Narrative: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.
|Date:||Sunday 30 December 2007|
|C/n / msn:|| 27181/2662|
|First flight:|| 1994-10-11 (13 years 3 months)|
|Engines:|| 2 CFMI CFM56-3C1|
|Crew:||Fatalities: 0 / Occupants: 6|
|Passengers:||Fatalities: 0 / Occupants: 117|
|Total:||Fatalities: 0 / Occupants: 123 |
|Airplane damage:|| Substantial|
|Airplane fate:|| Written off (damaged beyond repair)|
|Location:||Bucharest-Otopeni International Airport (OTP) ( Romania)
|Phase:|| Takeoff (TOF)|
|Nature:||Int'l Non Scheduled Passenger|
|Departure airport:||Bucharest-Otopeni International Airport (OTP/LROP), Romania|
|Destination airport:||Sharm el Sheikh-Ophira Airport (SSH/HESH), Egypt|
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.
Probable Cause:3. CONCLUSIONS
3.1. The accident occurred due to incorrect authorization of the turnover and aircraft takeoff ROT 3107 , without runway clearance.
3.2 . 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.
3.3. 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.
3.4 . Progressive evidence bands used were inconsistent with the procedures and regulations .
3.5 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
3.6 Previous findings highlight gaps in the training of CTA personnel and the full and correct knowledge of procedures.
3.7 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.
3.8 " 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.
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METAR Weather report:
09:00 UTC / 11:00 local time: LROP 300900Z VRB01MPS 0100 R08R/0250N R08L/0250V0375N FZFG VV000 M05/M05 Q1026 NOSIG 8819//95
10:00 UTC / 12:00 local time: LROP 301000Z VRB02MPS 0100 R08R/0325N R08L/0450V0650N FZFG VV000 M04/M04 Q1025 NOSIG 8819//95
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This map shows the airport of departure and the intended destination of the flight. The line between the airports does not
display the exact flight path.
Distance from Bucharest-Otopeni International Airport to Sharm el Sheikh-Ophira Airport as the crow flies is 1973 km (1233 miles).