic information that, in the eyes of the pilot, was interpreted as a clearance.
- The crew of NEF025 did not verify the status of the runway with air traffic control before proceeding.