LATAM A320 ground collision at SPJC

[violator]

https://twitter.com/fchullen/status/1593712813138124802?s=20&t=lyLhH8uto19XUapcbqB7QA

Amazing video

[Noxegon]

Story breaking right now. Appears to be CC-BHB operating LIM-JUL.

https://twitter.com/noticias_tvperu/status/1593710447601254400

[jimjim1]

Decoder ring.Lima, Peru (LIM) to Juliaca, Peru (JUL)CC-BHB - was recently and likely still is.

Airbus A320neo
LATAM Airlines Chile (https://www.planespotters.net/airline/LATAM-Airlines-Chile)

[Noxegon]

Picture of the aftermath here, taken by a passenger:
https://twitter.com/enriquevarsi/status/1593710356916051970

[Lake1952]

https://twitter.com/AlertaMundial2/status/1593713092856352771?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembe d%7Ctwterm%5E1593713092856352771%7Ctwgr%5E33c94906411233a815 f2a06b4f8178dacda3f27f%7Ctwcon%5Es1_c10&ref_url=https%3A%2F%2Fsimpleflying.com%2Fbreaking-news-latam-airlines-airbus-a320neo-collides-with-truck-in-lima%2F

[eagle21]

Clear collision with a fire truck on an emergency drill.
https://twitter.com/conflictsw/status/1593724438314459141?s=21


ATC Recording Ground: accident around minute 12:00
https://archive.liveatc.net/spjc/SPJC1-Gnd-Nov-18-2022-2000Z.mp3

[NWSRG]

Any word on the fire crew? Doesn't look good at all...

[darkshadow]

Any word on the fire crew? Doesn't look good at all...
both deceased apparently.

[NWSRG]

both deceased apparently.

It's grim...guys trying to do a worthy job, and for whatever reason, this is their fate.

Do we know yet if they were responding to a call, or something more routine?

[eagle21]

It's grim...guys trying to do a worthy job, and for whatever reason, this is their fate.

Do we know yet if they were responding to a call, or something more routine?

It was a training exercise, they were in contact with the ground controller.

[MissChief]

Hmm. Not good. Training exercise on an active runway?

[estuardo]

It wasn’t a training exercise - there was a plane near the terminal with a problem which the firies were responding to. We don’t know enough yet, but either they crossed the active runway without clearance (unlikely), or ATC messed up and both the aircraft and the firies were given clearance at the same time.

If the firies were in emergency mode to get to the other plane it’s possible they didn’t hear ATC telling them to stop at the runway, or the call wasn’t made. All speculation of course, I’m assuming the plane was given takeoff clearance.

Terrible accident, but there are processes in place to stop this so somebody made a mistake. I hope it was the firies because at least they don’t have to live with the guilt, as horrible as that is.

[skydler]

Clear collision with a fire truck on an emergency drill.
https://twitter.com/conflictsw/status/1593724438314459141?s=21


ATC Recording Ground: accident around minute 12:00
https://archive.liveatc.net/spjc/SPJC1-Gnd-Nov-18-2022-2000Z.mp3

hopefully a native speaker can help here but sounds like:

4:58 "rescue 6, authorized to approach 90 meters from the axis of the runway, the cones on the vehicle road."
8:03 "proceed, rescue 6"
8:58 "rescue 6, ground.... confirm, ground"
11:47 (crash broadcast) "rescue, I repeat, I repeat, rescue, aircraft crash on the runway, I repeat"
12:26 "rescue units authorized to enter the runway"

also sounds like a change of controllers at 2:27

[PoppaJo]

https://mobile.twitter.com/Mario_Moray/status/1593729408590020608

[NATCAL]

2 deceased, one in serious condition

[estuardo]

It appears from this footage above that the firies saw the aircraft seconds before crossing the runway and did all they could do slow down and turn. They died, but they saved the lives of everyone on the aircraft by not directly crossing in front of the plane.

If the ATC is correct, then this was a mistake by the firies which should never have happened but it could have been far, far worse.

