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Accident: LATAM Chile A20N at Lima on Nov 18th 2022, collision with fire truck on takeoffBy Simon Hradecky, created Friday, Nov 18th 2022 22:36Z, last updated Monday, Oct 2nd 2023 17:24ZA LATAM Chile Airbus A320-200N, registration CC-BHB performing flight LA-2213 from Lima to Juliaca (Peru) with 102 passengers and 6 crew, was accelerating for takeoff from Lima's runway 16 at about 15:11L (20:11Z) when multiple fire trucks with flashing lights and sirenes sounding crossed the runway in front of the accelerating aircraft. The crew rejected takeoff at high speed (at about 125 knots over ground) but wasn't able to avoid contact with fire truck #3 although the truck tried to turn around turning right (into direction of the aircraft). The right main gear collapsed causing the aircraft to veer right towards the right hand runway edge coming to a stop partially off the runway about 2500 meters/8300 feet down the runway. A fire erupted around the right hand engine (PW1127G), all occupants were able to evacuate the aircraft. 4 passengers received serious and 36 passengers received minor injuries. The aircraft sustained substantial damage, the fire truck was destroyed. Two fire fighters on board of the truck involved in the collision did not survive, a third fire fighter on the truck involved received serious injuries.
The airline reported all occupants of the aircraft survived the accident. There were 102 passengers and 6 crew on board.
Lima's Airport Authority reported all passengers were "doing well" and are receiving the attention of their teams. According to recordings the fire truck(s) entered the runway without clearance. The fire trucks had been responding to another aircraft that had suffered mechanical problems. On Nov 19th 2022 the Airport Authority reported that works to remove the aircraft from the runway have begun. In the late evening of November 19th 2022 the airport authority announced, the aircraft had been moved off the runway in a very complex operation, repair works on the runway have begun. The runway had received extensive damage both in depth and length.
On Nov 20th 2022 Lima's Airport Authority (LAP) reported in a written communique, that a pre-planned response time exercise was performed by the Rescue Team, in which it was to prove that a response to an emergency on the runway would not take any more than 3 minutes. The exercise had been coordinated between the airport and the Air Traffic Authority (CORPAC) and set to be carried out between 15:00 and 16:00 local time on Nov 18th 2022. CORPAC (Control Tower) confirmed the start time of the exercise at 15:10L, the impact with the LATAM aircraft happened at 15:11. The exercise was duely authorized under the current aeronautical regulations. (Editorial note: this communique does not mention, whether the vehicles were cleared to enter the runway by tower or whether the pre-coordination with CORPAC also included that the vehicles would be cleared to enter the runway without actual tower clearance, in other words tower would halt all traffic at 15:10L).
On Nov 21st 2022 Peru's Ministry of Transport and Communication in its role as Civil Aviation Authority stated, that the communique by LAP was essentially correct, however, this communication and coordination did not mean that the trucks had been cleared to enter the active runway. The exercise is authorized, but this does not mean that using this exercise there is anyone cleared to enter the runway, in particular if there is an aircraft moving on the runway. At this time there is no comment available, whether the trucks were cleared to enter the runway or not. However, the ministry confirmed the LATAM aircraft was cleared for takeoff.
Medical Services reported 102 passengers and 6 crew were evacuated from the aircraft, 24 passengers were taken to hospitals with injuries. The numbers were later updated stating 4 passengers received serious and 36 passengers minor injuries.
The head of the fire fighters at Lima Airport reported that two fire fighters persished in the accident, a third was taken to a hospital with serious injuries and is in the Intensive Care Unit in stable condition. Later the head of the firefighters added, the surviving fire fighter was diagnosed with a fracture at the base of his skull, severe head trauma including bruises of the brain stem and facial trauma, the vital functions are stable, the neurological compromise can only be assessed at a later time. The next 24 hours will be crucial. On Nov 21st 2022 the condition of the injured firefighter was still assessed critical.
An ATC report states in writing that the rescue vehicle entered runway 16 from the west at the height of taxiway B without authorization and collided with flight LA-2213. Emergency procedures were invoked and rescue vehicles cleared onto the runway to deal with the accident. The runway was NOTAMed closed.
On Nov 21st 2022 CORPAC, Air Traffic Control, stated categorically, that no vehicle had been cleared to enter the runway. CORPAC confirmed there was coordination for an exercise to be carried out by rescue services, however, this did not affect the runway and was to be held outside the runway strip.
The airline reported that they do not know what the fire truck had to do on the runway and why it was there. They had no information about an emergency drill. In any case the normal procedure would be that any vehicle needing access to the runway would need to communicate with tower and obtain clearance to enter the runway. Their aircraft was cleared for takeoff.
The local prosecution office reported two firefighters died in the accident, another one was injured. The office have opened an investigation to determine the facts and possible culpability and are currently reviewing the CCTV recordings.
Peru's Comision de Investigacion de Accidentes de Aviacion (CIAA) opened an investigation into the accident.
On Nov 25th 2022 the CIAA reported a fire truck on an assistance exercise entered the main runway while CC-BHB was in the takeoff run and collided with the right hand wing and engine of the aircraft. Two firefighters were killed, another firefighter was injured. The aircraft crew rejected takeoff and stopped the aircraft about 1500 meters past the point of collision, an immediate evacuation was carried out. Other fire trucks extinguished the ensuring fire and assisted passengers, who received medical care. The aircraft was destroyed. An investigation is ongoing.
