What happened
On 8 September 2011, an AVRO 146-RJ85 operated by Brussels Airlines was performing a scheduled takeoff from runway 21 at Landvetter Airport. Simultaneously, a service vehicle, identified as RMS726, approached the edge of the runway. The vehicle driver had previously been instructed to wait but had moved to a different location via an alternative road.
As the aircraft was in its takeoff roll, air traffic controllers cleared two other service vehicles to enter the runway. Shortly thereafter, the driver of RMS726 began driving toward the runway. The driver noticed a light and heard a rumbling noise, prompting an immediate stop. At the moment the vehicle halted, it was positioned approximately 27 metres from the runway edge and 50 metres from the centerline. The aircraft completed its takeoff without the flight crew noticing the vehicle's proximity to the runway.
The investigation
SHK examined the coordination between air traffic controllers and the movement of ground vehicles. The investigation focused on the handover process between the departing trainee/instructor team and the relieving controller. Investigators looked into the use of radar, binoculars, and flight progress boards, noting that the ground radar had limitations in detecting vehicles not on asphalt surfaces. The investigation also reviewed the communication between the vehicle driver and the tower, as well as the impact of environmental factors like weather and nearby helicopter traffic on controller workload.
Findings
Several factors contributed to the runway incursion. During the shift handover, the trainee and instructor failed to correctly process the vehicle's reported position. Furthermore, the instructor provided the relieving controller with incorrect information, stating the vehicle was near a transformer substation rather than its actual location. This error was not questioned by the incoming controller.
Inaccurate information during the handover was a critical factor. The investigation also noted that non-operational, private conversations between controllers may have distracted the staff from monitoring the vehicle's position. Additionally, the driver of RMS726 had deviated from standard procedures by leaving a previous location without reporting the movement, which reduced the controllers' focus on that specific vehicle. The investigation also highlighted that the controllers' reliance on subconscious expectations—expecting the vehicle to be at a common landmark—likely hindered their situational awareness.
Safety action
SHK recommended that LFV establish clear guidelines regarding private conversations during operative work to support a "sterile concept" for air traffic controllers, similar to the sterile cockpit rule in aviation. The Swedish Transport Agency was also advised to take measures to ensure this sterile concept is implemented during critical operational phases.