[Pilot DAR]

As a volunteer firefighter, I drove any of a number of different fire trucks to emergency calls, there is an adrenaline rush in the response, and you can let your guard down at the wrong time. I could drive at highway speed for fifteen minutes, so lots of opportunity for something to go wrong. We had very few bumps with the trucks during all those years, and none serious, but there were so many times it could have been really bad - particularly at train level crossings. Sad, very sad, and I have empathy for the firefighters, sometimes you just forget something....

For those times I have been flying TCAS equipped airplanes (uncommon for me) I've always been a little surprised and amused at proximity warnings about airplanes taxiing on a parallel taxiway when I was on the runway. I now see value for TCAS in all airport vehicles which could plausibly access a runway - the driver would at least get a warning!

[JanetFlight]

Does anyone knows if Lima ARFFS operates under the policy "one runway, one language, one frequency", or not?
(at least in spanish, supposing both ATC'ers, Fiers and Pilots were spanish language-natives)

[Johnny_56]

Well done to the ARFF who responded after the crash. Especially after losing a truck and some mates only seconds before.

[eagle21]

https://archive.liveatc.net/spjc/SPJC1-Gnd-Nov-18-2022-2000Z.mp3

at 09:01 you can hear the controller saying: Rescate, confirmando ejercicio. “rescue, confirming exercise”

[Sallyann1234]

Fire truck on active runway. Fire staff killed.

https://www.itemfix.com/v?t=f6okrp

[Fortissimo]

https://www.youtube.com/watch?v=_0N5MsHWmbY

[FUMR]

eagle 21

That depends on if it's a statement or a question.

[Fortissimo]

Besides the runway incursion (incorrect presence) whether 'authorised' or not, there are questions about the length of time it appears to take to start an evacuation which should have been completed in 90 seconds per CS25.803. There is footage of pax still leaving the aircraft after ARFF has knocked down and then extinguished the fire. (Hats off to them, it must have been obvious that their colleagues had been involved, which would have been a real distraction. The footage also shows - yet again - people evacuating with cabin bags and stopping to take video...

[Denti]

As a volunteer firefighter, I drove any of a number of different fire trucks to emergency calls, there is an adrenaline rush in the response, and you can let your guard down at the wrong time. I could drive at highway speed for fifteen minutes, so lots of opportunity for something to go wrong. We had very few bumps with the trucks during all those years, and none serious, but there were so many times it could have been really bad - particularly at train level crossings. Sad, very sad, and I have empathy for the firefighters, sometimes you just forget something....

I would expect that in a volunteer, and i am absolutely grateful to those willing to spend their time and effort, not to mention risking their health, to help others. I do hold professionals, in any occupation, to a higher standard, even more so if they are professionals in a special environment that an airport certainly is. Basic runway safety demands at least a visual „safe and clear“ check before entering a runway, no matter if you have a clearance as ATCOs do mistakes as well. That should be part of their training, and as it is their job to work on and around aircraft that has to be constantly reinforced.

For those times I have been flying TCAS equipped airplanes (uncommon for me) I've always been a little surprised and amused at proximity warnings about airplanes taxiing on a parallel taxiway when I was on the runway. I now see value for TCAS in all airport vehicles which could plausibly access a runway - the driver would at least get a warning!

That shouldn’t happen. A correct TCAS and transponder installation automatically sets the ground flag and is then not displayed on the (correctly installed) TCAS of other planes. There are a few airports already that have (mode-s) transponders installed on every vehicle for ground control purposes and those have the ground flag set as well.

[FUMR]

It was daylight and relatively good visibility. The fire truck is facing the A320 as it approaches the runway. What is perplexing is how the heck did he not see the aircraft in time? And when he did, why attempt evasive action to the right and not to the left. We will never know the answers.

[fab777]

I may sound a little harsh or insensitive, but I am not surprised this happens in LIM, from my experience, and the pilot reports from my collegues: ATC there is always pushing you with the order "expedite", both at take off and landing, like they had a traffic similar to ATL to pass. They call you to order you to a shorter exit while you're still at 100 kts decelerating, they pressure you to line up and take off each and every time. Saddened, but not surprised.