On Sunday Nov 20th 2022 at 00:00L (05:00Z) the runway was opened for takeoffs and became fully available some time later. Flight operations at Lima Airport have resumed.
The transcript of the communication on ground frequency (tower frequency not available) in the crucial time between starting of the exercise (20:10:00Z) and the collision reads with all times in UTC (according to the ground recording Recate 6, Rescue vehicle #6, took position on taxiway Alpha near but outside the runway strip at 20:04, obviously being the target of the exercise, Ground cleared Recate 6 to a position 90 meters from the runway axis indicated by traffic cones).
20:10:10 Ground: "Recibido mantenga posicion" ("All received, hold position") 20:10:13 Unreadable 20:10:20 Ground: "Rescate 6 Recibido" ("Rescate 6, roger") 20:10:25 Unreadable 20:10:30 Ground: "Sky 05210 Superficie Buen dia ruede via A mantenga antes de B." ("Sky 05210 Ground Good morning, taxi via A hold before B") 20:10:35 Sky05210?: ""?A?"" unreadable. 20:10:39 Ground: "unreadable del rescate repita distintivo" ("unreadable, rescue, say again callsign") 20:10:52 Ground: "A la vista Rescate ingresando sedes" ("Rescue vehicle in sight, entering base") 20:10:56 Ground: "LAN Peru 2186 Cuando listo contacte Lima TWR 118.1?" ("LAN Peru 2186 When ready contact Lima TWR 118.1") 20:11:00 Ground: "LAN Peru 2023 continue rodaje A1 A punto de espera pista16" ("LAN Peru 2023 continue taxiing A1-A holding point runway 16") 20:11:08 LAN Peru 2186?: "Torre uno ocho coma unreadable" ("Lan Peru 2186? probably reading back the frequency") 20:11:09 ?: "?Listo rodar?"" ("? Ready taxi") 20:11:12 Ground: Jetsmart 7128 ruede via A mantenga antes de B ("Jetsmart 7128, taxi via A hold before B"). 20:11:16 Jetsmart 7128: "Mantenerse en bravo ... " ("Jetsmart 7128 Maintaining bravo") 20:11:38 unreadable because being stepped on by ground 20:11:41 Ground: "rescate repito, repito rescate, aeronave siniestrada en pista repito" ("Rescue repeat, repeat rescue, aircraft crashed on runway, repeat", note: there was shouting in the background)
The shouts on the CCTV video showing the emergency vehicles on their way out of the base to the runway indicate surprise and shock.
Related NOTAMs: A5194/22 NOTAMR A5178/22 Q) SPIM/QMRLC/IV/NBO/A/000/999/ A) SPJC B) 2211191500 C) 2211200500 EST E) RWY 16/34 CLSD DUE ACFT OBST A5178/22 NOTAMN Q) SPIM/QMRLC/IV/NBO/A/000/999/ A) SPJC B) 2211182020 C) 2211191800 E) RWY 16/34 CLSD DUE ACFT OBST
Metars: SPJC 182200Z 18009KT 9999 SCT015 BKN020 19/14 Q1012 NOSIG RMK TX21.7 PP000= SPJC 182100Z 19010KT 9999 BKN020 19/14 Q1012 NOSIG RMK PP000= SPJC 182000Z 18009KT 160V230 9999 BKN021 20/13 Q1012 NOSIG RMK PP000= SPJC 181900Z 21008KT 180V270 9999 SCT021 21/14 Q1012 NOSIG RMK PP000= SPJC 181800Z 27006KT 220V300 8000 SCT020 20/14 Q1013 NOSIG RMK PP000= SPJC 181700Z 27007KT 240V300 9999 BKN020 20/14 Q1013 TEMPO SCT025 RMK PP000= SPJC 181600Z 24007KT 220V280 9999 OVC020 19/14 Q1014 NOSIG RMK PP000=
The accident (Video: Flying for Real):
CCTV: the emergency vehicles on their way to the collision:
Still image out of CCTV: moment just before the collision:
The remains of the fire truck #3 involved in the collision:
The aircraft after the fire was put out:
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By Simon Hradecky, created Monday, Oct 2nd 2023 17:21Z, last updated Monday, Oct 2nd 2023 17:24ZOn Oct 2nd 2023 Peru's CIAA released their final report in Spanish only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Spanish only or no release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).
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.
At 15:03L the rescue services supervisor requested and received permission to remove the safety cones, however, omitted the information that these were across VSR4 and VSR4 was the intended route of the vehicles. The tower supervisor requested clarification regarding the location of the cones, the rescue supervisor was unable to provice that information demonstrating he was not familiar with the nomenclatura and location of taxiways and roads. The controller was not aware by granting the permission to remove the cones he was enabling unobstructed access to the runway, at the same time the rescue supervisor perceived this as clearance to directly access the maneouvering and runway area.
At 15:10L the exercise started.
Assumed vehicle path by CORPAC and tower (blue), actual path (yellow) (Graphics: CIAA):
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