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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 21st Feb 2024, 20:39
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As I am familiar with LYBE, at the very end of the 30L there is ravine. No more strip, only grass (ground) but like a ravine (continuous downslope), because of the motorway that is connecting airport with highway. So they didn't take off - they where held by ground effect in the air after the tail strike and nose pull up. They only took off right before highway, approx. 6m above passing cars. So, ravine saved the aircraft. Also in left turn they were too low above suburbs (about 150 meters maximum). Lucky for them they were using 30L with only highway ahead, not any single obstacle. Everything can be seen on the video that passenger recorded, if you look closely.

If the ground was level now we be talking about worst air disaster for after 50 years in Balkans.
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Old 21st Feb 2024, 20:39
  #162 (permalink)  
 
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Originally Posted by kontrolor
any ATCO giving take off clearance at TORA 1350 m on 3500 m runway should take its own part of the blame. And don't give me lectures on how CPT is ulitmately responsible for operation of an aircraft. ATCO has it own share of responsibilities in certain situations. There was NO operational or anyhow sound reasoning to allow take off at D5. They should order them to backtrack to at least D6. After decades of being ATCO on all positions (TWR, APP, ACC) I know what I'm talking about.
Originally Posted by FUMR
FullMetalJackass you may have noticed that several of us have given up trying to explain the obvious to one or two posters. It's a lost cause!
Not trying to defend any side of the active posters on the ATC subject, but you do notice that experienced ATCO's within EASA territory, can differ substantially in opinion?
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Old 21st Feb 2024, 22:29
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Originally Posted by FullMetalJackass
For what must be the twentieth time in this thread, how does someone in the tower know how much space is adequate for take off? It's not as if the controller has simply said: Cleared for take off. He's TOLD the crew that they are at D5 and not D6, the controller has given them the TODA available, he has ALSO questioned them whether that would be sufficient, he's also offered them the opportunity of turning around, backtracking up the runway to D6 in order to give them sufficient space without the crew losing their position as number one on the runway - what more could the controller do? Get out and fly the damned plane for them????
No. Just tell them to go back to D6 to avoid any possible confusion(why even bother offering options after they acknowledged they made the mistake), whats the worst that could happen? I'm convinced these pilot(s) had the original 2200m in their head all the time, that's why flaps were at the "wrong" position.

ATC doesn't have to know specifications of the plane but he should be aware of the fact that configuring the plane for T/O takes time and that cutting the runway in half by mistake and reconfiguring it under time pressure might cause problems, especially if it involves the jet that never ever took off from that position before.
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Old 21st Feb 2024, 23:30
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Originally Posted by FullMetalJackass
For what must be the twentieth time in this thread, how does someone in the tower know how much space is adequate for take off? It's not as if the controller has simply said: Cleared for take off. He's TOLD the crew that they are at D5 and not D6, the controller has given them the TODA available, he has ALSO questioned them whether that would be sufficient, he's also offered them the opportunity of turning around, backtracking up the runway to D6 in order to give them sufficient space without the crew losing their position as number one on the runway - what more could the controller do? Get out and fly the damned plane for them????
What should ATC do if they can feel that the pilots in a plane still on the ground are impaired, for example, drunk ?
It's close to this situation.

I would be very interested to know how much time it took the captain to answer if the takeoff was feasible from the D5 intersection.
If the answer was almost immediate (less than 10s) it is certain that the ATC could have suspected some sort of crew incapacitation.
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Old 22nd Feb 2024, 04:26
  #165 (permalink)  
 
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Kind of a reverse Swiss Cheese. After making a simple mistake that should have been fatal they got away with it.
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Old 22nd Feb 2024, 09:44
  #166 (permalink)  
 
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preliminary report (google translated from https://tangosix-rs.translate.goog/2...leti-sa-d6)The Center for the Investigation of Traffic Accidents (CINS) published yesterday the Notice on the initiation of the investigation into the Embraer Marathon Airlines accident on Air Serbia flight JU324 to Dusseldorf .

The preliminary report concludes that "one of the probable causes of the accident is the inadequate assessment of take-off parameters during the pre-flight preparation of the flight crew and after the decision to take off with a shorter runway length compared to the initially planned one."

This confirms Tango Six's writing as the first and only media outlet to reconstruct probable contributing causes based on the information we gathered on the night of the accident . CINS states in the preliminary report that there were no technical problems with the aircraft, the engine and other systems were working normally . Therefore, the probable conclusion of the final report, which, according to the Chief Investigator's announcement, will be ready in about 3 months , will be a human factor .

The preliminary report does not state any conclusions or explanations as to why the crew did what they did, but only presents the course and description of the events .

The preliminary report states that the event was classified as an accident . The plane suffered major damage to the fuselage, left wing and horizontal stabilizer .

The report states that the captain was a 58-year-old Italian with type ratings for the A320 and Embraer 170, while the co-pilot was Polish with an Embraer 170 rating . This was the second flight for the flight and cabin crew after the return flight to Vienna. There were 2 pilots, 3 cabin crew members and 106 passengers in the plane .

