Airbus A330-341, PK-GPE

Investigation number

200303726

Occurrence date

24/08/2003

Location

Sydney, Aero.

State

New South Wales

Report release date

05/11/2004

Report status

Final

Investigation type

Occurrence Investigation

Investigation status

Completed

Aviation occurrence category

Loss of separation

Occurrence class

Incident

Highest injury level

None

Summary Analysis Significant Factors Safety Action

Sequence of events

On 24 August 2003, at about 0935 Eastern Standard Time, a motor vehicle involved in catering duties on the international apron area at Sydney airport entered runway 34 left (34L) at taxiway Golf without the driver having first received a clearance from air traffic control to enter the runway. At that time, an Airbus A330-341(Airbus) aircraft had just become airborne from runway 34L. The aircraft passed directly over the vehicle while it was on the runway. The runway incursion by the vehicle resulted in an infringement of runway separation standards.

The driver of the vehicle was authorised to drive only on the perimeter roads, airside roads and apron areas. The driver was not aware that she had entered the runway and was not authorised, or trained, to drive on taxiways or runways. The driver eventually realised that she had entered an area of the airport with which she was not familiar. She attempted to return to the apron and was subsequently escorted from the movement area by an airport operations officer.

Sydney Airport Corporation Limited (SACL)

SACL was the airport licence holder and operator of Sydney airport at the time of the occurrence. In accordance with the legislation current at the time of the occurrence, SACL was ultimately responsible for the proficiency of drivers operating airside at Sydney Airport.

Under the Airports (Control of On-Airports Activities) Regulations 1997, part 4, division 4, s124, the airport operator was required to publish an Airside Vehicle Control Handbook (AVCH) for the airport over which it had control. The Sydney airport AVCH contained particulars for the management and control of surface vehicles operating on, or in the vicinity of, the airside area of Sydney airport. The stated 'intent of the requirements for airside operation of vehicles set out in the AVCH [was] to ensure the safe and orderly movement of staff, passengers, aircraft and vehicular traffic'.

SACL was responsible for issuing an authority to drive airside (ADA) to a driver who had an employment requirement to operate a vehicle airside. That responsibility could be delegated to an 'Approved Issuing Authority' (AIA).

'An Approved Issuing Authority is a company or organisation to which SACL delegated the responsibility to carry out the training, testing, and issuance of an ADA for the Airport' and was generally delegated to those organisations that employed airside drivers. SACL maintained overall responsibility for the training and testing standards of Approved Issuing Authorities at Sydney airport. The AVCH stated that AIAs 'must:

Provide the SACL Manager Safety with reasonable access to its records and premises to enable the SACL Manager Safety to carry out audits to ensure that the AIA is maintaining satisfactory standards in the carrying out of its functions as an AIA; and
Train and test its employees and employees of its Subsidiaries to drive Airside to the standard required by the SACL Manager Safety'.

Training

Training for a category 2 ADA included information on the recognition of perimeter roadway markings, apron roadway markings, live taxiway crossing markings, runway and taxiway markings. It did not require the driver to be trained in the use of a radio. The catering vehicle was not equipped, nor was it required to be equipped, with a radio suitable for use on an airport to enable two-way communication with air traffic control.

The driver of the vehicle held a current category 2 ADA, having been trained about 2 years previously. A category 2 ADA authorised the driver of an authorised vehicle to operate the vehicle on perimeter roads, airside roads and apron areas of the airport in accordance with the AVCH.

The AVCH specified the prerequisites for applying for the category 2 ADA. They included a requirement for drivers to hold a current State or Territory driver's licence and complete at least 4 hours of driving airside either as an observer or preferably as the driver under the supervision of another driver with at least a category 2 ADA.

Drivers were also required to demonstrate 12 practical and theoretical competencies to an approved training officer.

Category 2 ADA training did not include recommended actions or guidelines for drivers should they become lost or disorientated while driving airside.

Driver reference materials

The airport operator, SACL, produced a pocketbook for use by drivers with a category 2 ADA, and another for use by drivers with either a category 3 or a category 4 ADA. Holders of a category 3 ADA were authorised to operate an authorised vehicle on all movement areas excluding runway strips. Holders of a Category 4 ADA were authorised to operate on all airside areas which included an authorisation to enter a runway strip in accordance with airport procedures. The pocketbooks were intended to be 'a quick reference guide to explain the main rules which apply to all drivers operating airside'. The driver involved in this runway incursion had been provided with a copy of the category 2 driver's pocketbook.

The Category 2 pocketbook did not include recommended actions or guidelines for drivers should they become lost or disorientated while driving airside.

Air traffic control (ATC)

Air Traffic Controllers provided an Air Traffic Service to aircraft on that part of the Sydney aerodrome used for take-off, landing and taxying, excluding the apron areas, for the purpose of preventing collisions between aircraft and obstructions. The aerodrome controller (ADC) was responsible for authorising aircraft, personnel and vehicles to cross a runway or to operate on a runway strip.

The Manual of Air Traffic Services required ADCs to visually scan the length of the runway prior to issuing a take-off clearance and immediately before the take-off is commenced to confirm that the runway was free from obstacles including vehicles and other aircraft. Vehicle operators and pilots were also required to obtain a clearance from ATC prior to entering an active runway, and air traffic controllers operating from the control tower maintained a routine visual surveillance of the manoeuvring area of the airport.

A review of the recorded radar data showed that, when the controller issued a clearance to the crew of the Airbus to enter the runway, the vehicle was in the vicinity of bay 59 on the international apron. That was approximately 2.78 km from the Airbus and approximately 0.83 km from the intersection of taxiway Golf and runway 34L. When the Airbus commenced its take-off roll, the vehicle was near the intersection of taxiway Golf and taxiway Yankee. That was approximately 2.77 km from the Airbus and 0.5 km from the intersection of taxiway Golf and runway 34L.

