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OPS09IA004 · BE20

13 May 2009 · Camp Springs, MD, United States

BE20 · Incident: runway incursion (vehicle, aircraft or person) while taxiing

From Joint Base Andrews (ADW) to an unrecorded destination

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Event

NTSB case
OPS09IA004
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Incident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Military
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

BE20

Category
Airplane · from aircraft type
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
VM206
Operator
Unknown
Onboard fatalities
Unknown
Route
From Joint Base Andrews (ADW), Camp Springs, MDTo not recorded
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Armed Forces
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Taxi · into takeoff position
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Runway incursion (vehicle, aircraft or person)
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
None

Cause areas

  • Organizational issues › Management

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

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.

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record OPS09IA004
Event ID
20090518X01639
Case number
OPS09IA004
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status, cause areas, damage. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 4cd35853286e4b21f918e99ccb8ed2eb0ea598bd19ba17f45f2f3076e55c3ba9; retrieved 2026-09-15T11:03:46.956Z.