ASN Wikibase Occurrence # 316789
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Date: | Monday 21 February 2022 |
Time: | 13:12 UTC |
Type: | Dassault Falcon 2000EX |
Owner/operator: | NetJets Europe |
Registration: | CS-DFG |
MSN: | 044 |
Fatalities: | Fatalities: 0 / Occupants: 3 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | Sofia -
Bulgaria
|
Phase: | Take off |
Nature: | Ferry/positioning |
Departure airport: | Sofia-Vrazhdebna Airport (SOF/LBSF) |
Destination airport: | Stavanger-Sola Airport (SVG/ENZV) |
Investigating agency: | AAIU Bulgaria |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:The Falcon 2000EX aircraft, registration marks CS-DFG, operated by NetJets Europe was cleared for line up and take-off from runway 09 at Sofia Airport, Bulgaria.
Instead, the pilots began the take-off roll from taxiway 'H', which is parallel to runway 09. Then ATCO of Sofia Tower cancelled take-off clearance.
At a speed of 40 kts, the Runway Awareness Advisory System (RAAS) triggered the aural advisory message ‘On Taxiway, On Taxiway’. The aircraft reduced rolling speed and stopped before the intersection of taxiway C. After coordination with the flight crew, Sofia Tower ATCO issued instructions for a reverse turn and taxiing on taxiway H, line-up and take-off from runway 09.
Causes
Based on the analysis performed, the Commission points out that the serious incident resulted from the following cause:
The failure of the flight crew to positively identify that they were on the correct surface for take-off
Contributing factor:
- Ineffective crew coordination during the short taxi time from the parking stand to the line up of Runway 09, consisting in the lack of detailed briefing before taxiing and take-off by the PIC, lack of control by the co-pilot of the aircraft's movement on the aerodrome's manoeuvring area and erroneous change of the VHF radio frequency by the flight crew resulted in the inability to hear the ATCO's repeated warnings.
- Presence of an unusually taxiway "H" with dimensions larger than those of a normal taxiway parallel to runway (former Sofia Airport runway), located adjacent to and upstream of runway09;
- An early Issuance of the line up and take off clearance by the ATCO Tower to the flight crew before crossing Taxiway "H".
Sources:
AAI-2022-01
Accident investigation:
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| |
Investigating agency: | AAIU Bulgaria |
Report number: | |
Status: | Investigation completed |
Duration: | 1 year and 2 months |
Download report: | Final report |
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Revision history:
Date/time | Contributor | Updates |
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