Date:	Sunday 30 December 2007
Time:	11:27
Type:	Boeing 737-38J
Owner/operator:	Tarom
Registration:	YR-BGC
MSN:	27181/2662
Year of manufacture:	1994
Engine model:	CFMI CFM56-3C1
Fatalities:	Fatalities: 0 / Occupants: 123
Aircraft damage:	Substantial, written off
Category:	Accident
Location:	Bucharest-Otopeni International Airport (OTP) -   Romania
Phase:	Take off
Nature:	Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:	Bucharest-Otopeni International Airport (OTP/LROP)
Destination airport:	Sharm el Sheikh-Ophira Airport (SSH/HESH)
Investigating agency:	CIAS
Confidence Rating:	Accident investigation report completed and information captured

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.
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.

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

Filmul incidentului aviatic de pe Aeroportul Henri Coanda (TVR)
Raport preliminar: Cauza accidentului aviatic de duminica, coordonarea necorespunzatoare între turnul de control si echipa de interventie (Realitatea TV 1-1-2008)

photo (c) Harro Ranter; Amsterdam-Schiphol International Airport (AMS/EHAM); 16 July 2001; (CC:by-nc)

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