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Significant Factors

Summary

  1. The ADC did not conduct an effective scan of runway 30 or the flight progress strip display prior to clearing the Pilatus to take off.
  2. The presentation of the yellow flight progress strip did not alert the ADC that a runway 12/30 blanket clearance was in place.
  3. The ADC did not hear the SMC issue a clearance for the crew of the B737 to cross runway 30, nor did the SMC hear the ADC issue a take-off clearance to the Pilatus.
  4. The ADC did not observe the B737 moving towards runway 30.
  5. The SMC was distracted from a surveillance role by other tasks.
  6. The absence of the Tower Coordinator reduced the potential for recognising the development of a safety occurrence.
 
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