Primary finding
Probable cause
The local controller failing to follow established facility directives and issuing a clearance for takeoff from a runway not under his control.
Investigator assessment
Analysis narrative
The runway incursion sequence began when the air traffic control (ATC) local controller (LC) cleared (ENY3660) for takeoff from an inactive runway that had been NOTAM’d closed for arrivals to accommodate airfield mowing in the underrun. Interviews with controllers after the incident revealed SGF runway 14 had been NOTAM’d closed by SGF Airport Operations for arrivals but was available for departures. There were mowers in the underrun of runway 14 in the runway safety area (RSA) that prohibited an overflight by landing air traffic. The NOTAM was published and available to aircrew and air traffic control via the FAA website and covered the period from 1230 UTC to 2100 UTC. Because runway 14/32 was closed to landing traffic, SGF standard operating procedures permitted the transfer of control for the runway to the ground controller (GC) position to use for runway crossings without the need for coordination with LC. Because GC now had operational control of the runway, the LC was required to request the use of the closed runway from the GC prior to issuing any clearances for takeoff. The pilot of ENY3660 requested to use runway 14 for a departure, and the GC approved the request and issued taxi instructions to runway 14. While the airplane was taxiing to runway 14, VAN7 requested to cross runway 14 while GC maintained operational control of the runway. Because GC had control of the runway, there was no requirement to coordinate the closed runway vehicle crossing with LC. When the pilot of ENY3660 called the LC ready for takeoff from runway 14, the LC issued a takeoff clearance without coordinating with GC.
Source record
Factual narrative
On Wednesday June 27, 2018, about 1251 central daylight time (CDT), a runway incursion occurred at Springfield-Branson National Airport (SGF), Springfield, Missouri when an airport operations vehicle (VAN7) crossed runway 14 while an Embraer 145, N655AE, operated by Envoy Air as flight ENY3660, was on takeoff roll. Envoy Air 3660 was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 from SGF to Chicago O’Hare International Airport, Chicago, Illinois (ORD). There was no reported damage to the aircraft or operations vehicle, and no reported injuries. Visual meteorological conditions prevailed. History of Flight At 12:44:07, the crew of ENY3660 contacted GC and reported at the “gate with information delta ready to taxi”; the GC instructed the pilot to taxi to runway 20. Information “delta” indicated the crew was in receipt of the Automatic Terminal Information Service (ATIS). The pilot responded and asked if runway 14 was available. The GC advised the pilot it was available and instructed the pilot to taxi to runway 14 via taxiways “foxtrot whiskey”; the pilot read back the taxi instructions. At 12:50:14, the driver of VAN7 contacted GC and requested to proceed to the “firehouse”. The GC responded “VAN7 cross runway two zero at Charlie and proceed Uniform Echo”. The driver of VAN7 read back the instructions. At 12:50:37, the LC transmitted “Envoy 3660 fly runway heading, runway 14 cleared for takeoff”. At 12:50:43, the pilot of ENY3660 responded “cleared for takeoff runway 14 fly the runway heading Envoy 3660”. At 12:51:06, the GC instructed the driver of VAN7 to proceed across runway 14; the driver of VAN7 read back the clearance. At 12:51:21, an unidentified pilot transmitted on the LC frequency “truck, truck, truck” followed ten seconds later with “that was very close.” At 12:51:40, on the SGF LC frequency, an unidentified pilot stated “tower.” The LC responded by transmitting “ah Ozark Tech, correction Envoy 3660 contact departure ah…very sorry”. The pilot of ENY3660 responded “over to departure that was beyond ah…(unintelligible)”. There were no further transmissions between the LC and the pilot of ENY3660. At 14:33:18, the chief pilot from Envoy Airlines contacted Springfield Terminal Radar Approach Control (TRACON) on a recorded telephone line and spoke with the Operations Supervisor regarding the runway incursion. During the conversation, the chief pilot reported the pilot of ENY3660 had reported that as the aircraft was abeam taxiway U, the vehicle was off the runway surface but between the runway edge marking and the hold short lines on taxiway U and that there was no overflight. Airport and Video Data The SGF airport was not served by any ground-based radar system to assist ATC personnel with surveillance of movement areas or runways. A recording of voice communications with associated time stamp was obtained from FAA and airport operations video was obtained from City of Springfield airport. The SGF