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Old 16th Jan 2024, 14:24
  #1102 (permalink)  
ATC Watcher
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Join Date: May 1997
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Ok first , I still do not believe adding new Phraseology or new lights , rings and bells ( sorry African Skies , good idea but .... ) would help and most probably will create new problems , like for instance. just to take one, increasing the risk of cross transmissions.

Back to basics investigation techniques :
Here we have a Captain who apparently strongly believed he was clear to enter a runway and take off. The TWR R/T does not show this. Then it stayed for 40 seconds idle on the runway for unknown reasons. That is the cause .of the accident . This has to be investigated first , fortunately we have the Capt alive and , according the latest info, the 4 recorders have been recovered . so that will be done quite soon

Then we have the failure of the redundancies , the open holes in the cheese layers if you like that need investigation I see at least a few of them '
1- The stop bars being U/S. maintenance or braking down can happen need repairs, etc..They were NOTAMed, Action from investigators : Was the NOTAM available during the Dash briefing and was it read ? Not buried and missed among 10-15 pages of other stuff ?
2- the non standard R/T by both ATC and Dash . Did this " number 1 " meant the same thing to the Controller and to the pilot ?. Was something mentioned during the briefing , or in the Ground Frequency that could leave the Capt believing that the " Nr 1 " would mean he had full priority and implying line up and take off ? Maybe, for instance , something like " expect priority departure and an intersection take off to put you ahead of the normal Departures" ( in C1) was mentioned or" promised " ? How as the IFR pre departure clearance issued and how was it read back ? this is what needs to be looked into.
3 . The 40 seconds . why ? Wake turbulence separation ? Was there a preceding Heavy or Super departing ( guys here who FR24 fans can maybe answer that one already ) that was known to the Dash ?
4- the SM R alerts not seen . Looks like tat the SMR was working , the Dash incursion was detected and alarms were issued but not seen . why ? was the display located in an area not visible by the TWR LOC controller ( like in Vnukovo) was it lack of staff ?
5- Differences between military and civil procedures : (There always are ) Were there any that could have contributed ? If yes were all the actors here , ATC and Cost Guard pilots aware of them ? Training issues ?

Until all points are investigated we can talk about changing things .

My wild guess here , having followed tis thread since the beginning , is that the , rush to depart plus this " Nr 1 " and the 40 seconds idle are the keys. If that is the case , we do not need to change procedures but enforce existing ones. (i.e. training)
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