[fab777]

Does anyone knows if Lima ARFFS operates under the policy "one runway, one language, one frequency", or not?
(at least in spanish, supposing both ATC'ers, Fiers and Pilots were spanish language-natives)

They speak in Spanish in LIM, but as you pointed out, not relevant here

[Pilot DAR]

Comment about post locations: Events which we all agree are accidents, and intended to be discussed in this forum, rather than R&N. Sure, when it happens, it's news, but after a while, it's still an accident, worthy of discussion, and not so much news anymore. W're not going to have the same event being simultaneously discussed in two different forums, it's just too much work to make sense out of, and moderate. So if you'd like to discuss an accident, here is the best place. Accidents which are first posted in R&N will be moved here, with a redirect message left in the original forum for a day or so to point readers to this forum.

Thanks for your support in keeping things on topic, and tidy here...

Pilot DAR

[A0283]

Impact (https://www.nu.nl/296756/video/passagiersvliegtuig-botst-tijdens-opstijgen-tegen-brandweerwagen-in-peru.html)

[ShyTorque]

The video makes chilling viewing. Although it’s not perfectly clear, it seems to me that two other vehicles also entered the runway but passed down the starboard side of the aircraft.

[JanetFlight]

Clip from the inside...

https://twitter.com/aviationbrk/status/1593943765596901377?s=46&t=ucYHDjVhKfvXp9vcvo_G7A

[FUMR]

Looking at that, I guess they were not that far from VR. I think it's fair to say that the A320 crew did a good job.

[A320 Glider]

Question, had the crew decided to continue the takeoff, would we be looking at a fatal outcome as the crew attempted an emergency return?

[jumpseater]

For those times I have been flying TCAS equipped airplanes (uncommon for me) I've always been a little surprised and amused at proximity warnings about airplanes taxiing on a parallel taxiway when I was on the runway. I now see value for TCAS in all airport vehicles which could plausibly access a runway - the driver would at least get a warningj!

There are already systems in use to prevent runway incursions. One type has a sensor based on the runway strip/holding points which gives an intrusive and clear audio warning to the driver approaching the runway, regardless if it’s active or not. Unfortunately it would likely have been of little use here due to the speed and momentum of the vehicle.

It’ll be interesting to see:

If aircraft cleared for take off.

If the fire crews monitor the runway frequency and ground simultaneously, especially if they are not bandboxed.

If the ground/runway frequencies aren’t combined what co-ordination occurred/didn’t occur in ATC to allow the runway entry by the fire crews. Were stopbars extant, activated, deactivated, or unserviceable?

Fire cab ergonomics, once rolling fast, are the comms able to be heard?

Fire crew training, current/adequate/familiarity? a whole Swiss cheese of options raising their head here.

[Pilot DAR]

Question, had the crew decided to continue the takeoff, would we be looking at a fatal outcome as the crew attempted an emergency return?

The emergency return would have been to earth, through and beyond the overrun, not a circuit. That airplane was no longer capable of controlled flight.

[Diff Tail Shim]

Question, had the crew decided to continue the takeoff, would we be looking at a fatal outcome as the crew attempted an emergency return?
The aircraft had one engine and it's landing gear ripped off. It wasn't flying anywhere. Lucky the hull stayed intacted.

[ATC Watcher]

There are already systems in use to prevent runway incursions. One type has a sensor based on the runway strip/holding points which gives an intrusive and clear audio warning to the driver approaching the runway, regardless if it’s active or not. Unfortunately it would likely have been of little use here due to the speed and momentum of the vehicle.

It’ll be interesting to see:

If aircraft cleared for take off.

If the fire crews monitor the runway frequency and ground simultaneously, especially if they are not bandboxed.

If the ground/runway frequencies aren’t combined what co-ordination occurred/didn’t occur in ATC to allow the runway entry by the fire crews. Were stopbars extant, activated, deactivated, or unserviceable?

Fire cab ergonomics, once rolling fast, are the comms able to be heard?

