What happened
On July 30, 2019, a P68 aircraft, registration F-GIEV, was conducting a flight for competency checks at Melun-Villaroche aerodrome. The flight, involving a pilot and an instructor, intended to perform approach exercises on runway 28.
At the time, maintenance work was underway on the runway 10/28 area, involving personnel and vehicles within the runway strips. To avoid the administrative burden of a NOTAM, the air traffic control organization decided to manage the runway closure "tactically," meaning the closure would be handled in real-time by the controller rather than through formal advance notice.
During the sequence of events, the controller was managing simultaneous traffic, including a helicopter approaching runway 19. While the crew of the P68 was on short final for runway 28, the controller authorized a touch-and-go maneuver. However, the aircraft actually landed on the runway while maintenance crews were still working in the adjacent areas. The pilot and instructor later stated they believed they had received landing clearance and did not notice the workers, though the instructor noted seeing vehicles nearby but assumed the controller would have warned them if there were a danger.
The investigation
The BEA investigation examined the communication protocols between the control organization and the air traffic controller. It was established that the decision to manage the runway closure "tactically" meant that no NOTAM was published, and no written instructions were provided to the controllers on duty. The controller had been informed of the works orally but had failed to place the required visual indicator (a red strip) on his workstation to signal that runway 10/28 was closed.
Furthermore, the investigation looked into the controller's situational awareness. Evidence suggested the controller was focused on managing the conflicting traffic between the helicopter and the P68, and was likely distracted by the use of a mobile phone shortly before the event.
Findings
- The primary cause of the incident was the unauthorized use of the runway by the aircraft while maintenance personnel and vehicles were present in the runway area.
- The decision to manage the runway closure without a NOTAM or written operational instructions led to a lack of shared situational awareness among the pilots, the controller, and the maintenance staff.
- The controller failed to realize the runway was unavailable due to the absence of a visual warning on his desk and a lack of formal written instructions.
- The controller's attention was likely compromised by distractions, specifically the use of a mobile phone.
- The simultaneous use of both intersecting runways increased the controller's workload and diverted attention from verifying the availability of runway 28.
Safety action
Following the incident, the local safety commission implemented several measures:
- Management will ensure that the duty log is completed prior to any maintenance work.
- Magnetic indicators for closed runways will be placed next to the wind indicator when only one runway is in service.
- Permanent instructions will be formalized to integrate these new working methods into the aerodrome's operating manual.