BE20 near Camp Springs, MD — 2009-05-13
- Date
- 2009-05-13
- Location
- Camp Springs, MD, USA
- Airport
- KADW
- Aircraft
- BE20
- Registration
- VM206
- Highest injury
- None
- Fatalities
- 0
- Phase of flight
- Takeoff roll
Probable cause
The failure of the ground controller to coordinate the runway crossings with the local controller and her failure to scan the runway prior to issuing the crossing instructions. Contributing to the incident was the combination of the front line manager/tower supervisor and the local control position, which prevented diligent oversight of the tower cab operations.
NTSB narrative
The Andrews Air Force Base (ADW), Camp Springs, Maryland, ground controller, who was working the ground control (GC), clearance delivery (CD), and flight data (FD) positions combined, authorized four vehicles to cross runway 19R without the local controller’s (LC's) approval while VM206, a BE-20, was departing runway 19R. At the time of the incursion, the LC was also the front line manager (FLM). VM206 was holding short of runway 19R at the midfield taxiway C waiting to back-taxi toward the approach end of the runway for departure. One of four vehicles was holding behind VM206 on taxiway C waiting to cross the runway from west to east, and three other vehicles were on taxiway S waiting to cross the departure end from east to west. After landing traffic cleared runway 19R, the LC/FLM cleared VM206 for takeoff from runway 19R at taxiway C, permitting the use of the full runway for takeoff. VM206 entered runway 19R at taxiway C, turned left and taxied approximately 500 feet toward the approach end of the runway, turned, and commenced the takeoff roll. As VM206 was turning and beginning its takeoff roll, the GC asked the LC, “am I crossing?”. The request was not made on a recorded landline as required by local air traffic control directives. The LC responded to the GC on the recorded land line, “You’re not crossing.” The GC then instructed the vehicles to cross the departure end of the runway. The vehicle operator who was holding behind VM206 again requested clearance to cross. The GC, performing tasks associated with CD, stated in her interview that she cleared the vehicle to cross runway 19R without visually scanning the runway. According to the controllers interviewed, the Airport Movement Area Safety System did not alarm. The LC noticed the vehicle cross the departure end and directed the GC to stop the vehicle. However, the vehicle was nearly across the runway by the time the GC instructed them to stop. The vehicle operator continued across the runway until clear of runway 19R. FAA Order 7110.65, “Air Traffic Control” states that the LC has primary responsibility for operations conducted on the active runway and must control the use of those runways. The GC is required to obtain approval from the local controller before authorizing an aircraft or a vehicle to cross or use any portion of an active runway and advise the local controller when the coordinated runway operation is complete.
Analysis
- Primary failure mode
- Human factors
- First missed decision gate
- Ground controller cleared vehicles to cross without local controller's approval.
NTSB coding
- Runway incursion veh/AC/person · Taxi-into takeoff position
Evidence available
- ATC audio
- 5 docket documents