The report recounts the course of events that Tango Six has already reconstructed and which was also confirmed by an audio recording of the conversation between air traffic control and the pilot that was found on social networks.

According to the statements given to CINS, the crew planned to take off from the position on the runway at intersection D6 , for which, as they stated, they performed a "double check of the calculation of the take-off parameters" . During the departure from the gate, the crew received clearance to taxi to intersection D6 from airport control, which they confirmed. The crew then reported to the control that they were approaching the D6 intersection, to which they received a response to prepare for takeoff from D6 , exit and line up with the runway. Then comes the message of the second controller: are they aware that they came out on D5 ?

The preliminary report states that the controller then told the crew that TORA was 1273 meters .

The crew asked the control for a minute to make checks. According to the statement of the crew, they then calculated the parameters for take-off using a hand-held flight computer in the hand-held tablet of the co-pilot . During this time, the controller informs the crew to perform the calculations and also to report if they want to go back down the runway to position D6. The crew announced 30 seconds later that they were able to take off from D5 .

Air traffic control, according to the preliminary report, confirmed the reception but with another question whether they were able to take off, which the crew immediately confirmed. Then they got the final approval to take off and the information that there was no wind .

The preliminary report then states that the plane took off leaving behind a cloud of dust and climbing slowly. According to the statements given, the cabin crew estimated that the plane had normal acceleration upon take-off. According to the statements, the flight crew made changes in the thrust of the engine in order to get as high a speed as possible. At 80 knots, the crew stated that everything was fine, while at 100 knots, they noticed that there was not enough runway length . Considering the available length of the runway and the speed at which the plane was moving, the crew decided that it was safer to continue the takeoff because they estimated that the plane would soon separate from the ground . According to the crew, the plane then started to shake and they felt an impact on some object .

After separating from the ground, the crew then heard an unknown noise from the left side and noted that the lights on the left wing had stopped working. The crew began to receive information about problems with a number of systems, the most significant of which were the flaps and non-functioning of the engine's warm air system ("bleed air"), and they proceeded to go through the appropriate "emergency" checklists .

The preliminary report then states that air traffic control asked if everything was OK since they had deviated from the approved takeoff vector. The crew replies that they are not sure but that they will most likely have to return to the airport. Soon after, they declared a "mayday" (a general danger to flight safety) . The report then states the same events that Tango Six has already reconstructed.

During a low fly-by near the tower to visually confirm that the landing gear was extended, the crew reported a problem with the flaps and increased vibrations on the plane. They decided to land at a higher speed due to problems with the flaps, but, as they said, within the prescribed limits. Apart from the occurrence of vibrations, they did not have any other problems during landing .

The report then states that the crew had no problem with the plane after landing, and after communicating with the control, according to the instructions of the control, they reached the parking position at the gate C2 of the passenger terminal . After landing and leaving the runway, the plane was followed all the time by the vehicles of the Belgrade Airport Fire and Rescue Unit. After stopping, the crew received information from the ground staff that fuel was leaking from the left wing, and quickly shut down the engine and other systems .

The crew and passengers were disembarked through the air bridge . After securing the place of the fuel leak, the authorities ordered the airport services to move the plane away from the airport building to a safer place as soon as possible, which was done. The fuel leak continued the next day, in addition to fuel leaking from the tank.

The preliminary report states that the plane dragged its tail along the RESA surface, but does not provide more precise altitudes after immediate separation from the ground . He notes that the approach lights for runway 12R are damaged and the control boxes in the middle of the lights are broken .

The antenna buried in the root of the left wing of the plane is the "monitoring antenna of the ILS system" .
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Old 22nd Feb 2024, 10:56
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A moderate to poor conversion + google translation of the original pdf report.
Less readable than previous posted summary, but I'll put it here anyway, until better becomes available.

EDIT: replaced with newer, much more readable 'google translation' (but not yet proof-read)

Last edited by DIBO; 22nd Feb 2024 at 13:11.
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Old 22nd Feb 2024, 12:22
  #168 (permalink)  
 
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Originally Posted by DIBO
Less readable than previous posted summary, but I'll put it here anyway, until better becomes available.
The interim report reads as if it was compiled from contributions found in this thread (minus the blaming of ATC)...
Regarding the question posed above about how long it takes to recompute the takeoff distance: We use a tablet app for that. If the app is still open from the previous calculation then computing new takeoff data for a different intersection is a matter of five seconds. Easily possible between the question from ATC and the answer of the crew. Of course if you do it so fast there is ample room for mistakes, e.g. overlooking that a different flap and power setting is required.
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Old 22nd Feb 2024, 12:41
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Originally Posted by CVividasku
Except the situations are very different. There is no real risk in being too high on approach, you might just go around..
However departing from a quarter of the available runway, whereas you planned to use twice that, with a jetliner full of passengers, is a bit stupid and very likely to lead to some damage.
The situations are very different until the example I gave becomes one of a crash with a contributory factor of an unstable approach - hardly unheard of. Rare, but I’d guess less rare than instances of failed takeoffs resulting from using a shortened runway where the pilot has been asked “this is the TORA, are you sure?” and “are you realllly sure?” before insisting it’s all fine.
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Old 22nd Feb 2024, 13:50
  #170 (permalink)  
 