Fire crew training, current/adequate/familiarity? a whole Swiss cheese of options raising their head here.

There are many systems aimed at preventing runway incursions , not sure which model they have in LIM and if it was active, but looking at the videos, the truck was at full speed and any alarm sounding in the TWR would've not made much difference
To answer some of your questions based on a normal international airport ::
1-a/c cleared for take off : Tape will confirm that , but I assume it was.
2-Fire Trucks are normally on ground frequency only , but can be instructed to switch to TWR when penetrating a runway , and to be on the same frequency of the crew of the aircraft they are attending to.
3- Stopbars, were most probably active if they have them in LIM , but a fire truck responding to an emergency can cross them ONLY if they get authorization by GND ATC..
4- Frequency loud enough to be heard in cab ; yes,
5- Training . Yes and is normally very high nowadays.
One thing on the first video surprised me, if that the Fire chief ( the pick-up car) is rather far behind the 2 fire trucks. Not really the norm.

One of the R/T transcript poste earlier, it is difficult to draw a correct picture as we canot hear the requests or responses made . The trucks ( Rescue6 ) were cleared to stop 90m from runway axis , by some cones. That is in fact the only part which is clear. .

[A320 Glider]

The emergency return would have been to earth, through and beyond the overrun, not a circuit. That airplane was no longer capable of controlled flight.

My point exactly. If the pilots had decided to continue, the outcome would have been completely different. The flight crew, along with the cabin crew, deserve absolute recognition here. This could be the South American Sully moment for this crew!

[tubby linton]

Have any photos appeared of the missing gear leg and the engine? The engine and pylon are obviously missing and I am sure that Airbus will be very interested to see the damage to the wing structure . Did the gear leg separate from the structure or did the leg break on impact with the fire truck?

[PoppaJo]

Besides the runway incursion (incorrect presence) whether 'authorised' or not, there are questions about the length of time it appears to take to start an evacuation which should have been completed in 90 seconds per CS25.803. There is footage of pax still leaving the aircraft after ARFF has knocked down and then extinguished the fire. (Hats off to them, it must have been obvious that their colleagues had been involved, which would have been a real distraction. The footage also shows - yet again - people evacuating with cabin bags and stopping to take video...
Valid question, will always be a whole range of opinions around evacuation, always a tough one to answer. Decision making is tested like never before.

With the info that the crew would have had initially, front of mind concerns for me is, minus an engine, serious wing damage, fire/smoke. Having seen how fast aircraft skin will burn through in previous examples, rear passengers certainly at risk. Looking at the footage, it appears the area 1L/R is clear for an immediate evacuation.

Had they have conducted an evacuation, likely people would have died/serious injuries. Had they not have conducted an evacuation, every chance the rear will burn through and people will start to die as the fire spreads. I would be interested to see any interior photos in the last 10 rows.

The NEO held up well regardless.

[Capn Bloggs]

evacuation which should have been completed in 90 seconds per CS25.803.
Is that correct? My understanding is that the requirement for certification is that the evacuation should take no more than 90 seconds, which is demonstrated in controlled conditions.

In real world conditions, things are obviously very different. All manner of influences are going make the 90 seconds irrelevant in a real-world evacuation. For example, what if only one door was available?

[Flying Clog]

After ploughing into a fire truck, pax and crew are likely to be a little bit startled, so of course the 90 seconds goes out the window until the dust settles.

[mickjoebill]

From the pov where aircraft is filmed moving right to left in frame, the truck appears to be travelling parellel to runway, makes a right turn, proceeds for a few seconds then makes a further turn a second before the impact.
From this angle there is a trail of presumably either dust or exhaust from the trucks.This is also visible from the camera on the tarmac.
If it is dust is could there have been a loss of control/skid to capture the drivers attention?

Also, the ground camera where the trucks pass right to left, reveals how the vision between driver and to the left and right is compromised by large exterior mounted rear view mirrors, which create a blindspot.

[krohmie]

The new fire station is south of the runway.

The whole area there seems to be under construction, so only unpaved roads, marked with cones.

