Van L410 at Dubrovnik on Nov 29th 2018, touched down before displaced threshold

Last Update: May 18, 2020 / 20:58:16 GMT/Zulu time

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Incident Facts

Date of incident
Nov 29, 2018

Classification
Incident

Flight number
C3-821

Aircraft Registration
OK-LAZ

Aircraft Type
Let L-410 Turbolet

ICAO Type Designator
L410

Airport ICAO Code
LDDU

A Van Air Europe Let L-410 on behalf of Trade Air, registration OK-LAZ performing flight C3-821 from Split to Dubrovnik (Croatia) with 7 passengers and 3 crew, landed on Dubrovnik's runway 12 at about 12:45L (11:45Z) but touched down before the displaced threshold of the runway. The aircraft rolled out safely and became stuck amidst machinery and workers performing runway reconstruction work. There were no injuries, the aircraft did not sustain any damage.

About 10 minutes later a taxi path was cleared for the aircraft and the aircraft was able to taxi to the apron.

Croatia's Civil Aviation Authority have opened an investigation.

Trade Air confirmed their flight C3-821 landed on the closed portion of Dubrovnik's runway, Croatia's CAA is investigating. Fire brigades and ambulances responded and deployed to the aircraft, however, did not need to intervene. A short time later the aircraft was able to taxi to the apron, where the passengers disembarked normally. The aircraft had been leased in from Van Air Europe.

Dubrovnik Airport is currently undergoing a major reconstruction project, the threshold of runway 12 was displaced by 1745 meters leaving 1425 meters of runway (TORA=TDA=ASDA=LDA=1425 meters) available.

Croatia's Air Accident Investigation Department (AIN) released their final report concluding the probable cause of the serious incident was:

Immediate cause

The immediate cause of the serious incident in question was failure to identify the active portion of the runway and the closed portion of the runway by the commander of the aircraft.

Contributing factors

The factors that led to the immediate cause of this accident are:

- Inadequate flight preparation by flight crew.

- A visual approach below the ideal aircraft path.

- Non-marking of the closed portion of the runway with horizontal signalling closed marking (“X”) in accordance with the applicable standards.

- Partial visibility of the covered horizontal markings of the portion of the runway, which was out of use.

- Lack of information on the displaced runway 12 threshold in ATIS and/or in information published by the controller of Croatia Control to the aircraft in question.

The AIN analysed:

It was established that on the day of the serious incident in question during flight preparation, by inspecting NOTAM information, the flight crew noted that construction works were being performed at Dubrovnik Airport and that the wind was blowing with the strength exceeding the permitted limits for the aircraft in question. The NOTAM in force contained information on the current Phase of the construction works (Phase II) and the information on issued AIP SUP Document (013/2018, in force as of 25 November 2018). The specifics of construction works and their impact on the flight operations were contained in the extensive AIP SUP documentation. The flight crew did not check the content of the AIP SUP document. More detailed information on the construction works were also contained in Jeppesen Airport Cards which the flight crew did not thoroughly examine.

On the day of the serious incident, the subject crew first actively flew on lines Osijek-Rijeka and Rijeka-Split, during which the wind intensity at Dubrovnik Airport decreased and fell within the range acceptable for the subject aircraft. On the subject flight, during the approach to Dubrovnik Airport, the crew was informed of its condition via ATIS (at a frequency of 118.425 Mhz). ATIS for Dubrovnik Airport contained information on the shortened runway (1,425 meters) but did not contain any other information on construction works.

The crew, after being offered approach possibilities by the controller, selected a visual approach for the runway direction 12. During the clearance for landing, the controller of Croatia Control did not provide information related to the construction works via radio link in any form, and therefore did not provide information on the displaced runway 12 threshold. During the approach itself, the first officer addressed the commander who operated the aircraft twice, informing him of presence of construction vehicles in the middle of the runway. Considering his recent experience of landing at Dubrovnik Airport, after the second addressing to the commander, she had no doubts regarding correctness of the aircraft flight path.

During the visual approach, the aircraft descended below the perfect approach path to the runway 12. From this position, due to the curvature of the runway, the crew was no longer able to see the lights of the active runway, the displaced runway threshold or the construction vehicles located at the end of the closed portion of the runway 12. The only markings on the closed portion of the runway that the flight crew from that position could see did not indicate, by their condition, that the runway was closed. The covered horizontal markings of the closed portion of the runway 12 became partially visible due to the fact bitumen emulsion has been washed out by rain. Also, on the closed portion of the runway there was no closed marking “X” which would indicate the closed status of the runway to the crew.

After landing and stopping, the flight crew noticed the construction vehicles at the end of the runway, and received information via radio link from the controller of the Croatia Control that they have landed on a closed portion of the runway and that they should wait for the airport vehicle.

Standards of horizontal marking of a closed runway or its portion are included in the ICAO Annex 14, EU Regulation CS-ADR-DSN, and Ordinance on Aerodromes, Official Gazette 58/14. All three of these documents envisage a white closed marking “X” when a runway or its portion is closed for use. The said documents also state that the placement of the closed marking “X” is not necessary if the runway or its portion is closed for a short period of time and when the information on its closing information is published by an adequate warning issued by the aeronautical information provider (in this event, the Croatia Control). All three of these documents do not define the meaning of the terms “short duration” or “adequate warning”. The documents set out standards related to the colour and dimensions of the marking, but not the manner in which the marking itself should be performed.

Considering the entire operating area (runway) was a construction site, the construction safety plan foresaw covering the existing markings on the portion of the operating area out of use until they are destroyed by the construction works. The closed marking “X” was not placed since the entire closed area was the construction site where the pavement surface was being removed.

...

During the safety investigation, it was established that in the operator's analysis of the subject event it was stated that the runway and PAPI lights were not turned on at the time of the aircraft landing. In the analysis of the subject event by Dubrovnik Airport it was stated that the runway and PAPI lights were turned on at full intensity during the subject event in accordance with the prescribed procedures.

During the safety investigation it was not possible to determine with certainty whether the said lights were turned on or off during the landing of the aircraft. If the lights were on, the possibility that the flight crew could not have seen them due to the characteristic curvature of the runway, the lower approach angle of the aircraft to the runway and the construction machinery and vehicles that were located in the middle of the runway, could not be excluded.

Metars:
LDDU 291300Z VRB04KT CAVOK 14/M01 Q1020 NOSIG=
LDDU 291230Z 18008KT 150V240 CAVOK 13/M00 Q1020 NOSIG=
LDDU 291200Z 22007KT 160V270 CAVOK 13/M01 Q1020 NOSIG=
LDDU 291130Z 33003KT 230V030 CAVOK 14/M03 Q1020 NOSIG=
LDDU 291100Z 01004KT 330V050 CAVOK 14/M03 Q1020 NOSIG=
LDDU 291030Z 36008KT 330V030 CAVOK 13/M03 Q1021 NOSIG=
LDDU 291000Z 02010KT 330V070 CAVOK 12/M03 Q1021 NOSIG=
LDDU 290930Z 02014KT 350V050 CAVOK 12/M03 Q1021 NOSIG=
LDDU 290900Z 02016KT 340V060 CAVOK 11/M04 Q1021 NOSIG=
Incident Facts

Date of incident
Nov 29, 2018

Classification
Incident

Flight number
C3-821

Aircraft Registration
OK-LAZ

Aircraft Type
Let L-410 Turbolet

ICAO Type Designator
L410

Airport ICAO Code
LDDU

This article is published under license from Avherald.com. © of text by Avherald.com.
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