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FINALREPORT on SERIOUS INCIDENT of the AIRCRAFT Type

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FINALREPORT on SERIOUS INCIDENT of the AIRCRAFT Type THE REPUBLIC OF CROATIA Air, Maritime and Railway Traffic Accident Investigation Agency Air Traffic Accident Investigation Department Class: 343-08/18-03/06 No: 699-04/3-20-33 Zagreb, 29 April 2020 F I N A L R E P O R T ON SERIOUS INCIDENT OF THE AIRCRAFT type LET-410, registration OK-LAZ Dubrovnik Airport, 29 November 2018 AIN04-FR-03 AIR, MARITIME AND RAILWAY TRAFFIC Final Report ACCIDENT INVESTIGATION AGENCY L-410, 29.11.2018, Dubrovnik Airport PUBLICATION OF REPORT AND COPYRIGHT This report has been made and published by the Air, Maritime and Railway Traffic Accident Investigation Agency (hereinafter: AIA) pursuant to Article 6 section 1 and 2 of the Act on Establishment of the Air, Maritime and Railway Traffic Accident Investigation Agency (Official Gazette no 54/13 and 96/18), Article 7 Section 1 and 2 of the Statute of the Air, Maritime and Railway Traffic Accident Investigation Agency, Article 16 of the Regulation (EU) No 996/2010 of the European Parliament and of the Council on the Investigation and Prevention of Accidents and Incidents in Civil Aviation, provisions of the Air Traffic Act (Official Gazette no 69/09, 84/11, 54/13, 127/13 and 92/14), and pursuant Chapter 6 of the Annex 13 ICAO. This report or any part thereof shall not be produced, reproduced or transmitted in any form or in any manner, without the express written consent of AIA. This report may be freely used for educational purposes only. For all further information contact AIA. The aim of the investigation relating to safety is in no case determination of guilt or liability. Investigations are independent and separate from court or administrative proceedings and should not prejudice determination of guilt or liability of individuals. The final report cannot be used as evidence in court proceedings whose aim is determining civil or criminal liability of individuals. AIN04-FR-03 Page: 2/28 AIR, MARITIME AND RAILWAY TRAFFIC Final Report ACCIDENT INVESTIGATION AGENCY L-410, 29.11.2018, Dubrovnik Airport CONTENT OCCURRENCE INFORMATION .........................................................................................................5 INVESTIGATION .............................................................................................................................5 SUMMARY ....................................................................................................................................5 1. FACTS AND INFORMATION ....................................................................................................5 FLIGHT INFORMATION .......................................................................................................................... 5 INJURIES ............................................................................................................................................ 6 INFORMATION ON THE OPERATOR AND THE OWNER OF THE AIRCRAFT .............................................................. 6 CREW INFORMATION ............................................................................................................................ 7 INFORMATION ON THE AIRCRAFT LET-410UVP-E (SN: 902504).................................................................. 7 METEOROLOGICAL INFORMATION ........................................................................................................... 8 COMMUNICATION ............................................................................................................................... 9 AIRPORT INFORMATION ........................................................................................................................ 9 FLIGHT DATA RECORDERS .................................................................................................................... 10 INFORMATION ON THE IMPACT AND THE REMAINS OF THE AIRCRAFT .............................................................. 10 MEDICAL INFORMATION ..................................................................................................................... 10 RESCUE AND SURVIVAL ASPECTS ............................................................................................................ 10 ADDITIONAL INFORMATION ................................................................................................................. 10 2. ANALYSIS ............................................................................................................................ 22 COURSE OF EVENTS ............................................................................................................................ 22 FLIGHT PREPARATION ......................................................................................................................... 