Investigation Summary
On the morning of December 30, 2007, TAROM Flight 3107 was cleared for takeoff from Bucharest Henri Coanda International Airport. Visibility was significantly restricted by dense fog. Unknown to the flight crew, a maintenance team consisting of four workers and two vehicles was on the runway performing repairs on a flight strip beacon. The air traffic control tower had permitted the maintenance crew onto the runway, but the aircraft was subsequently authorized for departure while the team was still present. During the takeoff roll, the aircraft struck one of the two maintenance cars. The aircraft veered off the runway and was severely damaged, resulting in a hull loss, though all 123 occupants survived without injury.
Final Conclusions
The investigation concluded that the primary cause was the incorrect authorization for takeoff without ensuring the runway was clear. A critical factor was the deficient management of human resources at the tower, resulting in an insufficient number of controllers (4) and the absence of the team supervisor from the operations room at the time of the accident. Furthermore, when the controllers realized the runway was occupied, they focused on calling the maintenance team via radio instead of using emergency procedures such as the 'STOP TAKEOFF' command or cycling runway lights. The Low Visibility Procedures (LVO) were found to contain unclear or uncorrelated provisions that were not rigorously applied.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Air Traffic Control (ATC) Coordination
The system of communication between ground maintenance and the tower failed to prevent a runway incursion during active flight operations.
Low Visibility Procedures
Procedures designed to manage ground traffic during fog were insufficient to detect the presence of the maintenance vehicle on the active runway.
Interesting Facts
- 01The aircraft involved was a Boeing 737-300 named Constanta, manufactured in 1994.
- 02Visibility was approximately 100-250 meters in freezing fog (FZFG) with a vertical visibility of zero (VV000) at the time of the accident.
- 03The maintenance team consisted of four workers and two vehicles working on runway center lights.
- 04The collision occurred with the aircraft's No. 1 engine and left landing gear.
- 05The tower supervisor was absent from the operations room during the sequence of events leading to the collision.
Safety Actions & Advisories
ATC Training Gaps
The investigation recommended addressing gaps in the training of ATC personnel, specifically regarding the strict follow-up of applicable procedures and emergency communication.
LVO Procedure Revision
Authorities were advised to clarify and correlate provisions within the Low Visibility Operations (LVO) and vehicle movement regulations to prevent differing interpretations.
Human Resource Management
Recommendations were made to ensure sufficient staffing levels in the tower and the constant presence of a supervisor to oversee procedural compliance.