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Air Serbia E195 runs into runway lights at Belgrade

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Air Serbia E195 runs into runway lights at Belgrade

Old 19th Feb 2024, 22:39
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I have to say that AreOut has, for the very first time in more than 20 years contributing to this site, made me consider blocking a poster.

To be more constructive, a quick Google suggests this is not the first time something similar has happened. I have no idea if the same systems were used for performance calculations but perhaps there is an easily missed HF gotcha.

More generally on the ATC/pilot responsibilities, as an ex-controller myself, I concur with pretty much all explanations to suggestions that ATC made an error. Listening to the recording it sounds like the controller did a pretty good job in, perhaps, difficult circumstances. Applying European ATC procedures there was little more that the controller could have done in the circumstances (that is to say, it was not inevitable that the TORA would be inadequate, and I have seen lightly-laden jets get off in remarkably short distances).

There are so many variables that contribute to take-off performance calculations, the only people who will really know the runway length required will be sitting at the front of the aircraft. The principle generally applied is that pilots fly the aircraft and controllers stop them banging into each other - crossing that boundary should be limited to suggestions only and these will rarely be necessary. The UK introduced a procedure a few years back whereby ATC was supposed to warn a pilot if they were about to start an approach below minimum (for AreOut's benefit, approach minima are another thing that are affected by many factors and are the pilots' responsibility to calculate) - it was a complete shambles and, IIRC, the CAA guy who designed the procedure was ripped to shreds in court when the CAA tried to prosecute a pilot for landing below minimum.
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Old 19th Feb 2024, 23:45
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An ATR42 would have been easily able to legally take of with 1283m TORA.

They operated daily with full pax loads from EDLW (Dortmund) in the 90s with 800m + 200m stop way.
Pretty interesting visual experience on the flight deck.

However, no one would do that on a long runway to avoid 1000m more taxi.
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Old 19th Feb 2024, 23:51
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Originally Posted by FiveGirlKit
I would like to see pictures of the track of the aircraft on the ground. They finally had a positive rate of climb when they crossed the Autobahn at 50', and that is ~1500m past the end of the threshold. Very lucky to have got airborne ​​​​​​
The AvHerald article description was seriously scary, even without knowing anything more when I read it:

"Following a collision with the high precision approach lights of runway 12R past the end of the runway the aircraft became airborne about 500 meters/1650 feet past the runway end, climbed through 50 feet AGL about 2050 meters/6700 feet past the runway end . . ."
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Old 20th Feb 2024, 00:12
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I have a question about ATC: If one assumes that the runway that an aircraft is to use for takeoff is clear, there is no conflicting traffic if it takes off now, and the pilot insists that the aircraft can take off from the intersection where it is, does ATC have the right to refuse to give a takeoff clearance on the basis that it looks like an odd place for the aircraft to start from?
Flying a multi engined helicopter from an airport we rarely visited, procedures conformed with heavy jet take off procedures such as V1 and reject distances, taxied to an intersection for take off on the runway and the tower called "you know you only have XXX metres from there?". All was good, but it showed an on the ball tower controller who understood helicopter operations, likely because of the resident helo operators, thumbs up Essendon.
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Old 20th Feb 2024, 00:28
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a very similar incident happened two years ago also with Embraer at EDDB

https://aviation-safety.net/wikibase/268534

Conclusions
The Dutch Safety Board investigated the incident and found that the aircraft took off from Intersection L5 - as the crew intended - while the performance calculation was based on Intersection K5, because both pilots accidentally selected intersection K5 instead of L5 in the takeoff performance calculation application. The selection error resulted in a slower acceleration leading to a hazardous situation in which the aircraft became airborne 443 metres before the end of the runway.

The Dutch Safety Board found several contributing factors related to the selection error:
• Accidental misselections occur commonly when using a touchscreen tool with finger-touch interaction, especially if it is used routinely and therefore quickly. The lack of system feedback about the location of the finger and the ‘fat finger’ problem contribute to selection errors when working on a touchscreen.
• The takeoff performance calculation application does not provide visual feedback about the selected intersection and runway (airport synoptic).
• The pull down menu contains selection options (runway intersections) that are not normally used by the operator.

