Created Tuesday, May 24th 2022 09:37Z, last updated Friday, Dec 30th 2022 16:01Z
A TAP Air Portugal Airbus A321-200N, registration CS-TJI performing flight
TP-1869 from Lisbon to Ponta Delgada (Portugal) with 180 passengers and 6 crew, was cleared to land on Ponta Delgada's runway 30 and was already in the flare when the pilot monitoring spotted a white van at the right hand side of the runway about 650 meters down the runway (just after the last fixed distance marker), the crew initiated a go around. Only after the aircraft initiated the go around tower advised of the vehicle on the runway. The aircraft climbed to 5000 feet, positioned for another approach and landed without further incident, the vehicle had sped off the runway after being overflown by the Airbus, about 15 minutes after the go around.
Portugal's GPIAA reported the estimated separation between aircraft and vehicle reduced to 280 meters/920 feet, the occurrence was rated a serious incident and is being investigated. Tower had cleared the maintenance vehicle, tasked to perform scheduled maintenance work on the glidepath transmitter of ILS runway 30, onto the runway about 30 minutes prior to the approach of the A21N.
While releasing the final report for another occurrence, see Incident: ASL Belgium B734 at Porto on Apr 27th 2021, cleared for takeoff despite vehicle on runway, the GPIAA annotated that the conclusions of that report are also valid for this occurrence:
- The provision of air traffic services with unified tower and approach positions, provided by a single controller without any supervision, working in continuous duty without interruptions for an extended period of time, in a tedious and low-activity environment.
- Archaic memory aid system, ineffective and totally dependent on human action to prevent simultaneous use of the runway by vehicles and aircraft.
- An inactive RIMCAS system.
- Decision process on the application/inhibition of technological tools, in particular the inhibition of RIMCAS, without a risk analysis supported by facts or mitigation measures to allow such inhibition.
- The absence of advanced ATC surveillance systems, including multilateration and electronic flight strips which can offer additional protection when compared with traditional, entirely human-dependent systems.
- The absence of H24 stop bars procedure or other equivalent lighting systems at all runway holding positions, as recommended by EAPPRI for ANSPs.
- Absence of objective criteria set by the organisation for the tactical management of teams by supervisors, based on risk assessment in order to ensure that the required level of safety is not compromised.
- ANSP deficient organisational culture, resulting in misrepresentation of the position logs not in line with reality.
- NAV Portugal’s failure to oversee and detect operational, managerial and safety shortcomings over the different Units, namely at Porto and Ponta Delgada towers.
- Deficiencies in NAV Portugal’s safety management system, just culture and its compliance with the requirements of Part-ATS were not identified by the regulator.
- Regulator’s shortfall in properly supervising the Runway Safety Committees at Porto and Ponta Delgada airports, ensuring effectiveness of their activities and compliance with Regulation 8/2018.
- The lack of a single frequency for all aircraft and vehicle movements in the manoeuvring area (as recommended by EAPPRI, and others) which would allow both flight crew and ground vehicle drivers to be aware of any possible threats to safety.
- Unreliability of the radio scanners which were installed by the infrastructure management in the Follow-Me vehicles at Porto airport, which were not user friendly and for which no formal training had been given to the drivers on how to operate them.
- The Follow-Me driver’s decision not to actively monitor the aeronautical frequency even though it was not a mandatory requirement.
- The non-standardised manner of conducting the runway inspections which, in this case, resulted in a prolonged period of TETRA radio silence.
Estimated positions of aircraft and van according to CCTV (Graphics: GPIAA):
