Four safety recommendations issued due to a serious incident at Helsinki-Vantaa airport on 28 October 2016

Published 29.6.2017  Updated 30.6.2017

A serious incident occurred at Helsinki-Vantaa airport on 28 October 2016. Air traffic control accidentally gave a taxiing passenger plane (FIN7PN) permission to cross an active runway for arrivals, on which another passenger plane (SAS1706) was landing at the same time. The cockpit crew noticed the mistake and did not start to cross the runway. The air traffic controller also quickly noticed the mistake and amended the erroneous clearance.

The Safety Investigation Authority, Finland (SIAF) has issued four safety recommendations in order to avoid serious incidents and accidents and to improve aviation safety:

Firstly, SIAF recommends that Finavia Corporation (Finavia) and Air Navigation Services Finland Oy (ANS Finland) perform a joint risk analysis on the crossing of an active runway in connection with parallel runway operations.

Finavia's safety management system – which has been approved by Trafi and meets the requirements of the European Aviation Safety Agency (EASA) – enables various types of risk analyses. In this instance, the purpose of the risk analysis would be to assess, from a safety viewpoint, the taxiing of aircraft across an active runway to operational parallel runways at Helsinki-Vantaa airport.

Secondly, SIAF recommends that Finavia and ANS Finland jointly acquire a technical alarm system. This could be technically linked to the various alarm systems currently used by the control tower (TWR) at Helsinki-Vantaa, enabling automatic alarms based on the movement of aircraft and vehicles. Due to the guidelines currently in force, such alarms are not in place. Such alarms could indicate, for example, a contradiction between the aircraft location data and the status of the illuminated stop bar.

Thirdly, SIAF recommends that ANS Finland ensures a sufficient supply of high-quality training about human factors (HF), as well as the HF competency of instructors providing refresher and further training for air traffic controllers.

As traffic volumes are growing and technical systems are becoming increasingly complex, human activity is playing an increasingly important role in aviation safety management. The investigation carried out by the Safety Investigation Authority revealed that the emphasis placed on human factor-related training has decreased over the last few years, despite the fact that the EU regulation that entered into force on 1 January 2017 requires HF training as part of the refresher training for air traffic controller licence holders. Such training could raise awareness of the contradictory nature of air traffic controllers’ work, such as performing their tasks as quickly and safely as possible.

Furthermore, SIAF recommends that ANS Finland, in cooperation with the company operating weather balloons, develops its operations in such a way that the stress placed on TWR by the launch of weather balloons can be reduced.

The company that launches weather balloons requests launch permission from the TWR via phone. The call is received either by the shift supervisor or another person working in air traffic control. Since the shift supervisor was not present, the air traffic controller at the tower answered three phone calls concerning weather balloons right before the serious incident. The purpose of this recommendation is to improve aviation safety by reducing factors that disrupt air traffic controllers’ work.

Further information: Head of Communication Sakari Lauriala, tel. +358 295 150 714 (Twitter: @SakariLauriala)

Twitter: @OTKES_SIAF
Facebook: @Onnettomuustutkintakeskus

CORRECTION TO PRESS RELEASE 30.6.2017: The first recommendation concerning a risk analysis has been focused directly on Finavia PLC and ANS Finland Ltd as it reads in an investigation report and summary. In 1st version 29.6.2017 of the press release the Finnish Transport Safety Agency was faultily dealt with in connection with the safety recommendation.