In my humble opinion this is a contributing factor for this tragic event.

[jumpseater]

One thing on the first video surprised me, if that the Fire chief ( the pick-up car) is rather far behind the 2 fire trucks. Not really the norm.

One of the R/T transcript poste earlier, it is difficult to draw a correct picture as we canot hear the requests or responses made . The trucks ( Rescue6 ) were cleared to stop 90m from runway axis , by some cones. That is in fact the only part which is clear. .

I’m professionally aware of all those elements you mention. Those assumptions and controls in the list are all reasonable and expected, however something went wrong, and the list/questions are only starters for ten in what may have occurred.
The runway incursion audio alert I was referring to is vehicle fitted, not in the VCR. It gives the vehicle driver an audio alarm that they are approaching the runway strip. A system like might have given the vehicle crew an earlier warning/reminder re entering/crossing the runway and they had no clearance, (my assumption) to do so. In that event earlier braking or turn may have minimised or avoided the physical contact. As you correctly say we only have partial coms to make guesses from at the moment.

Depending on individual RFFS’ equipment and capability the Fire Chief doesn’t always deploy in a separate faster vehicle, they can be in one of the fire trucks, so in my experience I wouldn’t necessarily consider that to be the ‘norm’.

[JanetFlight]

Does anyone knows if in Lima the ARFFS were (operating/operates) on the same frequency of the ATC and departing Airbus (ATC aeronautical Freq), or it is/was a closed trunking like in many airports nowadays only between ATC and ground vehicles but "unknown" to aircraft&pilots?
I still emphazise on this question cause i think IMHO its pretty relevant here!
Tks

[Bosi72]

A confusion whether this was a training exercise or real emergency tells me that the fire dept and atc don't talk to each other.
I see sometimes similar at work where emails don't cc: relevant people for whatever reason.

[JanetFlight]

A confusion whether this was a training exercise or real emergency tells me that the fire dept and atc don't talk to each other.
I see sometimes similar at work where emails don't cc: relevant people for whatever reason.
I subscribe you 100!!!

[aeromech3]

Airside trained and approved drivers are drilled not to enter active runways without permission, Period!

[ATC Watcher]

There were 2 press conferences this week end , one by the CEO of LATAM in Peru , who declared the a/c was cleared for take off , but they ( whoever is "they") were not informed of the exercise.
The other by the LIM airport manager , wo said the fire trucks were only authorized to make their exercise in an area clear of the active runway .

With those 2 info, if they are confirmed by the investigation , it would seem that the briefing made before the exercise, and possibly the position of the warning cones could have played a role here. there is a blame game being played openly which is never good to get people talking to investigators.

@jumpseater : The runway incursion audio alert I was referring to is vehicle fitted, not in the VCR. It gives the vehicle driver an audio alarm that they are approaching the runway strip.
I am not aware that such a system exists. Not difficult to introduce in an airfield equipped with multilateration of SMGCS I would imagine. But not heard there is one on the market , and if there is none I am not sure there is market for it to justify development and certification costs.
Again, seen the speed at wich the truck enters the runway on the videos , I am not sure if would have helped. Good briefings and strict procedures are cheaper and work 99,999% of the time

Poor briefings on staff operating near active runways seems to be the common point in many of the runway incursions . (e.g. Vnukovo. Luxemburg , etc.) We will see here if this is the case again.

[jumpseater]

@jumpseater :
I am not aware that such a system exists. Not difficult to introduce in an airfield equipped with multilateration of SMGCS I would imagine. But not heard there is one on the market , and if there is none I am not sure there is market for it to justify development and certification costs.
Again, seen the speed at wich the truck enters the runway on the videos , I am not sure if would have helped
SNIP


A system does exist and it doesn't require SMGCS and is CAP1168/CAA compliant. It also configures for CATII/III operations and holding points as required.
It may have helped here, the alarm activates at CATI or as specified. Thus at 75m from the runway the alarm may have triggered a response from the driver to turn earlier and might have turned this into a near miss, or less severe accident.