When the ADC issued the take-off clearance to the crew of the Airbus, the catering vehicle was a significant distance from both the Airbus and runway 34L. In the circumstances the ADC would have had no indication that the vehicle was likely to enter the runway and pose a potential collision threat to the Airbus.

There was little, if any, action that the ADC could have taken to resolve the situation when it became apparent to him that the vehicle would enter the runway because:

The catering vehicle was not radio equipped;
The Airbus crew was committed to the take-off, if not already airborne; and
Any alert provided to the crew of the Airbus by the ADC may have exacerbated the problem, given the relative position of the aircraft to the vehicle at that time.

While a runway incursion by a vehicle driven by the holder of a category 2 ADA may have been reasonably unforeseeable, this occurrence has identified a significant risk to the safety of operations at Sydney airport.

A means of detecting knowledge gaps and evaluating the ongoing proficiency of qualified drivers may have identified a knowledge deficiency in the area of taxiway and runway markings recognition and in other areas of knowledge that may have contributed to this incursion. Such quality assurance would enable SACL, as the authority responsible for the management and control of surface vehicles operating on, or in the vicinity of, the airside area of the airport, to recognise and address systemic deficiencies in driver competence on an ongoing basis. That would give SACL the opportunity to mitigate any resultant risks.

The driver of the catering vehicle was properly licensed, and had been driving on perimeter roads and apron areas of the airport for two years. Despite her training, the driver may not have been operationally familiar with taxiway and runway markings because she had not operated on runways or taxiways since she obtained her ADA.

None of the training programs included advice to drivers about recommended actions they could take that might assist them should they become lost or disorientated while driving airside. Such a procedure may have reduced the risk of a collision with the departing Airbus in these circumstances by:

reducing the likelihood of a runway incursion in the first instance; and
reducing the time the catering vehicle remained on the runway following the incursion.

Local safety action

Airservices Australia safety action

In the January issue of one of its newsletter to controllers, Airservices reminded controllers of the factors that contribute to runway incursions. Those factors included inadequate supervision of the manoeuvring areas of the airport, lack of adequate coordination between controllers in the tower, ambiguous clearances and instructions issued by controllers, incorrect read-back of clearances and instructions by pilots and vehicle drivers, and controllers not detecting the errors in those read-backs.

Airservices is investigating the International Civil Aviation Organization's concept of the Advanced Surface Movement Guidance and Control System for Sydney and other Australian airports. The concept includes consideration of improved surface movement radar, improved Aerodrome Mandatory Instruction Signs and Aerodrome Information Signs and the installation of stop-bar lighting. Stop bar lighting consists of a row of red unidirectional, in-pavement lights installed on the taxiway along the holding position marking the entrance to a runway. These initiatives could improve conflict detection for controllers, reduce the incidence of runway incursions and reduce the risk of a collision as a result of a runway incursion.

Overall, the system has the potential to improve the level of safety for operators at airports and improve controller situational awareness.

Sydney Airport Corporation Limited safety action

Since this occurrence, SACL has:

formulated an updated Letter of Agreement with Airservices on the exchange of safety information;
nominated single points of contact between SACL and Airservices to act as representatives for the distribution of safety related information;
established a Runway Incursion Working Group with participation from Airservices, Qantas, Regional Express, Virgin Blue, Jetstar and Eastern Australia Airlines (involvement from other parties will be sought as required);
audited all AIA's in accordance with the AVCH (October 2003, s6.4.1, p.46) and acted to ensure any recommendations made, as a result of those audits, were implemented;
developed and issued updated category 2 testing examinations to all ADA issuing authorities which include guidelines for use by Approved Issuing Authorities when conducting the written tests;
re-issued the category 2 airside driver's pocketbooks with advice to drivers to stop and wait for assistance if they become lost or disorientated while driving airside; and
established an Airside Driving Forum co-facilitated with the NSW WorkCover that includes various airside users.

ATSB safety action

As a result of the investigation the Australian Transport Safety Bureau issues the following recommendations:

Recommendation R20040059

The Australian Transport Safety Bureau recommends that Sydney Airport Corporation Limited review the procedures used to ensure initial and ongoing driver competency and knowledge.

Recommendation R20040060

The Australian Transport Safety Bureau recommends Sydney Airport Corporation Limited ensures that Approved Issuing Authorities' driver training programs at Sydney Airport include a course of action that drivers can take should they find themselves lost or disorientated while driving airside.

¹ Civil Aviation Regulation 89 defined the Airport operator as 'in relation to a licensed aerodrome-the licence holder'.
² In accordance with the Airports Act 1996, s172, Airports (Control of On-Airports Activities) Regulations 1997.
³ Airside Vehicle Control Handbook, June 2003, p1.
⁴ Airside Vehicle Control Handbook, Sydney Airport, June 2003, p. 42.
⁵ Airside Vehicle Control Handbook, Sydney Airport, June 2003, p. 44.
⁶ A 'Runway Strip' is 'a defined area, including the runway (and stopway if provided), intended both to reduce the risk of damage to aircraft running off a runway and to protect aircraft flying over it during take-off, or landing operations. (ICAO) (Manual of Air Traffic Services effective 15 April 2004, Pt. 10, s.1, p. 10-18).
⁷ Drivers Pocketbook, Category 2, May 2002, p3.

Aircraft Details

Manufacturer

Airbus

Model

A330

Registration

PK-GPE

Operation type

Air Transport High Capacity

Sector

Jet

Departure point

Sydney, NSW

Destination

Denpasar, Indonesia

Damage

Nil