TAROM AT72 at Bucharest on Oct 13th 2016, rejected takeoff due to gear vibration
Last Update: June 18, 2021 / 15:13:41 GMT/Zulu time
A replacement ATR-42-500 registration YR-ATA reached Iasi with a delay of 4 hours.
Romania's CIAS have opened an investigation, a team investigators had been dispatched on site.
On Oct 20th 2016 the CIAS reported that a runway inspection found pieces of runway lights on the runway, the pieces were identfied as parts of runway edge lights, a number of runway edge lights from the southern edge of the runway were completely missing.
On Jun 18th 2021 the CIAS released their final report concluding the probable cause of the serious incident was:
The cause which led to the serious incident is the aircraft alignment and its take-off roll performed along the runway edge lights line of the R/H edge of the runway.
- The lack of crew concentration during this flight phase;
- Distraction of crews’ attention during this flight phase;
- The aircraft did not follow the yellow line marking the centerline of the “W” taxiway until the intersection with the runway centerline.
The CIAS reported:
The aircraft started the takeoff roll but, few moments later, the crew rejected the takeoff, the reason given to the control tower being the sensing of vibrations at the nose gear.
After stopping the takeoff, the aircraft vacated the runway on taxiway” O”, continued on taxiways ”P” and ”C” then returned on the apron, at the parking spot.
After the runway was declared vacated, another aircraft, registration YR-ASB, was given the clearance for lineup and hold, by informing them to wait for a runway inspection.
An employee of the airport did perform a runway inspection, using an airport service car. The path followed by this car, was: entry on the runway by the taxiway ”V”, towards the 08L threshold, then along the north side of the runway and turning in front of the aircraft which was aligned for takeoff, continuing on the south side until the intersection with the taxiway ”V”, after that following a path on the runway centerline and then runway was vacated at its end, on the taxiway ”O”. During this runway control, nothing unusual was noticed.
After this control, three other commercial flights took off on runway 08L.
The airport personnel in duty, requested a control of the YR-ATI aircraft
at the parking position. It was found that the ventral fuselage, behind the nose gear, presented few deformations following hits, some of them with skin punctured and also, at least three blades of the left-hand engine, presented hits scars.
As a consequence of the findings on the aircraft, a thorough inspection of the 08L runway was performed and there been found metallic elements and glass cullet which were identified as broken parts of the runway edge lights. It was found that six runway edge lights were destroyed (numbers 3, 4, 5 ,6, 14 and 16), all of them on the south edge of the 08L runway.
Following these findings, the 08L/26R runway was closed.
The aircraft was flown by a captain (32, ATPL, 4,723 hours total) and a first officer (31, ATPL, 1,488 hours total). At the time of the occurrence following METAR was valid:
LROP 131830Z 11005KT CAVOK 08/07 Q1019 NOSIG=
The CIAS analysed:
According to the records analyzed by the investigation commission, the time framing of the events was the as follows:
- At 21:06 LT (18:06 UTC), the crew requests clearance for engines start-up, from OTP GND (Ground Otopeni);
- After engines start-up, at 21:08 LT, the crew requests taxi clearance, which was performed maintaining a radio communication with cu OTP GND;
- During its taxi along ”O” taxiway, when was approaching from the intersection with ”W” taxiway, the crew entered in radio contact OTP TWR (Otopeni Tower) and was cleared to enter, line-up and hold on 08L runway.
- For the entrance on the runway and line-up, initially the pilot followed the yellow centerline of the “W” taxiway/, which leads to the runway centerline. At the moment of entering the runway, she turned to the left, leaving this marking.
- After this maneuver, she turned to the right and aligned on the line of right runway edge light considering that is the runway centerline
After lineup, the crew continued with the cockpit checks, according to the FCOM ATR72 Normal Procedures Cap 2.03 Before Take Off. OTP TWR issued the clearance for take-off.
After receiving the takeoff clearance, the crew requested a delay of 30 seconds for take-off, in order to gain a timely and spatial separation behind an aircraft which just took-off.
The aircraft started the take-off roll and after approximate 700 m, at an indicated speed of 82 kt, the take-off was rejected, the reason given by the crew being “the appearance of some vibrations at the nose wheel”:
18:16:44 ROT717: ”ROT717 stopping”;
CTA TWR: ”Roger ROT717. Do you need any assistance on the runway?
