Safety investigation of a serious incident on 22 March 2018 at Kokkola-Pietarsaari Airport completed – a business aircraft landed on a runway occupied by three runway maintenance vehicles.

Published 21.1.2019

The Safety Investigation Authority, Finland has completed a safety investigation on a serious incident which occurred on 22 March 2018 at Kokkola-Pietarsaari Airport. A close call took place when a Swedish Jonair AB’s Piper PA-31-350 landed on a runway which was simultaneously occupied by three runway maintenance vehicles: two brush blower vehicles and a runway friction measuring vehicle. The occurrence did not result in any injuries to persons or damage to material.

The Safety Investigation Authority issues three safety recommendations to improve safety and to prevent similar occurrences and damage.

The Safety Investigation Authority recommends that Air Navigation Services Finland ensure sufficient scope and content of local recurrent training for air traffic controllers at each aerodrome regarding special situations. The air traffic controller had little experience in coordinating runway winter maintenance and air traffic. Sufficient training in realistic circumstances is needed in order to reach a satisfactory level of competence for special situations such as coordinating runway winter maintenance and air traffic in challenging weather conditions. The extent and quality of the air traffic controller’s work experience must be taken into consideration when the scope of the training is being decided.

- This case is already the fourth safety investigation in a little more than a year of aviation incidents associated with runway winter maintenance. It is essential that the coordination of runway winter maintenance and air traffic progress seamlessly and in a timely manner at all Finnish airports, says Adjunct Professor Veli-Pekka Nurmi, Executive Director of the Safety Investigation Authority.

Second, the Safety Investigation Authority recommends that Air Navigation Services Finland and Finavia also update the communication and air traffic services/management systems at airports where there is little traffic so as to meet modern requirements. Ground control transmissions on the ATC loudspeakers were simultaneously heard on the aviation frequency which distracted the radiocommunication between the pilots and the air traffic controller. Furthermore, the ATC radio equipment was old. The radiocommunication systems equipment at Kokkola-Pietarsaari Airport was manufactured in 1982 by the then Finnish Civil Aviation Administration’s communications repair shop. Furthermore, the air traffic controller could not, with their existing system, monitor the position of the aircraft during the final stages of its approach. The materialisation of safety in air traffic services requires appropriately functioning communication equipment and flight monitoring systems.

- When it comes to the modernity, performance and condition of Kokkola-Pietarsaari’s communication and flight monitoring equipment, they must be upgraded to the technical level of 2019 as soon as possible. It is unacceptable to permit less busy airports to operate with 1980s radio equipment and with antiquated and partly inadequate technology. Regarding these matters, there is zero tolerance for compromise in aviation safety, sums up Veli-Pekka Nurmi.

In addition, the Safety Investigation Authority recommends that the Swedish Transport Agency (Transportstyrelsen) ensure that crew resource management and the radiocommunication of the operators they supervise as well as the operators’ training comply with the Agency approved training programmes. Proper crew coordination, radiocommunication and training are part and parcel of safe air traffic culture.

The flight crew did not clearly enough describe the effects of the icing on the airplane’s performance and so the air traffic controller was unaware of the severity of the icing. The captain felt that it was necessary for them to land because of the severity of the icing and the business aircraft landed without a landing clearance.

- The flight crew must clearly express their intentions and the limitations that affect aircraft performance. In all situations they must make certain that they are cleared to land before they do so, emphasizes Chief Air Safety Investigator (deputy) Kalle Brusi

The investigation revealed that there were problems and irregularities both in crew communication as well as in the communication between the flight crew and the air traffic controllers. These contributed to the fact that they landed without a clearance.

More information: Adjunct Professor Veli-Pekka Nurmi, Executive Director of the Safety Investigation Authority, tel. +358 295 150 701.