What happened
In the early hours of September 5, 2013, a Cessna 510 Mustang, registration F-HDPN, was preparing for a medical evacuation flight from Lyon Saint-Exupéry Airport to Saint-Etienne Bouthéon. Due to ongoing construction work, the runway configuration was restricted. To reduce taxi time for the crew, the air traffic controller proposed using runway 36L, despite the runway being partially closed for works.
As the aircraft accelerated for takeoff, the pilot noticed an unlit construction vehicle positioned in the middle of the runway. The pilot performed an immediate rotation and a steep climb, narrowly passing approximately one meter above the obstacle. There were no injuries and no damage to the aircraft.
The investigation
The BEA investigation focused on why the aircraft was cleared to use a runway segment that was occupied by an obstacle. The investigation established that the controller activated the runway lighting without requesting the required runway inspection. Furthermore, the controller'-s radar display did not correctly reflect the closed status of the runway segment, and the construction vehicle's radar identification system was inactive to save battery life.
At the time of the event, the controller was working alone during the night shift, as the supervisor and a second controller had already begun their rest periods. The investigation also found that the safety study for the construction works had not been updated to account for the specific use of a mobile light trailer instead of fixed lighting, nor did it address the risks of nighttime operations with low traffic volumes.
Findings
- The primary cause was the failure to follow established procedures, which led the controller to authorize a takeoff on a closed runway occupied by an obstacle.
- The controller failed to notice an orange warning strip on the flight progress strip board that should have alerted them to the construction zone.
- The construction vehicle lacked omnidirectional lighting, making it invisible to the pilot during the takeoff roll.
- The radar surface display provided an erroneous representation of the runway status, failing to highlight the closed area.
- The safety impact study (EPIS) was outdated and did not specifically address the risks associated with nighttime operations or the use of unmapped mobile obstacles.
Safety action
- The BEA recommended that the DGAC ensure air traffic control staffing levels always comply with operational manuals.
- Recommendations were made to ensure all vehicles on active or potentially active runways are visually detectable and visible on radar screens.
- The BEA advised that safety management systems (SMS) must include loops to verify that all safety measures and instructions from risk reduction studies are strictly applied in practice.