It's no good people banging on about airside staff being trained not to enter runways without permission. We train pilots not to crash aeroplanes but they still do it, and far more frequently than ground staff cause accidents by entering active runways or maneuvering areas. Clearly several factors as a minimum came into play here, we need to know what, why, to ensure we're not being complacent.

[nivsy]

So no truth in rumour that pilots were detained "in jail" for two days? 🫣​​​​​

[LowandSlow1]

So no truth in rumour that pilots were detained "in jail" for two days? 🫣​​​​​

I read in Flight Global this morning that the two pilots are still being detained by the police.

[Equivocal]

Poor briefings on staff operating near active runways seems to be the common point in many of the runway incursions . (e.g. Vnukovo. Luxemburg , etc.) We will see here if this is the case again.Not sure that poor briefing contributed to at least one of the examples you cite.

A very sad event which could have been avoided by applying routine procedures. A whilst it is no consolation to the family and friends of the RFFS crew involved - to whom one can only offer condolences and wishes for the survivor - it is fortunate that so few injuries were suffered by those on the aircraft.

[ATC Watcher]

Not sure that poor briefing contributed to at least one of the examples you cite.

A very sad event which could have been avoided by applying routine procedures. .
Yes, and those routine procedures should be reminded at every briefing before working in or close to an active runway.

On the poor briefings :yes in both Vnukovo and Luxembourg examples I mentioned (but I could have included more like the Dublin lawn mower for instance) , poor préparions and lack of proper briefings played the major role . You can also add or even replace to poor briefing , by poor training, or lack of understanding how the whole system works if you prefer . But the root cause is there
. In my (old) days as a TWR controller is was mandatory that the crew chief of any intervention planned in the manœuvre area or any of the runways came physically to the TWR to discuss what was planned with the TWR supervisor , which included info passed to the crew chief on planned departures and arrivals during that time .
Today time is money , and this is long gone .

[eagle21]

It wasn’t a training exercise - there was a plane near the terminal with a problem which the firies were responding to. We don’t know enough yet, but either they crossed the active runway without clearance (unlikely), or ATC messed up and both the aircraft and the firies were given clearance at the same time.

If the firies were in emergency mode to get to the other plane it’s possible they didn’t hear ATC telling them to stop at the runway, or the call wasn’t made. All speculation of course, I’m assuming the plane was given takeoff clearance.

Terrible accident, but there are processes in place to stop this so somebody made a mistake. I hope it was the firies because at least they don’t have to live with the guilt, as horrible as that is.

So, it is now confirmed that it was a training/safety drill. What made you rebuke this information?

[Jetset 88]

Received a call from my wife who is in Peru,and then checked with Reuters who are reporting an accident last week on 18 November at 1511 local time at Lima Intl Airport, Peru.
An airport firetruck taking part in an exercise at the LIM/SPIM airport was hit by an Airbus (model unknown) but operated by LATAM. The aircraft was one minute into its takeoff run and the collision killed two firemen and injured some 20 pax on the aircraft. No crew or passengers were killed on the aircraft.
No further info as yet.
See: Reuters: Peru airport says firetruck on arranged drill before fatal collision | Reuters (https://www.reuters.com/world/americas/peru-airport-says-firetruck-arranged-drill-before-fatal-collision-2022-11-20/)

[DIBO]

The whole area there seems to be under construction, so only unpaved roads, marked with cones.
Indeed, newly constructed paved service road without much markings, a new parallel twy under construction probably still with few or no markings, stop signs, etc. ARFFS not yet fully acquainted with the vast expansion, with all its new roads/twy's and second rwy (driving in the other direction they could have crossed the whole lot (including rwy) without any risk of active traffic).
In my humble opinion this is a contributing factor for this tragic event.I second that.

[DIBO]

an update on the blancolirio YT channel
https://www.youtube.com/watch?v=wOTC7TlMmQE

[carpi]

Report is out, for those who speak Español. Can't post link or upload here (6mb) but you'll find it if you go looking. Dunno about any translations yet.

[VHOED191006]

From the AvHerald:

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.

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.