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Three most useless `things` in aviation,
1,The altitude above you.
2.The fuel in the `Bowser/tanker.
3.The length of runway behind you.
A clear case of `pressonitis`/loss of credibilty......
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Old 22nd Feb 2024, 13:53
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Originally Posted by what next
The interim report reads as if it was compiled from contributions found in this thread (minus the blaming of ATC)...
Well, then that's a compliment for PPrune's AAIB


Originally Posted by what next
We use a tablet app for that. If the app is still open from the previous calculation then computing new takeoff data for a different intersection is a matter of five seconds. Easily possible between the question from ATC and the answer of the crew. Of course if you do it so fast there is ample room for mistakes
So I take it that what in fact you are trying to say is, that you can never ever do it in around 5 second, then?
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Old 22nd Feb 2024, 14:15
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Originally Posted by Cozmo_NS
Serbian police in this case (and Public Prosecutor) will only determine is this a criminal act or not. The rest is on CINS (Serbian NTSB). They are not friendly to small criminals and similar, but this is different ball.
Due to the actual political regime I would not feel confortable for any investigation, no matter of Serbian prosecutor or serbian CAA, the last elections showed enough. source: https://www.europarl.europa.eu/RegDa...)757638_EN.pdf
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Old 22nd Feb 2024, 15:31
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Do we know yet if they preserved the CVR?

From the ATC recording, the FO sounds extremely shaky after the disastrous take-off. Not surprising, of course, but I'd be interested to know if the FO was nervous BEFORE take-off, ie was he having a bad time in the cockpit?

There's something about the Captain asking "I assume that's not enough?" that bothers me. It's a pointless question to ask ATC. I think he's really probing to see if ATC will insist they track round again to D6, or if they'll let him away with it. So I suspect he was happy to take off from D5, which would make me wonder if they did much in the way of recalculation.
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Old 22nd Feb 2024, 15:36
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Originally Posted by AirScotia
Do we know yet if they preserved the CVR?

From the ATC recording, the FO sounds extremely shaky after the disastrous take-off. Not surprising, of course, but I'd be interested to know if the FO was nervous BEFORE take-off, ie was he having a bad time in the cockpit?

There's something about the Captain asking "I assume that's not enough?" that bothers me. It's a pointless question to ask ATC. I think he's really probing to see if ATC will insist they track round again to D6, or if they'll let him away with it. So I suspect he was happy to take off from D5, which would make me wonder if they did much in the way of recalculation.
It's the controller who says that, not the captain.
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Old 22nd Feb 2024, 16:25
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Originally Posted by MercedesBenz240
It's the controller who says that, not the captain.
Indeed, my initial mistake also based on the incomplete and misleading ATC recording, but in the meantime rectified by several posters and confirmed just recently in the prelim report.
But still incorrectly transcribed in the AVHerald report (together with maintaining the claim that "was still on the ground at position N44.8274 E20.2846", which is nonsense)
Originally Posted by CINS prelim report
KL immediately contacted the crew again with the information that the available length for take-off from the given intersection was 1,273 meters, with the suggestion that this was not sufficient for a safe take-off.
*KL = Beograd TWR ATC
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Old 22nd Feb 2024, 16:34
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how often pilots require to get shorter position after they have departed the gate? Maybe the simplest solution is that ICAO just bans such practice?
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Old 22nd Feb 2024, 17:02
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Originally Posted by AreOut
how often pilots require to get shorter position after they have departed the gate? Maybe the simplest solution is that ICAO just bans such practice?
Why? You want to punish the entire class because one made a mistake? Runway lengths differ from airport to airport. If for example a particular type operates without problem and meeting all criteria from an airport with a 2000m runway. Why can they not depart from an intersection with a TORA of 2000m from an airport with a 3000m runway. As has already been explained, at busy airports this also helps with minimizing delays. One pilot makes an odd and rare error and you want to change something that has been going on for a great many years with millions of movements because of that? Go sell your idea to the Americans!
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Old 22nd Feb 2024, 17:05
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departing from intersection is not the problem if it is handled at the gate, I meant changing assigned position(for a shorter one) after you depart from gate
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Old 22nd Feb 2024, 17:06
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Originally Posted by AreOut
Maybe the simplest solution is that ICAO just bans such practice?
Banning your way to perfection, one edict at a time.
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Old 22nd Feb 2024, 17:30
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Originally Posted by MercedesBenz240
It's the controller who says that, not the captain.
If that's true, the ATC recording is missing a lot of the conversation, ie no comms from 86C until after the incident.

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