CTA TWR: ”Roger ROT717, if able vacate via taxiway Oscar”
ROT717: ”Will vacate via Oscar”
18:17:45 CTA TWR: ”ROT717 can you please tell me the reason?”
ROT717: ”Vibrations at the nose wheel”.
After rejecting take-off, the aircraft vacated the 08L runway on ”O” taxiway, then it followed the taxiways ”P” and ”C” and returned to the parking position.
According to the CVR (Cockpit Voice Recorder) records the following
aspects can be evidenced:
- during the whole period, since engines start-up, taxi, aircraft line-up on runway for takeoff and until the moment of starting the takeoff roll, inside the flight deck were recorded talks which were irrelevant for the flight (critical phase).
- after the lineup clearance on 08L runway was obtained, the flight deck crew passed to the cabin crew, the specific message to take their positions for takeoff: ”Cabin crew take your seat for Take Off”.
- after 37 seconds since this message was given, a flight attendant entered the cockpit and an irrelevant talk for the flight phase took place.
The path followed by the YR-ATI aircraft, from its parking position until the runway vacation after rejecting takeoff on 08L, according to the GPS data analyzed by the investigation commission, reveals the maneuver executed for runway line-up and the aircraft alignment on the runway edge line of the R/H edge of the runway.
This data has been compared to and validated by the records of the radar
A-SMGCS system and have been used to create a real movie of the events.
The radar surveillance system is used by the ground traffic controller, which has no responsibilities regarding checking the aircraft position on the runway and also, is not anymore in radio communication with the crew when the aircraft is on the runway, aligned for takeoff and waiting for its takeoff clearance.
As a consequence, the responsibility for the maneuvers of runway entering and alignment for takeoff are lying only with the flight deck crew.
Out of the analyzed images can be revealed that the aircraft did not perform a correct line-up on the runway centerline and the take-off roll, until its rejection, was been executed completely along the runway edge lights line of the R/H runway edge.
Also, the investigation commission considers that two more contributive
factors for the analyzed occurrence can be evidenced:
- failing to use all the means and resources to obtain a positive confirmation of the aircraft position, such as a cross-check done by the copilot of the visual references (first officer & captain of the visual references (the runway centerline beacon and the two runway edges light lines) and the onboard navigation means (check according to FCOM FD BAR CENTERED, HDG=RWY HDG).
- crew behavior, which was conducted by the routine and their actions were not according to CRM (Crew Resource Management).
CRM is a principle of team work for the flight crews, actually referring to the optimal management of all the onboard resources, offered by: the onboard technology, the flight crew, navigation means, air traffic controllers, etc.
CRM is a concept by which is intending to mitigate the errors and to increase the efficiency of the flight crews and can be defined as the efficient use by the crew, of all the available resources (information, material equipment and human resources) to achieve an efficient and safe flight operation.
According to CRM, the duties of each pilot are clearly defined for each flight phase.
The copilot declared that she kept all the time her eyes within the cockpit, despite the 30 seconds supplementary waiting before starting the takeoff roll.
The copilot did not continuously monitor the maneuvers during aircraft taxi, and neither monitors the space around, and the pilot in command, probably due to routine, performed incorrectly a critical phase of flight, respectively, the lineup on the runway for takeoff. More of that, the crews’ attention was being distracted by irrelevant talks.
Analyzing the records of the A-SMGCS system can be noticed the moment when the aircraft returns on the runway centerline, then continues taxiing until the “O” taxiway. It can be considered that the crew acknowledged that the takeoff roll was wrongly performed along the runway edge lights of the R/H side.
According to the opinion of the investigation commission, the pilot in command should report to the air traffic controller the real reason for the takeoff rejection, in order to prevent the exposure of the next operating aircraft on the same runway to the high risk represented by the debris of the destroyed beacons remained on the runway (FOD).
The investigation commission considers also that neither the last safety filter which should of prevent that other three aircraft to takeoff from a FOD contaminated runway, did not work. That is the first runway inspection performed by the airport designated personnel.
This article is published under license from Avherald.com. © of text by Avherald.com.
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