Description

On 18 November 2022, an Airbus A320neo (CC-BHB) being operated by LATAM Peru on a scheduled domestic passenger flight from Lima to Juliaca as LPE 2213 was accelerating for takeoff in normal day visibility on runway 16L when a fire appliance entered the runway not far ahead. An unavoidable collision with the aircraft, which was accelerating and had reached a speed of 131 knots, 14 knots below rotation speed, occurred. Two of the vehicle's occupants were killed and the third seriously injured. Although only one of the 102 passengers escaped injury altogether, only nine of the injuries sustained by them were classified as serious, and all six aircrew were uninjured. The collision completely wrecked the vehicle and caused the aircraft's right engine to be detached from the wing, which caused ground contact and a fuel-fed fire which, although quickly extinguished, caused further damage to the right wing and rear right fuselage. The runway surface and lighting equipment in the vicinity of and beyond the collision point were also damaged.

The aircraft where it stopped with the fuel-fed fire well alight and the right engine missing. [Reproduced from the Official Report]

Investigation

An Accident Investigation was carried out by the Peruvian Aviation Accident Investigation Commission (CIAA). The FDR and CVR were removed from the aircraft and their data were successfully downloaded by the Accident Investigation Authority of Brazil, CENIPA. Recorded ATC communications and video recordings from various sources, as well as a range of written reports, were also available.

The 35 year-old PF A320 captain had a total of 8,229 hours flying experience, including 3,114 hours on A320 family aircraft and had been employed by LATAM for 12½ years. The 30 year-old A320 first officer had a total of 3,390 hours flying experience, including 583 hours on A320 family aircraft and had been employed by LATAM for 8 months in what was his first job as an airline pilot. Both pilots were Peruvian nationals. 

The five Airport Controllers (all Peruvian nationals) working the standard 12-hour day shift were covering four operating positions, with two hours in the Clearance Delivery, GND and TWR positions in two cases, and two hours in the Supervisor position, which was not continuously assigned but was manned during the time when the accident occurred. The duration of their employment with the ANSP was 18 years (1), 8 years (3) and 7 years (1) and all five held current OJTI authorisations.  

The three occupants of the fire appliance (45 years old, 32 years old and 23 years old and also all Peruvian nationals) were all qualified as aeronautical firefighters with 11 years (the vehicle driver), 8 years and 15 months experience respectively, in the latter case accumulated during 3 work periods spread over 16 months. The Airport Fire Service was under the overall control of a 61 year-old ‘General Rescue Supervisor’ who had 22 years relevant experience assisted by a 45 year-old ‘Rescue Team Supervisor’ with 13 years of service. 

What Happened

At a takeoff weight well below the maximum permitted, the flight received pushback clearance from GND five minutes before the five controllers occupying the Supervisor, Tower, Ground and Clearance Delivery positions had routinely changed. Two minutes after this change had occurred, which left the most senior controller in the Supervisor position, the flight received taxi clearance to the holding point of 3,610 metre-long runway 16L and was asked to change to TWR “when ready”. A few minutes later, having checked in with TWR, the crew advised ready for takeoff and were so cleared with a spot wind of 190° at 10 knots given. The captain was acting as PF.

Eight seconds after accelerating through 100 KIAS towards the calculated V1/VR of 145 KIAS, the captain saw a fire appliance subsequently identified as ‘Rescue R3’ ahead entering the runway from the south side at a subsequently calculated speed equivalent to approximately 39 knots. Three seconds later, after this vehicle had made a right turn of around 45° towards the upwind end of the runway on which the aircraft, having travelled approximately 1,200 metres, was approaching, the aircraft’s right wing collided with the vehicle at a recorded speed of 131 knots. The right main landing gear collapsed, and the right engine and its pylon were severed from the aircraft wing. The remains of the vehicle and the detached engine and pylon remained at the point of impact, but as the right wing travelled with its outer section in contact with the runway surface, a substantial fuel leak led to a major wing fire. The aircraft came to a stop 192 metres from the upwind end of the runway, upon which an emergency evacuation was ordered. One evacuation slide did not deploy, and this was subsequently determined to have been due to a defective component which had not been identified. It was noted the extent of collision damage was unsurprising given the high speed of the 64-tonne aircraft and the substantial (23-tonne) weight of the vehicle.

