What happened
On February 5, 2011, an Airbus A319-112, registration D-ABGQ, was involved in a serious runway incursion at Arlanda airport. After receiving push-back from stand 66, the crew requested taxi clearance. The air traffic controller provided a clearance that deviated from the published standard route, directing the aircraft to taxi via taxiway D rather than the standard route via taxiways UC and U.
As the aircraft proceeded, the crew intended to turn right onto taxiway Y. However, due to the specific path taken, the aircraft continued straight onto intersection Y3, which leads directly onto runway 01L/19R. At the moment the aircraft passed the Y3 intersection, another aircraft was already in the process of taking off on runway 19R. The takeoff aircraft observed the taxiing Airbus A319-112 approximately 500 meters ahead at a speed of 120 to 130 knots. The controller immediately ordered the taxiing aircraft to hold its position, narrowly avoiding a collision.
The investigation
The Swedish Accident Investigation Authority (SHK) examined the sequence of events, the airport's operational systems, and the physical state of the taxiway markings. The investigation focused on why the crew failed to recognize they were approaching an active runway and why the taxi clearance was non-standard. Investigators also reviewed the airport's Safety Management System (SMS) and the accuracy of the Aeronautical Information Publication (AIP) regarding ground markings.
Findings
Several contributing factors led to the incident:
- The taxi clearance provided by air traffic control did not follow the published standard route.
- The required holding position marking at intersection Y3 was missing.
- An outdated, no longer valid yellow daylight marking was still present near the Runway Guard Lights (RGL). The crew perceived this old line as the correct holding position for Y3.
- The taxi clearance deviation combined with the lack of proper markings at the intersection prevented the crew from identifying the runway entry.
- The pilots' taxiway charts, derived from the AIP, contained information that was inconsistent with the actual ground markings.
- The airport's SMS showed shortcomings, as the lack of updated markings at Y3 had not been reported as a deviation, and some maintenance work had been performed outside the standard work order system.
Safety action
The SHK issued recommendations to the Swedish Transport Agency to review the implementation and compliance of safety management systems at Swedish airports. Additionally, the agency was advised to perform a special review of materials in the AIP and to ensure that Arlanda airport implements recurrent quality controls for its visual navigation aids.