There were several contributing factors to the propagation of the misselection:
• The cross check did not reveal the selection error because the pilots likely only focused on the performance calculation outputs, which probably did not differ as both pilots had reportedly selected the same wrong intersection.
• Passing the sign indicating intersection L5 and the available runway length could not reveal the selection error either, because the crew had this intersection in mind. Also the calculated N1 was within range of expectation. Variant flying might have widened their range of expected performance parameters.
• The crew trusted the performance calculation application.
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Old 20th Feb 2024, 00:31
  #66 (permalink)  
 
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An humble question here, without "pointing fingers" to anyone, be it pilots or Atc'ers (that task for official entities).
To all dear colleagues reading this and flying drivers of the fantastic E-jet...
Having in mind Azul operates similar type from Santos Dumont daily dozens per day ops, with more or less the same rwy declared distances, had this very same accident plane (crew) done the correct calculations for TO data and performance, it could have been in the air without any issue at all, commencing at D5 ..?
Tanx to all.. Peace ✌️
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Old 20th Feb 2024, 01:10
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Originally Posted by JanetFlight
An humble question here, without "pointing fingers" to anyone, be it pilots or Atc'ers (that task for official entities).
To all dear colleagues reading this and flying drivers of the fantastic E-jet...
Having in mind Azul operates similar type from Santos Dumont daily dozens per day ops, with more or less the same rwy declared distances, had this very same accident plane (crew) done the correct calculations for TO data and performance, it could have been in the air without any issue at all, commencing at D5 ..?
Tanx to all.. Peace ✌️
The answer is maybe. You would need to know the passenger load, altimeter, winds, cargo load, fuel load, temp and any performance restrictions. We don’t have that information.
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Old 20th Feb 2024, 02:38
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Originally Posted by Sailvi767
The aircraft is capable of accelerating to V1 and stopping in 4700 feet with a full load of people and fuel for 500 miles.
which they didn't have with a 4177 feet TORA
Originally Posted by Sailvi767
There are other factors involved. I suspect they had an incorrect takeoff power setting as well as the incorrect runway Intersection.
To be used with some caution until official ADSB data is published, but as all other datapoints seem to be pretty consistent, it seems to indicate they accelerated very slowly the first couple of hundreds meters, direction D4



Originally Posted by OldnGrounded
The AvHerald article description was seriously scary, even without knowing anything more when I read it:
"Following a collision with the high precision approach lights of runway 12R past the end of the runway the aircraft became airborne about 500 meters/1650 feet past the runway end, climbed through 50 feet AGL about 2050 meters/6700 feet past the runway end . . ."
The estimate of DRUK seems to be more likely
Originally Posted by DaveReidUK
I see that Avherald is also quoting "50 feet" - but then it has form for not understanding ADS-B data.
At that point, height AAL would have been approx 175-200 feet - still low enough to scare the motorists ...
Originally Posted by AVHerald
was still on the ground at position N44.8274 E20.2846 and climbed through 50 feet AGL at position N44.8335 E20.2673 just ahead of the motorway.
I very much doubt that at the first position indicated, they were still on the ground = plowing through the fields, as that terrain has a very slight downhill slope.
Just after crossing the airport access road (with some trees and pretty tall lighting posts) they were at around 75ft (rounded to the nearest 25) + a little extra terrain clearance from the slight downhill slope.
THe ADSB reported wind is fully cross, with a pinch of tail component. That didn't help either...

Seconds (or should I say feet) from disaster....
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Old 20th Feb 2024, 05:59
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I rarely if ever, comment on this Accident Forum, so please allow me to note my observation.

I see that upon looking at the Runway Chart for Declared Distances shows a Take Off length available from from Intersection D5 on heading 12R is 2266m.

Whereas the Take Off distance from D5 on heading 30L (which they used) is just 1273m.

