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ASN Wikibase Occurrence # 230972
Last updated: 14 October 2021
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Date:14-NOV-2019
Time:22:35 LT
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8D6 (WL)
Owner/operator:Algeria - Air Algerie
Registration: 7T-VKR
MSN: 60754/6214
Fatalities:Fatalities: 0 / Occupants: 95
Aircraft damage: None
Category:Serious incident
Location:Lyon Saint-Exupéry Airport (LYS/LFLL) -   France
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Lyon Saint-Exupéry Airfield (LYS/LFLL)
Destination airport:Annaba-Les Salines Airport (AAE/DABB)
Investigating agency: BEA
Narrative:
In LVP conditions and at night, the ground controller at Lyon Saint-Exupéry Airport cleared a snow-plough to enter runway 35L to clear snow at the intersection with TWY A4 without coordinating with the LOC controller. At the same time, the LOC controller cleared flight DAH1157, a Boeing 737-800, to take off from runway 35L. The two controllers saw the conflict. The LOC controller ordered the aeroplane taking off to perform an acceleration-stop. The aeroplane came to a halt around 1200 m before the intersection with TWY A4.


Causes of the serious incident:
The runway incursion was related to an erroneous runway clearance resulting from a lack of coordination between the ground and LOC controllers and the maintenance on the groud frequency of vehicles authorised to enter.
Contributing factors to the conflicting clearance and maintenance on an inadequate frequency were:
- A high workload in an unusual context where roles within the tower were sometimes unclear.
- Re-opening of the inner runway after snow clearance when snow clearance of taxiways and junctions with the runway required snow clearance vehicles to enter the runway.
- Practices lacking a clear framework on the use of frequencies for vehicles during temporary runway closures.
- A configuration of stop bars that was incompatible with the snow clearing routes followed by the vehicles.
The runway incursion, if it can be considered a failure as such, is above all symptomatic of the confusion and disorganisation generated by the management of the snowy episode.
The following contributed to the confusion and disorganisation:
- A snow plan defined in an overly formal manner and partly disconnected from operational realities.
- Inaccurate measurements of runway conditions leading to a high workload and difficulties in the snow clearing strategy to be implemented.
- Regulation and suspension principles that are difficult to apply by those directly involved in traffic management and snow clearance.

Sources:

https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-grave-du-boeing-737-immatricule-7t-vkr-exploite-par-air-algerie-survenu-le-14112019-a-lyo/
https://www.flightradar24.com/data/aircraft/7t-vkr#22d866f3

Accident investigation:
cover
  
Investigating agency: BEA
Status: Investigation completed
Duration: 1 year and 9 months
Download report: Final report


Images:

Photo of 7T-VKR courtesy AirHistory.net


London - Heathrow (EGLL / LHR)
13 August 2019; (c) Fergal Goodman

Revision history:

Date/timeContributorUpdates
29-Nov-2019 16:30 harro Added
07-Sep-2021 19:59 harro Updated [Time, Total occupants, Location, Narrative, Accident report]

Corrections or additions? ... Edit this accident description