Aviation Accident Summaries

Aviation Accident Summary OPS07IA010

Washington, DC, USA

Aircraft #1

N66NJ

Learjet 35

Analysis

On September 12, 2007, 3:13 am, a runway incursion occurred at Dulles International Airport involving N66NJ, a Learjet 35, and CV11, an airport vehicle during night visual meteorological conditions. At 2:56 am, runway 19R was closed for surveying and the runway lights were off. ATIS information G advertised the closure and an X was placed on the tower's ASDE display to confirm the closure. The closure was also displayed on the IDS 5 status display although not included in the Tower's Daily Log. A survey crew was working at the south end of runway 19R. There were weighted cones about 2000 feet from the south end of the runway. The crew got in their truck and started driving northbound on runway 19R to get something. As they approached the north end of the runway, the controller cleared the N66NJ into position and hold (prohibited with only one controller in the tower), then cleared it for takeoff. The survey crew in the truck heard the clearance and advised the controller that they were still on the runway. Instead of canceling the takeoff clearance, the tower controller asked the survey crew if they could clear the runway. The survey crew drove off into the grass around taxiway Y1 and reported clear as the Lear is heard to roar by in the background. AMASS data has been requested but the FAA estimated the airplane missed colliding with the vehicle by about 600 feet. The departure controller at Potomac TRACON noticed the departure off runway 19R and asked the tower controller if the runway was open, and was told "no." There were two controllers assigned to the shift. At the time of the incident, one controller was working all positions in the tower cab and was responsible for 1 aircraft. The second controller was on break.

