LATAM A320 ground collision at SPJC
From the AvHerald:
To me, it sounds like the airport and their CAA literally went "YOLO!" and 'executed' this exercise without a lot of thinking involved. How tragic for those 3 men.
The report concludes the probable causes of the accident were:
During the LATAM aircraft being in its takeoff run a Lima Airport Rescue Vehicle entered the runway without clearance by the control tower while in a response time exercise from the new fire station and collided with the aircraft.
This chain of events was caused by lack of joint planning, poor coordination and non-use of ICAO standardized communication and phraseology.
Contributing factors were:
- failure to hold a briefing meeting between airport and Civil Aviation Authority after the first response time exercise to determine errors, deficiencies, discrepancies, missing materials and procedural shortcomings in the development of the exercise in order to arrange improvements for an optimal execution of the second response time exercise.
- The Civil Aviation Authority's (CORPAC) acceptance of the proposal by the airport to carry the response time exercise out from partially implemented facilities that had not officially been handed over to control by CORPAC
- No meetings were held between CORPAC and airport to assess hazards, manage risks and mitigation actions with respect to the new areas and facilities of the airport
- Failure to hold a joint meeting between CORPAC and airport to plan the execution of the second response time exercise, which would participating personnell permitted to know clearly concept and details of the exercise
- Failure to provide instructions to control tower and emergency services for the execution of the second exercise permitting tower controllers to familiarize themselves with the location, designation and operational functioning of new aircraft and vehicle taxiways
- Incorrect application of aeronautical communication principles (clarity and precision) generated a wrong interpretation with CORPAC tower controllers of the execution of the exercise
- The tower controllers did not realize that by permitting the airport to remove the safety cones the only lane for the emergency vehicles to enter the runway was opened
- The erroneous interpretation by airport rescue services that the clearance to begin the response time exercise also included the clearance to enter the runway
- The aerodrome and surface controllers received information about the training exercise only minutes prior to its start, insufficient time to assess the hazards and risks
- Failure to use standard ICAO phraseology for communications between airport rescue services and the control tower
The CIAA analysed, that there was a clear and distinctive difference between the planning of the first response time exercise and the second one, while for the first exercise there had been a joint meeting to prepare and plan the exercise, there was no evidence of such a briefing for the second exercise.
On the day of the exercise and accident tower was not aware of the scheduling of the exercise until about 13:58L. During the visit of the CIAA to the control tower it was noticed that the controllers did not have any information about the new facilities like firestation, taxiways Q and R as well as VSR4 (the vehicle service road on which the fire engines ultimately entered the runway).
Coordination on the day of the accident between Tower and emergency services was done by an on call supervisor at the control tower who was not familiar with the exercise and developed an erroneous understanding of the exercise, in particular how the rescue vehicles would approach the runway. No clarification was sought or provided by either party.
During the LATAM aircraft being in its takeoff run a Lima Airport Rescue Vehicle entered the runway without clearance by the control tower while in a response time exercise from the new fire station and collided with the aircraft.
This chain of events was caused by lack of joint planning, poor coordination and non-use of ICAO standardized communication and phraseology.
Contributing factors were:
- failure to hold a briefing meeting between airport and Civil Aviation Authority after the first response time exercise to determine errors, deficiencies, discrepancies, missing materials and procedural shortcomings in the development of the exercise in order to arrange improvements for an optimal execution of the second response time exercise.
- The Civil Aviation Authority's (CORPAC) acceptance of the proposal by the airport to carry the response time exercise out from partially implemented facilities that had not officially been handed over to control by CORPAC
- No meetings were held between CORPAC and airport to assess hazards, manage risks and mitigation actions with respect to the new areas and facilities of the airport
- Failure to hold a joint meeting between CORPAC and airport to plan the execution of the second response time exercise, which would participating personnell permitted to know clearly concept and details of the exercise
- Failure to provide instructions to control tower and emergency services for the execution of the second exercise permitting tower controllers to familiarize themselves with the location, designation and operational functioning of new aircraft and vehicle taxiways
- Incorrect application of aeronautical communication principles (clarity and precision) generated a wrong interpretation with CORPAC tower controllers of the execution of the exercise
- The tower controllers did not realize that by permitting the airport to remove the safety cones the only lane for the emergency vehicles to enter the runway was opened
- The erroneous interpretation by airport rescue services that the clearance to begin the response time exercise also included the clearance to enter the runway
- The aerodrome and surface controllers received information about the training exercise only minutes prior to its start, insufficient time to assess the hazards and risks
- Failure to use standard ICAO phraseology for communications between airport rescue services and the control tower
The CIAA analysed, that there was a clear and distinctive difference between the planning of the first response time exercise and the second one, while for the first exercise there had been a joint meeting to prepare and plan the exercise, there was no evidence of such a briefing for the second exercise.
On the day of the exercise and accident tower was not aware of the scheduling of the exercise until about 13:58L. During the visit of the CIAA to the control tower it was noticed that the controllers did not have any information about the new facilities like firestation, taxiways Q and R as well as VSR4 (the vehicle service road on which the fire engines ultimately entered the runway).
Coordination on the day of the accident between Tower and emergency services was done by an on call supervisor at the control tower who was not familiar with the exercise and developed an erroneous understanding of the exercise, in particular how the rescue vehicles would approach the runway. No clarification was sought or provided by either party.
