ASN Wikibase Occurrence # 347176
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Date: | Thursday 21 January 2021 |
Time: | 09:38 UTC |
Type: | Boeing 737-86J (WL) |
Owner/operator: | Flybondi |
Registration: | LV-HFR |
MSN: | 28071/133 |
Year of manufacture: | 1998 |
Fatalities: | Fatalities: 0 / Occupants: 181 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | Buenos Aires/Ezeiza Airport, BA (SAEZ) -
Argentina
|
Phase: | Take off |
Nature: | Passenger - Scheduled |
Departure airport: | Buenos Aires/Ezeiza-Ministro Pistarini Airport, BA (EZE/SAEZ) |
Destination airport: | San Carlos de Bariloche International Airport, RN (BRC/SAZS) |
Investigating agency: | JST |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:Flybondi flight FO5238, a Boeing 737-86J, was involved in a runway incursion incident at Buenos Aires/Ezeiza Airport, BA (EZE).
During the take-off run on runway 17, the crew noticed the presence of cones marking an area of the runway that was under repair. The aircraft took off ahead of the repair area and the flight continued to the destination airport, where it made a safe landing.
Conclusions related to factors related to the incident:
- During the takeoff run on runway 17 at Ministro Pistarini International Airport, the crew of flight FO5238 noticed the presence of cones in their path.
- Runway 17/35 was closed due to repair work on its surface.
- The section of runway 17/35 under repair also corresponded to a segment of TWY I, located between the intersection of runways 17/35 and 11/29, and TWY H.
- The area under repair was marked with the use of orange cones with white stripes.
- Apart from the cones used, there were no other visual aids indicating that runway 17/35 was out of service.
- A NOTAM was issued in relation to the repair work, which stated the closure of TWY I from 04:00 to 13:00 on January 26.
- A NOTAM explicitly stating the closure of runway 17/35 from 04:00 to 13:00 on January 26 was not issued.
- In the initial communication at 8:44:51 between the crew of flight FO5238 and the surface position at the TWR of Ministro Pistarini International Airport, it was reported that runway 11 was active.
- A scheduled shift change took place at the TWR of Ministro Pistarini International Airport at 9:00. During the shift change, it was communicated that TWY I was out of service, but it was not explicitly stated that runway 17/35 was also out of service.
- At the time of the incident, the shift at the TWR of Ministro Pistarini International Airport consisted of an approach CTA, a surface CTA, and a TWR supervisor.
- After the shift change, the crew inquired with the surface CTA about the availability of runway 17 for takeoff, and they were told it could be used.
- The crew of flight FO5238 was authorized by the surface CTA to taxi, start up, and taxi to runway 17. Subsequently, the crew was authorized by the approach CTA to take off from runway 17.
- The 9:00 ATIS recording, made by one of the incoming shift's CTAs, indicated that runway 17/35 was out of service.
- The crew of flight FO5238 did not communicate the receipt of ATIS information as required by the NyPTJA.
- Although Flybondi's MOE stipulates that the copilot should copy the current ATIS information, it does not explicitly require acknowledgment with the appropriate ATS authorities.
- The CTAs did not inquire with the crew of flight FO5238 whether the ATIS information had been copied.
- Jeppesen's cartography used by Flybondi's crews did not include the existence of TWY I on its airport layout.
- At the time of the incident, Flybondi did not conduct low visibility operations, so its crews were not familiar with the use of TWY I.
- The risk analysis conducted by AA2000 was approved by ANAC on January 26, approximately 10 minutes before the scheduled start of the construction work.
- The risk analysis performed by AA2000 did not consider the possibility of an aircraft taking off from runway 17/35.
- EANA did not conduct a risk analysis as it was notified after the start of the repair work.
Accident investigation:
|
| |
Investigating agency: | JST |
Report number: | |
Status: | Investigation completed |
Duration: | 2 years and 9 months |
Download report: | Final report |
|
Sources:
JST
History of this aircraft
Other occurrences involving this aircraft
17 November 2018 |
LV-HFR |
Flybondi |
0 |
Paso de los Libres |
|
non |
Loss of pressurization |
Revision history:
Date/time | Contributor | Updates |
23-Oct-2023 16:54 |
harro |
Added |
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