airport operations surveillance video was from a camera located on top of the control tower and captured the incident (see figure 1). The airport video showed VAN7 departing a hangar complex near taxiway N on the general aviation side of the airport and entering taxiway C. VAN7 held short of runway 20 at taxiway C for about 26 seconds and then proceeded across runway 20. After crossing runway 20, VAN7 turned left onto taxiway U. VAN7 then proceeded across runway 14. About 3 seconds after VAN7 crossed the southwest edge of runway 14, and still within the runway safety area (RSA), ENY3660 is seen on the video passing through the intersection of runway 14 and taxiway U. VAN7 continued down taxiway U and turned right onto taxiway E and to the KSGF fire station (see figure 2). The distance from the runway threshold of runway 14 to the intersection of taxiway U is about 5,900 feet. Figure 1 - Screen grab from video of runway incursion incident. Figure 2 - Airport diagram showing VAN7 route of travel and ENY3660 departure runway. Runway Incursion Device The RID is a device designed to assist controllers to prevent runway incursions. It is part of the Memory Aid Toolbox (MAT) available to air traffic controllers to assist with tracking the status of runways in use. RIDs are normally used when there is something occurring such as a vehicle on the runway, an airplane taxiing, or runway closure, that will preclude its use for normal aircraft operation. The RID is a piece of equipment that has 1 red push button associated with each runway on the airport. Each button has backlighting that flashes continuously 1/2 second on and 1/2 second off when activated. Depending on what runway(s) are occupied, the controller depresses the corresponding button on the RID to activate the system. The RID also has a speaker integrated into the system that broadcasts a user recorded aural “check runway” message when any button on the RID is activated and the controller’s push to transmit (PTT) button is depressed at the position associated with that individual RID. At SGF, the RID was installed at the local control and ground control positions. They are linked into the headset jack associated with each of those positions. The RIDs were interconnected and when one RID was activated, all the RIDs in the tower cab would flash in the same configuration. Only the RID that was activated would trigger an aural alert each time that position PTT was pressed. Figure 3 - Exemplar of the SGF Runway Incursion Device. Weather Data The runway incursion occurred at 1251 local. The SGF ATIS was current and advertising active runway 20 with wind at the time of the incident as 240 at 15 knots with gust to 22 knots, visibility 6 miles, and a few clouds at 6,000 feet. The 1152 SGF Meteorological Aerodrome Report (METAR) was wind 230 degrees at 14 knots, 10 statute miles visibility or greater, clear sky conditions, temperature 32° Celsius, dew point 22° degrees Celsius, altimeter 29.90 inHg (1026 hPa). METAR KSGF 271652Z 23014KT 10SM CLR 32/22 A2990 RMK AO2 LTG DSNT SE SLP108 T03220222= The 1252 SGF METAR was wind 250 degrees at 9 knots, 10 statute miles visibility or greater, clear sky conditions, temperature 33° Celsius, dew point 23° degrees Celsius, altimeter 29.91 inHg (1027 hPa). METAR KSGF 271752Z 25009KT 10SM CLR 33/23 A2991 RMK AO2 SLP112 T03280228 10333 20228 55003= Notice to Airman (NOTAM) A NOTAM is a notice containing information essential to personnel concerned with flight operations but not known far enough in advance to be publicized by other means. It states the abnormal status of a component of the National Airspace System (NAS) to include runway availability, not the normal status. NOTAM 06/083 was published and in effect from 1230 UTC to 2100 UTC, and closed runway 14/32 to landing traffic. Figure 4 - Screen capture of the NOTAM. Air Traffic Control Personnel Ground Controller (GC) The GC began working for the FAA as air traffic control specialist in October 1991, reporting directly to the FAA Training Facility in Oklahoma City, Oklahoma. After graduating the training facility, he reported to Kodiak Airport (ADQ) ATCT in Kodiak, Alaska. In September 1997, he reported to SGF where he has remained. He was qualified on all operating positions at SGF and was designated as a controller in charge (CIC). He held a current medical certificate with a restriction for corrective lens which he was wearing during the incident. The GC was current on all operating positions He held no other aeronautical licenses. Local Controller (LC) (Trainee) The LC in training began with the FAA in November 2017 reporting directly to the FAA Training Facility in Oklahoma City, Oklahoma. After graduating from the training facility, he reported to SGF. He was qualified on clearance delivery (CD) and GC and was trainin