C3/2010L Serious incident at Rovaniemi aerodrome on 10 February 2010 involving a transport aircraft and an airport maintenance vehicle

A serious incident occurred on the runway of Rovaniemi aerodrome on Wednesday, 10 February 2010 at 16.19. A Finnish Air Force Learjet 35A/S took off from runway 21 while an airport maintenance vehicle was clearing the other end of the runway. On 18 February 2010 Accident Investigation Board Finland appointed investigation commission C3/2010L for this incident. Investigator Ari Huhtala was named Investigator-in-Charge, accompanied by Investigator Pekka Orava serving as member of the commission. Ms. Anna-Maria Teperi, Licentiate of Psychology, was invited to serve as a Human Factors expert to the commission.

Maintenance vehicle HARJA 3 (radio call sign) had turned onto the far end of runway 03 and was driving towards aircraft M21 (radio call sign) which was taking off from the opposite direction. Realising the erroneously issued takeoff clearance to M21, the tower controller immediately ordered HARJA 3 to veer to the left. Due to the undulating profile of the runway at Rovaniemi, the aircrew of M21 did not detect HARJA 3 at the end of the runway and only learned of the occurrence and its gravity after having landed in Jyväskylä. HARJA 3 was still in the process of vacating the runway onto taxiway L when M21 became airborne. At that time it was estimated that the horizontal distance between HARJA 3 and M21 was at least 500 metres and when M21 passed over HARJA 3 it was at approximately 100 m altitude.

The serious incident was caused by the inadvertent takeoff clearance to the aircraft without first ensuring the runway was clear. Contributing factors included the air traffic controller’s limited experience and the fact that the controller was working alone. In addition, due to busy helicopter operations, there was more air traffic than normal. Meteorological conditions at the time of the occurrence did not impair visibility from the tower to the runway.

The investigation commission issued five safety recommendations. Firstly, considering the air traffic controller’s limited work experience, the commission recommends that Finavia Oyj review the air traffic controllers’ rating requirements. Secondly, the commission recommends that Finavia Oyj resolutely push the development and introduction of an electronic positioning system for ground vehicles, including an ancillary warning system in the control tower. Thirdly, the commission recommends that Finavia Oyj, in its own training and in the aerodromes’ internal training activities, emphasise to the maintenance personnel the significance of certain key English language-phrases used in aviation radiocommunications. Finally, the commission recommends that Finavia Oyj supplement its ground radiocommunications guidelines so as to draw up emergency instructions for air traffic control and aerodrome maintenance.

C3/2010L Report (pdf, 0.87 Mt)