Why It Happened

At the time of the accident, a new parallel runway 16R/34L was being constructed southwest of the existing single runway. It was intended prior to opening this runway to relocate both the Control Tower and the Fire Station from a position northeast of runway 16L/34R to a new location between and equidistant from both the existing and new runways. Although the opening of this new runway was not imminent, it had been decided to carry out trials to confirm that all airside areas of the airport would still be within three minutes reach of the Fire Station (defined as the interval between the first sounding of an alarm and the first fire retardant discharge at the accident site) as required by the applicable regulations.  

A plan view of the accident showing the runway access used by the fire appliance, the collision site and where the aircraft stopped. [Reproduced from the Final Report]

An initial trial to establish that a convoy of emergency vehicles could travel between the (as yet non-operational) new fire station location and the existing runway had already been held and debriefed. Preparations for a second such trial had been made and the emergency service personnel involved had been briefed. ATC had only been informed of this second trial just before it commenced, and the communication between the RFFS and TWR Supervisors failed to ensure that ATC unambiguously understood intended routing for the trial. The ATC Supervisor was left with the understanding that the vehicle convoy would turn right onto the parallel taxiway and proceed along it to the 35R threshold - the designated position of the “fire” being used for the trial, rather than continue ahead onto the runway before turning right.

The fire appliance involved - the lead vehicle of three - had not requested or been given permission from ATC to enter the runway but was proceeding at speed as briefed in order to make a second assessment of the emergency response time. Having entered the runway at speed just as the aircraft was approaching, the collision was inevitable. The driver of the second fire appliance stated that he and his colleagues understood from their Supervisor that ATC had pre-cleared the convoy to enter the runway as had happened in the first trial. When asked by the RFFS Supervisor for permission to remove a line of traffic cones obstructing the intended trial route, the GND Controller stated that he had been unaware that doing so would provide direct access to the active runway.   

The Probable Cause of the Accident was formally documented as follows:

During its takeoff roll, the LATAM aircraft collided with a Fire Appliance which had entered the runway without having received explicit clearance to do so from TWR, while conducting a response time exercise from the relocated Airport Fire Station. This situation was the result of a lack of joint planning, poor coordination, and a failure to use standardised communication and phraseology according to ICAO regulations.
 
Ten Contributory Factors were also identified:

1. The failure of the Lima Airport Operator and the ANSP to conduct a briefing meeting after the first Emergency Response Time Exercise using a yet-to-be-adopted airport layout to identify errors, deficiencies, discrepancies, and to identify material and procedural shortcomings in the exercise's development. Such a briefing could have allowed for an analysis and implementation of improvements in all aspects, serving as a foundation for the optimal execution of a subsequent exercise.
2. The ANSP's acceptance without comment of Lima Airport's proposal to conduct Emergency Response Time Exercise from partially implemented and testing-phase facilities located in new airport areas that had not yet been officially handed over to ANSP control.
3. The absence of meetings between Lima Airport's SMS and the ANSP's SMS for hazard identification, risk management and mitigation actions inherent to the scheduling and execution of Emergency Response Time Exercises from the new airport areas and facilities.
4. The failure to hold a joint meeting between the Lima Airport Operator and the ANSP to plan the execution of the second Emergency Response Time Exercise, which would have provided participating personnel with a clearer understanding of the concept and details.
5. Inadequate instruction provided to both Airport Emergency Services personnel and TWR Controllers to familiarise them with the location, designation, and operational functioning of the new aircraft taxiways and vehicle roadways.
6. The Emergency Services’ mistaken interpretation that the TWR Controller's confirmation of the start of the second Emergency Response Time Exercise also implied authorisation to enter the runway.
7. When authorising the removal of the safety cones at the Airport Emergency Services base, the TWR Controller did not notice that the only access route available for the convoy of Rescue Vehicles direct to the runway was Vehicle Service Road 4.
8. The mistaken interpretation by the Airport Emergency Services Section, who thought that the Tower's confirmation of the start of the second Emergency Response Time Exercise also implied authorisation to enter the runway.
9. The GND and TWR Controllers were informed about the second Emergency Response Time Exercise minutes before its execution, which did not allow them to properly analyse the risks and prioritise air traffic management.
10. The failure to adequately use the standardised phraseology established by ICAO for communications and exchanges between the fire appliances and the TWR Controller during the notified Emergency Response Time Exercise.