Factual Information

On September 12, 2007, at 0312 Eastern daylight time, a runway incursion occurred when N66NJ, a LJ35, departed on a closed unlit runway at Washington Dulles International Airport (IAD), Chantilly, Virginia. At 2256 on September 11, runway 19R was closed for survey work and unlighted construction cones had been placed the departure end of runway 19R (approach end of runway 1L). The incident occurred during night visual meteorological conditions. The flight was operating as a Part 135 flight. N66NJ landed on runway 1R at 0104 EDT on an instrument flight rules (IFR) flight from Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida as a lifeguard flight to discharge a patient/passenger. While on the inbound taxi to Landmark Aviation Fixed Based Operator at 0105, the tower local controller issued N66NJ an IFR clearance for the return flight to FLL . At 0309, N66NJ called IAD tower for taxi, stated they had automatic terminal information service (ATIS) information G, and was instructed to taxi to runway 19R. ATIS information G was current from 0159 EDT to 0333 EDT and was broadcast as: "Washington Dulles International Airport Information Golf, 0552 Zulu (0152 EDT), wind 270 at 9, visibility 10, few clouds at 6000, temperature 21, dew point 21, altimeter 29.88. All arrival aircraft are expected to exit the runway as soon as practicable. Approach in use: ILS and visual approach to runway 1R, departing runway 30. NOTAMS: runway 1L closed. Taxiway K closed between taxiway D and taxiway J3, taxiway K2 closed, taxiway K3 closed, taxiway J between [taxiways] E and F restricted to wingspans of 118 feet or less. Bird activity in the vicinity of the airport. Attention all aircraft: Hazardous weather information for Dulles area is available from Flight Watch or Flight Service Station. Aircraft use caution for new runway construction west of airport. Advise on initial contact you have information golf." At 0312, N66NJ called Dulles tower and advised N66NJ was holding short of runway 19R ready for takeoff. The tower local controller directed N66NJ to taxi into position and hold on runway 19R to allow the local controller to coordinate with Potomac Terminal Radar Approach Control. At 0312:52, the IAD local controller cleared N66NJ for takeoff from runway 19R and 6 seconds later, directed N66NJ to contact departure control. According to the crew, the departure was uneventful. At 0313:10, CV11, a vehicle operator conducting survey work on runway 19R/1L, called the tower and advised that the vehicle was on runway 19R. The local controller asked CV11 if he could exit the runway and the vehicle operator responded that the vehicle was off the runway and the runway was clear. The local controller stated that he did not see CV11 on the runway and the pilots of N66NJ did not recall seeing a vehicle on the runway. Non-certified ASDE-X and airport video recording playback indicated CV11 was not on the runway at the same time as N66NJ. IAD tower was equipped with an airport movement area system (AMASS) used to monitor movement of aircraft and specially equipped vehicles on the airport. This visual aid is used by tower controllers to monitor and de-conflict airport surface movement of aircraft and vehicles while on the runway. The IAD AMASS system had been configured with an electronic "X" on runway 19R/1L to indicate the runway was closed. When the AMASS is configured that way, the alerting system designed to provide a warning to the controller of a departure on a closed runway, is no longer active. Accordingly, while the AMASS provided a visual indicator that runway 19R was closed, it did not provide an aural alert to the tower controller when N66NJ departed on the closed runway. Technical experts at the Federal Aviation Administration attempted to playback the AMASS recording but were unsuccessful because the AMASS recording had become corrupted. An improved Airport Surface Detection Equipment (ASDE-X) system was being installed at IAD at the time of this incident. The playback of the un-certified ASDE-X recording was correlated with video recordings provided by the Dulles Airport Authority and used to determine the actual location of N66NJ and CV11 . The controllers at IAD tower were required to use memory aids, such as a flight progress strip to remind controllers of a closed runway, in addition to the AMASS. According to the controllers working on the day of the incident, the flight progress strip memory aid indicating runway 19R/1L was closed was not in place. PERSONNEL INFORMATION N66NJ had a captain, first officer, and two crewmembers on board. N66NJ was on a 14 Code of Federal Regulations Part 135 repositioning flight from IAD to FLL at the time of the incident. During a telephone interview, the captain initially stated that N66NJ had departed runway 1, but after reconsidering, the captain stated that N66NJ departed runway 19R. The captain stated that he saw a white van with a yellow light on top and that it was stationary on the west side of the approach end of runway 19R, clear of the runway possibly on a pad, prior to takeoff. The captain stated that he believed the runway lights were illuminated. He also stated that when he landed at IAD two hours earlier, runway 19R was closed and that the runway closure had been on the ATIS at that time. The captain did not listen to ATIS for the departure flight, but relied on his copilot to complete that task. The captain stated he did not see any cones at the far end of the 11,500 foot runway and that takeoff roll was only about 3000 feet. The departure controller did not ask any questions about whether or not the runway had been closed and the flight to FLL was uneventful. The first officer stated that the flight was uneventful. The first officer stated that when the medevac crew returned to the aircraft, she obtained the departure clearance and listened to the ATIS broadcast, which was about 10 to 15 minutes prior to departure and the ATIS did not contain runway closure information. The first officer stated that she thought that they would depart from runway 1 but the flight was cleared to taxi to and hold short of runway 19R. She indicated that the taxi time was very short. According to the first officer, the crew completed the checklist, were cleared into position, and then cleared for takeoff. The first officer noticed that one controller was doing everything. The first officer stated that she noticed a vehicle off in the grass on the west side of the approach end of runway 19R. The first officer stated that there was a full moon and that the runway lights were low or glowed dimly. IAD TOWER PERSONNEL There were two controllers assigned to IAD tower between 2230 and 0630. Beginning at 0245, the local controller was working all positions in the tower combined and as well as the controller- in-charge. The second controller of the shift went on break at 0245 and was not in the tower cab at the time of the incident. The controller on duty at the time of the incident entered duty with the FAA in November 1982 and had worked at Dulles tower since July 1990. ADDITIONAL INFORMATION IAD ATCT was an ATC level 11, 24 hour, seven day a week facility with approximately 420,000 operations annually. The facility had three crews with 31 certified professional controllers (CPC), one CPC in training, six developmental controllers and five supervisors with a sixth supervisor in training. The new control tower at Dulles had been in operation since July 15, 2007 and was commissioned on September 12, 2007. IAD had two parallel runways, 1L/R and 19L/R, each 11,500 by 150 feet and runway 12/30 that was 10,501 by 150 feet.

Probable Cause and Findings

The probable cause of this incident was the IAD tower local controller's failure to ensure that the runway was free of all known ground vehicles, equipment, and personnel before permitting a departing aircraft to start takeoff roll. Additionally, the controller did not comply with local directives prohibiting taxi into position and hold operations while tower positions were combined.

 

Source: NTSB Aviation Accident Database

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