Using D6 for 30L is 2349m (almost the same as using D5 for 12R)

I think it is glaring that a mistake here was possibly made by the Flight Crew (or they were misled by other reasons, as yet unknown) when viewing and checking those numbers,
hence the ATC calls to remind the Crew that they were now lining up for a very short Take Off distance available.

I err to superior knowledge of course.
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Old 20th Feb 2024, 06:54
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Originally Posted by rog747
I see that upon looking at the Runway Chart for Declared Distances shows a Take Off length available from from Intersection D5 on heading 12R is 2266m.

Whereas the Take Off distance from D5 on heading 30L (which they used) is just 1273m.
Indeed so - see my earlier post.

Originally Posted by DaveReidUK
A 12R takeoff from D5 would give a 2266m TORA/TODA/ASDA, in fact not much different from a 30L takeoff from D6 (2349m)
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Old 20th Feb 2024, 07:07
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Originally Posted by rog747
I rarely if ever, comment on this Accident Forum, so please allow me to note my observation.

I see that upon looking at the Runway Chart for Declared Distances shows a Take Off length available from from Intersection D5 on heading 12R is 2266m.

Whereas the Take Off distance from D5 on heading 30L (which they used) is just 1273m.

Using D6 for 30L is 2349m (almost the same as using D5 for 12R)

I think it is glaring that a mistake here was possibly made by the Flight Crew (or they were misled by other reasons, as yet unknown) when viewing and checking those numbers,
hence the ATC calls to remind the Crew that they were now lining up for a very short Take Off distance available.

I err to superior knowledge of course.
In the ATC tape the controller clearly asks (at 1:23)

"are you aware that ... TORA is 1273 m. I assume that's not enough. Calculate and call me"

So the blame lies squarely with the crew. They ignored a very specific warning. I find that very hard to grasp!
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Old 20th Feb 2024, 07:55
  #72 (permalink)  
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Originally Posted by DaveReidUK
Indeed so - see my earlier post.
Originally Posted by DaveReidUK
A 12R takeoff from D5 would give a 2266m TORA/TODA/ASDA, in fact not much different from a 30L takeoff from D6 (2349m)
And not to labour my earlier post, but the aircraft replied to ATC along the lines of:
  • ASL86C: yes tora is two two actually sorry tora is one two seven three metres i assume that's [?not] enough
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Old 20th Feb 2024, 08:12
  #73 (permalink)  
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@ DIBO :
Quote:
Originally Posted by Sailvi767
The aircraft is capable of accelerating to V1 and stopping in 4700 feet with a full load of people and fuel for 500 miles.
which they didn't have with a 4177 feet TORA
But were they at MTOW?
Anyway local rumors are that CRM and authority gradient played a role with a very experienced (Italian) Capt with a wannabee on right seat. Time will tell a bit more.as the blame game has started..
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Old 20th Feb 2024, 08:38
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ATC recording
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Old 20th Feb 2024, 09:34
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Originally Posted by AreOut
a very similar incident happened two years ago also with Embraer at EDDB

https://aviation-safety.net/wikibase/268534

Conclusions
The Dutch Safety Board investigated the incident and found that the aircraft took off from Intersection L5 - as the crew intended - while the performance calculation was based on Intersection K5, because both pilots accidentally selected intersection K5 instead of L5 in the takeoff performance calculation application. The selection error resulted in a slower acceleration leading to a hazardous situation in which the aircraft became airborne 443 metres before the end of the runway.

The Dutch Safety Board found several contributing factors related to the selection error:
• Accidental misselections occur commonly when using a touchscreen tool with finger-touch interaction, especially if it is used routinely and therefore quickly. The lack of system feedback about the location of the finger and the ‘fat finger’ problem contribute to selection errors when working on a touchscreen.
• The takeoff performance calculation application does not provide visual feedback about the selected intersection and runway (airport synoptic).
• The pull down menu contains selection options (runway intersections) that are not normally used by the operator.