23 HORIZONTAL RUNWAY MARKINGS ......................................................................................................... 23 AERONAUTICAL INFORMATION ............................................................................................................. 24 ANALYSIS OF EVENTS OF THE ORGANIZATIONS INCLUDED IN THE SUBJECT EVENT ............................................... 24 ANALYSIS OF THE INFLUENCE OF LIGHT SIGNALIZATION OF THE RUNWAY AND PAPI SYSTEM ON THE EVENT .............. 24 3. CONCLUSION ....................................................................................................................... 25 FINDINGS ........................................................................................................................................ 25 CAUSE ............................................................................................................................................ 26 4. SAFETY RECOMMENDATIONS .............................................................................................. 26 AIN04-FR-03 Page: 3/28 AIR, MARITIME AND RAILWAY TRAFFIC Final Report ACCIDENT INVESTIGATION AGENCY L-410, 29.11.2018, Dubrovnik Airport AIN04-FR-03 Page: 4/28 AIR, MARITIME AND RAILWAY TRAFFIC Final Report ACCIDENT INVESTIGATION AGENCY L-410, 29.11.2018, Dubrovnik Airport OCCURRENCE INFORMATION Type of the occurrence: Serious incident Date: 29 November 2018 Local time: 12:43 LT Place: Dubrovnik Airport Type of the aircraft: Aeroplane Manufacturer / model: Let Kunovice / L-410 Registration: OK-LAZ Owner: Van Air Europe Operator: Van Air Europe Number of persons on board: Ten (pilot, co-pilot, flight attendant and seven passengers) Injuries: No injured persons Damage to the aircraft: No material damage INVESTIGATION AIA received the first information about the serious incident on the same day from Dubrovnik Airport and the Croatia Control. AIA opened the safety investigation on the same day. SUMMARY On 29 November 2018 at 12:00 hours, the L-410 aircraft departed from Split Airport to Dubrovnik Airport. After landing on the runway, direction 12, they noticed that there are construction machines in front of them, and the air traffic controller informed them that they have landed on the closed portion of the runway where construction works were being performed. At the time of the serious incident, three crew members and seven passengers were on board the aircraft, none of whom were injured, and no material damage occurred. The immediate cause of the serious incident in question was failure to identify the active portion of the runway and the closed portion of the runway by the commander of the aircraft. AIA issued safety recommendations to Dubrovnik Airport, Croatia Control (CC), aircraft operator - company Van Air Europe, and Croatian Civil Aviation Agency (CCAA). 1. FACTS AND INFORMATION FLIGHT INFORMATION On 29 November 2018 the crew of the aircraft type LET L-410 of the Czech operator, the company Van Air Europe, had 6 flights scheduled between 6.00 hours in the morning and 17.00 hours in the afternoon. The flights took place between Osijek, Rijeka, Split and Dubrovnik. The flight in question was the third in a row, between Split Airport (LDSP) and Dubrovnik Airport (LDDU). During the morning preparation, by reviewing NOTAMs (Notice to Airmen), the aircraft crew noticed a wind information AIN04-FR-03 Page: 5/28 AIR, MARITIME AND RAILWAY TRAFFIC Final Report ACCIDENT INVESTIGATION AGENCY L-410, 29.11.2018, Dubrovnik Airport on the LDDU whose strength exceeded the permissible limit for the aircraft in question, and noted the information on the construction works. At 11:00 hours the aircraft departed from Split Airport (LDSP) to Dubrovnik Airport (LDDU), under flight number C3821, and call sign TDR821, in accordance with IFR flight rules. The crew decided to perform a visual approach considering a good visibility. During the approach, the first officer informed the captain of the aircraft (also the commander of the aircraft), who operated the aircraft, that the vehicles were located on the runway. The commander continued the landing, and the aircraft landed on the closed portion of the runway (Figure 01) where the construction works were being performed. Figure 1 – Portion of the closed runway marked by yellow line (aircraft landing site) INJURIES Injuries Crew Passengers Others fatal 0 0 0 serious 0 0 0 minor / none 3 7 0 No persons were injured during the serious incident. INFORMATION ON THE OPERATOR AND THE OWNER OF THE AIRCRAFT The operator of the aircraft in question is the Czech company Van Air Europe, which has several LET L- 410 aircraft. The company was founded in 2004 by the company Aeroservis, which provides aircraft maintenance services. The company started flight operations
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