What happened
On December 19, 2021, at approximately 11:08 local time, a runway incursion occurred at Da Nang International Airport involving flight VN1441. The aircraft, an ATR72-212A with registration VN-B218, was taxiing from its parking position toward Cần Thơ. During the taxi process, the aircraft entered runway 17L/35R.
This movement directly interfered with flight VJ651, an Airbus A321-211 (registration VN-A685), which was in the middle of its takeoff roll on runway 35R/17L. The crew of VJ651 was forced to execute an aborted takeoff. Simultaneously, flight VN128, which was on approach to runway 35R at a distance of 8NM, was required to perform a missed approach. There were no injuries to the passengers or crew, and no damage was reported to the aircraft involved.
The investigation
The Civil Aviation Authority of Vietnam (CAAV) classified the event as a high-risk safety incident (Level C). The investigation examined flight data recorder (DFDR) information from both VN-B2 and VN-A685, reviewed air traffic control (ATC) recordings, and analyzed airport signage and ground movement charts. Investigators also interviewed the flight crews and air traffic controllers involved.
Findings
- The crew of VN1441 failed to follow the taxi instructions provided by Ground Control (GCU) and inadvertently entered the active runway.
- The crew of VN1441 did not fully repeat the ATC instruction, omitting the specific "CAT I" holding point designation.
- The flight crew's workload increased significantly while attempting to locate the CAT I holding point, as this specific location was not clearly identified by name on the airport's ground movement charts.
- The pilot in command of VN1441 had not operated at Da Nang airport for a considerable period, with the pilot flying last having operated there in May 2020.
- The Ground Controller (GCU) failed to monitor the taxi progress of VN1441 closely enough to detect the deviation from the assigned route.
- The failure to adhere to taxi instructions by the VN1441 crew was the primary cause of the incursion.
- The absence of the supervisor (ATCC) from their station during the shift was noted as a contributing factor.
Safety action
- VASCO has been directed to provide additional training to the VN1441 crew regarding standard operating procedures (SOPs), taxi instruction compliance, and crew coordination.
- Air traffic control authorities are required to enhance monitoring of aircraft ground movements and ensure controllers provide clear, unambiguous instructions.
- Training for air traffic controllers will be conducted regarding incident reporting accuracy and the responsibilities of the supervisory controller.