A total of 25 Safety Recommendations were made as a result of the Investigation as follows:

• that the Lima Airport Operator carries out awareness campaigns directed at personnel in charge of the Direction, Planning, Coordination, Execution and Supervision of Airport Emergency Response Exercises to achieve in the short term:
  • Improved situational awareness regarding risks and responses to the risks.
  • Promote a culture of safety and strengthen human capacity in this regard.
  • Increase collaboration and mutual assistance with the ANSP.
• that the Lima Airport Operator carries out periodic evaluations of skills and professional and technical performance of the personnel in charge of the Planning, Coordination, Execution and Supervision of Airport Emergency Response Exercises, who have participated in the aforementioned awareness campaign to strengthen Operational Safety and guarantee an optimal level of preparation and knowledge.
• that the Lima Airport Operator maintains the airport map in a constantly updated state, incorporating any relevant modifications that may result in significant operational changes in respect of taxiways, runways, service roads, facilities and manoeuvring areas to ensure its precision and validity at all times.
• that the Lima Airport Operator keeps the Aerodrome Diagram published in the Peru AIP updated, with special attention given to the verification and registration of Hot Spots to ensure accurate and relevant information is available for operators, thus contributing to safer and more efficient management.
• that the Lima Airport Operator identifies the dangers and risks inherent in Airport Emergency Response Exercises so that such exercises are carried out in a safe, organised manner and without conflict with aircraft operations. To achieve this, it will be necessary, in collaboration with the ANSP, to analyse the proposal presented by the Commission in Annex ‘A’ of this Report as a basis for strengthening and improving such exercises as detailed in Annex 11 of the Airport Emergency Plan so that they are duly harmonized and aligned with the procedures specified in section 5.3.6. of the Operational Instruction Manual for ATC TWR Operations which covers "Procedures for the Control of Movement of People and Vehicles in the Manoeuvring Area".
• that the Lima Airport Operator implements a Formal Training and Evaluation Programme regarding the Prevention of Runway Incursions aimed at operational emergency services to cover, among other aspects, the following:
  • Instruction on both the the theoretical and practical aspects of Manoeuvring Area access, covering familiarisation with service roads, taxiways, runways, and the horizontal and vertical warning and danger signage.
  • Ensuring that the Airport Movement Manual provides detailed knowledge of the procedures and regulations which support safe operation.
  • Instruction in the new procedures for Emergency Services Exercises as detailed in the new section 6.4 of Annex 11 of the Airport Emergency Plan. 
  • Training in ICAO Aeronautical Communication Standards, including radiotelephone phraseology and read-back/hear-back techniques in respect of TWR operational instructions under the tutelage and guidance of ANSP expert staff and additional instruction based on ICAO Document 9870 “Manual on the Prevention of Runway Incursions” taught by duly qualified instructors covering the content of this manual.
  • All aspects of this programme must be integrated into successive reviews of the training programme contained in Annex 14 of the Airport Emergency Plan intended for emergency services personnel and address both Initial and Recurrent Training.
• that the Lima Airport Operator in collaboration with the ANSP carries out a comprehensive analysis from both an operational and technical perspective, into the viability of providing the emergency services vehicles TWR frequency radio receivers (listening mode only), in addition to the existing two-way communications frequency 121.9 MHz, in accordance with the recommendation contained in ICAO Document 9870 "Manual on the Prevention of Runway Incursions”.
• that the Lima Airport Operator in coordination with the Emergency Services Technical Team, carries out an exhaustive evaluation of the feasibility of improving the external lighting of Rescue Vehicles to increase their visibility to Tower controllers, aircraft, and vehicles operating on the manoeuvring area.
• that the Lima Airport Operator, in coordination with the team implementing the Lima Airport Expansion Project, carry out a comprehensive evaluation of the visibility of Vehicle Service Road 4, which is assigned for use by emergency service vehicles during both emergencies and exercises with the aim of optimising its observation from the TWR by improving its detection and recognition.