There were several contributing factors to the propagation of the misselection:
• The cross check did not reveal the selection error because the pilots likely only focused on the performance calculation outputs, which probably did not differ as both pilots had reportedly selected the same wrong intersection.
• Passing the sign indicating intersection L5 and the available runway length could not reveal the selection error either, because the crew had this intersection in mind. Also the calculated N1 was within range of expectation. Variant flying might have widened their range of expected performance parameters.
• The crew trusted the performance calculation application.
It isn't 'very similar' at all.

L5 still gives over 2000m, a do-able TORA for an Embraer E295 payload/weather permitting. The problem here was that they calculated for a much longer distance and hence the performance figures will suggest a lesser Thrust setting and lower flap setting than they might need if they had put in the correct intersection.

1300m is NOT a usual TORA for a E295 (or I doubt an E195), and if this distance was relayed to them, it should have been immediately obvious that something was wrong.
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Old 20th Feb 2024, 10:13
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Originally Posted by DIBO



The estimate of DRUK seems to be more likely

The photo from your post is old.For accurate distances, you can use official charts (scroll to the bottom of page) https://smatsa.rs/wp-content/uploads...D0911161450244
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Old 20th Feb 2024, 10:48
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Globaliser: I picked up on that phrase as well. The captain saying to ATC "I assume that's not enough?" Effectively passing to ATC the decision on whether he has enough runway. In no way is that acceptable. If he doesn't know, he shouldn't be there. I don't just mean the holding point, but the LHS.
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Old 20th Feb 2024, 11:45
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From exyuaviation (still cannot post links, sorry):

1. The plane almost experienced a disaster immediately after takeoff, because it barely avoided a huge billboard located on the approach road of the airport, almost perfectly aligned with the inserted runway. ILS antennas are light structures, but if the plane had hit the billboard, it would have disintegrated on the spot, and probably crashed in the middle of the highway, killing who knows how many people. On FR24, it can be seen that immediately upon take-off, the plane turned very slightly to the left, thereby saving itself.
(The billboard is mentioned by a passenger who sat next to the right wing. They flew about 20 meters left from billboard at about 5-6 meters of height above highway).


2. The statements of AvHerald and other media that the plane started flying only 500m after the end of the runway are correct for two reasons. 12R does not have extended approach lights as 12L has, so the plane did not hit them as some write, also, after the end of runway 30L there is a downhill that descends a few meters towards the approach road of the airport from the highway. The plane did not take off from the runway at all, it careened off of it, collided with the ILS antennas, the ground "droped out from under the plane" while it was flying more or less horizontally, and then it accelerated and began to climb slowly. This can be seen in detail: AIP SMATSA Precision Approach Terrain Chart RWY 12L/R.
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Old 20th Feb 2024, 13:07
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Originally Posted by DIBO
which they didn't have with a 4177 feet TORA
They did not however lose an engine or abort. The aircraft’s actual takeoff distance should have allowed them to get airborne on the runway. There are additional issues at play. It might be that seeing the end of the runway coming up the aggressive and perhaps early rotation and tail strike reduced performance.

Originally Posted by ATC Watcher
@ DIBO :
But were they at MTOW?
Anyway local rumors are that CRM and authority gradient played a role with a very experienced (Italian) Capt with a wannabee on right seat. Time will tell a bit more.as the blame game has started..
4700 feet is the balanced field length to allow the aircraft to either continue the takeoff with a engine failure and be at 35 feet over the end of the runway or abort and stop on the remaining runway. It is not the actual takeoff distance which would be shorter.
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Old 20th Feb 2024, 13:29
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Originally Posted by Herod
Globaliser: I picked up on that phrase as well. The captain saying to ATC "I assume that's not enough?" Effectively passing to ATC the decision on whether he has enough runway.
It is impossible to know what he meant with that phrase. There are several non-native speakers involved, communicating in short sentences. Maybe what he really inteded to say was: "I assume you want to say that's not enough?" which would have quite a different meaning. We all have heard countless examples of non-perfect communication in our CRM courses.
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