Incident Overview

Date: Sunday 30 December 2007
Aircraft Type: Boeing 737-38J
Owner/operator: Tarom
Registration Number: YR-BGC
Location: Bucharest-Otopeni International Airport (OTP) – ÿ Romania
Phase of Flight: Take off
Status: Substantial, written off
Casualties: Fatalities: 0 / Occupants: 123
Component Affected: Boeing 737-300 aircraftBoeing 737-300 aircraft
Investigating Agency: CIASCIAS
Category: Accident
A Boeing 737-300 crashed at Bucharest-Otopeni International Airport (OTP) on runway 08R shortly before 11:00 AM, due to incorrect authorization for takeoff and runway clearance. The aircraft hit a car 600 meters past the threshold, causing significant damage and landing off the centerline. Investigation reveals a lack of coordination between the traffic control tower, CTA EXE TWR, and CTA GND/TAXI, leading to a failure to recognize the runway’s status and initiate immediate action. Insufficient training and oversight within the control tower, coupled with a shortage of personnel, exacerbated the situation. The incident highlights critical gaps in procedures and training, particularly concerning radio communication protocols and the application of LVO regulations.A Boeing 737-300 crashed at Bucharest-Otopeni International Airport (OTP) on runway 08R shortly before 11:00 AM, due to incorrect authorization for takeoff and runway clearance. The aircraft hit a car 600 meters past the threshold, causing significant damage and landing off the centerline. Investigation reveals a lack of coordination between the traffic control tower, CTA EXE TWR, and CTA GND/TAXI, leading to a failure to recognize the runway’s status and initiate immediate action. Insufficient training and oversight within the control tower, coupled with a shortage of personnel, exacerbated the situation. The incident highlights critical gaps in procedures and training, particularly concerning radio communication protocols and the application of LVO regulations.

Description

Just before 11:00 in the morning a team of maintenance workers entered runway 08R at Bucharest-Otopeni International Airport (OTP), Romania, to perform maintenance work on the runway center lights. The maintenance team consisted of four workers and two vehicles. Two of the men were working at about 600 meters from the threshold and the two other men were working at about 1500 meters from the threshold. Visibility at the time was poor due to thick fog. At 11:04 the runway was vacated by both vehicles due to landing traffic. At 11:06 they were recleared to enter the runway. At 11:25:13 flight ROT3107, a Boeing 737-300, was cleared to enter runway 08R for takeoff. The flight was cleared for takeoff at 11:26:07. Between 11:26:40 and 11:26:50 the control tower asked the maintenance workers if the runway was clear but got no reply. Accellerating for takeoff, at a speed of about 90 kts, the Boeing 737 hit a car 600 m past the runway threshold with the no. 1 engine and with the left landing gear. The aircraft ran off the left side of the runway and came to rest 137 meters left of the centerline and 950 meters from the threshold. CONCLUSIONS 1. The accident occurred due to incorrect authorization of the turnover and aircraft takeoff ROT 3107 , without runway clearance. 2 . Error to allow the taking off of ROT 3107 was possible because of disruption in the activity of CTA EXE TWR, misperceptions regarding the clearance status of the runway and cumulative lack of coordination between CTA EXE TWR and CTA GND/TAXI to release the track. 3. Provisions RCAST and LVO were incompletely applied by the traffic controllers involved . Team supervisor who was responsible for direct supervision of applying this procedure did not notice this fact and did not take corrective action. 4 . Progressive evidence bands used were inconsistent with the procedures and regulations . 5 When they realized that the track is not free, CTA EXE TWR and CTA GND / TAXI focused on calling on the radio frequency of beaconing team instead of initiating immediate cancellation of the takeoff by: – Transmission to crew aircraft “stop the takeoff”; – Stop & start the runway lights 6 Previous findings highlight gaps in the training of CTA personnel and the full and correct knowledge of procedures. 7 mismanagement of human resources at TWR OTP , which led to an insufficient number of CTA personnel present in the shift and absence of the supervisor from operating room at the time the accident occurred, given that accepted shift personnel number was 4. 8 ” Rules of movement of vehicles and people ,” “Rules of organizing and development of ground-to-ground radio communications system with multiple access” and “Low Visibility Procedures Operations (LVO)” were not strictly applied. They contain unrelated or unclear provisions that can be interpreted differently and make it difficult to apply them rigorously.

Primary Cause

Incorrect authorization of the turnover and aircraft takeoff ROT 3107, without runway clearance.Incorrect authorization of the turnover and aircraft takeoff ROT 3107, without runway clearance.

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