• that the Lima Airport Operator, in collaboration with the ANSP SMS Manager, carries out a detailed evaluation of the matters recorded as “Pending” or “In Progress” in the Minutes of the 9 June 2022 and 25 August 2022 meetings of the SMS-RST External Operating Committee. These elements are within the "Runway Incursion Prevention Program" and its 100% comprehensive execution must be guaranteed.
• that the Lima Airport Operator carries out an exhaustive review of their Manuals, with the purpose of complementing, and if necessary correcting, the Aeronautical Terminology used by their staff. This effort should seek to achieve complete harmonisation with the Aeronautical Terminology stipulated by the Civil Aviation Organisation International (ICAO).
• that the Lima Airport Operator, within the scope of the functions of the SMS-RST External Operating Committee, carries out actions linked to hazard identification and shared risk management in the context of its interface with the ANSP.
• that the Peruvian Airports and Aviation Corporation (CORPAC), in its capacity as ANSP at Lima Airport, carries out awareness campaigns aimed at personnel in charge of the Direction, Planning, Coordination, Execution and Supervision of Emergency Response Exercises with the objective of achieving in the short term:
  • Improved situational awareness of risks and response they might require.
  • Promoting a culture of safety and strengthen human capacity in this regard.
  • Increased collaboration and mutual assistance with the Airport Operator.
• that the Peruvian Airports and Aviation Corporation (CORPAC), in its capacity as ANSP at Lima Airport, carries out periodic evaluations of the professional and technical competence of the personnel in charge of the Management, Planning, Coordination, Execution and Supervision of Emergency Response Exercises, who have participated in the aforementioned awareness campaign to strengthen Operational Safety and guarantee an optimal level of preparation and knowledge.
• that the Peruvian Airports and Aviation Corporation (CORPAC), in its capacity as ANSP at Lima Airport, requests the Airport Operator to officially deliver the updated Plan for the new airport infrastructure being implemented including:
  • The disposition of the current and new Control Towers so that controllers can provide guidance to Emergency Response Vehicles responding to or practising for actual emergency situations.
  • The incorporation of the aerodrome movement map in ANSP Manuals to ensure a complete and up-to-date reference is available.
• that the Peruvian Airports and Aviation Corporation (CORPAC), in its capacity as ANSP at Lima Airport, comprehensively recognise the dangers and risks inherent in emergency response exercises so as to guarantee that the participation of airport rescue vehicles is carried out in a safe and organised manner and without any compromise to aircraft operations. To this end, it is necessary, in collaboration with the Airport Operator, to analyse the proposal presented by the Commission "Fundamental Considerations for Improving Planning and Execution of Emergency Response Exercises" and determine their relevance to strengthening and improving the procedure specified in the section 5.3.6 of the Operational Instruction Manual for ATC TWR operations “Procedures for the Control of Movement of People and Vehicles in the Manoeuvre Area”.
• that the Peruvian Airports and Aviation Corporation (CORPAC), in collaboration with the Airport Operator, analyse the proposal presented by the Investigation Commission (see Appendix A) on "Fundamental Considerations for Improving the Planning and Execution of Emergency Response" and determine their relevance to strengthen and improve the procedure specified in the section 5.3.6 “Procedures for the Control of Movement of People and Vehicles in the Manoeuvre Area” of the ATC TWR Operational Instruction Manual.
• tthat the Peruvian Airports and Aviation Corporation (CORPAC), in collaboration with the Airport Operator, guarantees that the new procedures that are established in the Operational Instruction Manual for ATC TWR operations are duly harmonised and aligned with the procedures specified in section 6.4 of the Airport Emergency Response Plan.
• that the Peruvian Airports and Aviation Corporation (CORPAC) implements a formal Training and Evaluation Programme on the Prevention of Incursions aimed at their Lima TWR controllers to cover, among other aspects, the following points:
  • Instruction on the Manoeuvring Areas of the airport under the supervision and guidance of expert Airport Operator staff to ensure understanding of both the theoretical and practical aspects of including familiarisation with service roads, taxiways, runways and the horizontal and vertical signage warning of dangers. 
  • The Instruction Manual for ATC TWR operations, which provides detailed knowledge of procedures and regulations for safe operations, including the new section 5.3.6 “Procedures for Control of Movement of People and Vehicles in the Manoeuvring Area”.
  • Instruction based on ICAO Document 9870 “Manual on the Prevention of Runway Incursions” be taught by qualified instructors and cover the content of the manual.
  • This Programme must be integrated into successive reviews of the ANSP’s Initial and Recurrent Training Plan for TWR Controllers.
• that the Peruvian Airports and Aviation Corporation (CORPAC) carries out a study with the objective of ensuring the safety and efficiency of ATS at Lima Airport, which must take into account significant aspects such as:
  • Compliance with the functions and responsibilities of Controllers in their respective operational positions, optimising the standardisation of the concepts associated with their performance in each operational position.
  • Increasing the number of Controllers and/or improvement of management in respect of factors such as fatigue, shift rotation, work schedules, rest periods, medicals, vacations, permits, and training.
• that the Peruvian Airports and Aviation Corporation (CORPAC) require its controllers to strictly comply with the instruction's operational details contained in the Operational Instruction Manual for ATC TWR operations including, in particular, aspects related to personnel management, shift handover protocol in different operational positions, the restriction on the use of personal electronic devices, the correct application of aeronautical phraseology, reading operational instructions, adopting ergonomic postures appropriate to their functions and responsibility, the obligation to answer telephone calls from landlines (for investigation purposes), and, in general, everything that contributes to raising their level of safety and effectiveness. Guidelines should be based on the recommendations of Annex 11 of the Convention International Civil Aviation, entitled "Air Traffic Services", as well as in the Requirements of the Aeronautical Regulations of Peru 311.
• that the Peruvian Airports and Aviation Corporation (CORPAC), in collaboration with the Airport Operator Safety Management Manager, carry out a comprehensive evaluation of the activities or topics relating to the "Runway Incursion Prevention Program” recorded as in the Minutes of meetings of the SMS-RST External Operating Committee held on 06 September 2022, 25 August 2022 and 17 November 2022 as either "PENDING" or "IN PROGRESS" as documented with the objective of achieving their 100% complete implementation.
• that the Peruvian Airports and Aviation Corporation (CORPAC), within the scope of the functions of the Airport Operator’s SMS-RST External Operating Committee, collaborate in the identification of hazards and the management of shared risks in the context of interfaces with the Airport Operator.
• that the Peruvian Airports and Aviation Corporation (CORPAC) consider the feasibility of carrying out a short-term study to evaluate the need for a Movement Surveillance System in accordance with the guidelines stipulated in Volume I of the Aeronautical Regulations of Peru 314 and the ICAO Annex 14 as a way to improve the Situational Awareness of TWR Controllers to effectively provide safe and efficient advice for both pilots and vehicle drivers accessing airport manoeuvring areas.
• that LATAM AIRLINES PERU; as an operator of Airbus A320 series aircraft, follow up on the issue of the Service Bulletin proposed by the equipment manufacturer “SAFRAN”, to replace the Emergency Door Slide inflation hoses S/N 63667-series and S/N 68906-101 (before S/N 4407) during the next scheduled maintenance input in order to ensure the inflation and deployment of emergency evacuation slides and inform the DGAC Chile about this action within the type Maintenance Program they have approved and which is accepted by the DGAC Peru.

The Final Report was completed on 29 September 2023 and subsequently published in Spanish. This summary of its contents is based on an informal and unofficial translation.

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• Risk Management
• Risk Mitigation
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• Safety Culture