The Center for Investigation of Accidents in Transport has filed findings on the serious accident that occurred on February 18, 2024, involving an Embraer E190-200LR aircraft operated by Greece’s Marathon Airlines in a wet-lease arrangement on behalf of Air Serbia, which occurred at Belgrade Airport. The investigation found the pilots at fault for the accident, in which no passengers were hurt, but also criticised some airport procedures upon the aircraft’s emergency landing.
The aircraft, registered OY-GDC, was scheduled to operate flight JU324 to Dusseldorf with 111 people on board, including five crew members from the Greek carrier. The incident unfolded during takeoff and, despite significant aircraft and ground infrastructure damage, resulted in no injuries.
The chain of events began when the crew was cleared to line up on Runway 30L via intersection D6, which provided a takeoff run of 2.349 meters. However, the aircraft mistakenly entered the runway at intersection D5, leaving only 1.273 meters available, far less than the required distance for the aircraft’s actual takeoff weight of over 45 tonnes. Air traffic control immediately noticed the error and warned the pilots that the available takeoff distance was insufficient. They suggested the crew vacate the runway and taxi back to D6. Despite this, the captain insisted they had enough runway and carried out a quick recalculation using the wrong intersection/runway combination (entered as 12R/D5 instead of 30L/D5), with discrepancies noted between the captain’s and first officer’s data entries. This gave a misleading sense of safety margins. The report highlights that the captain exerted pressure on the first officer, who deferred instead of challenging the decision.
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Planned taxi and takeoff path (blue), actual taxi and takeoff path (red) |
During the takeoff roll, thrust was not advanced to maximum (TOGA) until very late, further reducing performance. As the aircraft accelerated, the crew quickly realised the end of the runway was approaching. The first officer rotated at the calculated Vr, resulting in a tail strike and the aircraft making contact with airport lighting installations and the localiser antenna for Runway 12R. Debris from the damaged structures was later found scattered beyond the airport perimeter. The impact caused structural damage to the left wing, fuselage, stabiliser and climate control systems, as well as fuel leakage from the left tank. Ground facilities also sustained considerable damage, including multiple approach lights and the far-field monitor antenna, rendering the ILS downgraded from CAT III to CAT I capability.
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Moment the aircraft hits the localiser antenna |
After departure, the crew reported abnormal vibrations, unusual noises, as well as flap problems, and declared an emergency. Air traffic control coordinated with emergency services, arranging for a low pass so the landing gear could be visually inspected. The aircraft then landed safely back on Runway 30L at 18:36 local time, escorted by fire and rescue vehicles. The evacuation was carried out via jet bridge at a parking stand, while firefighting teams worked to contain leaking fuel. The flight crew was unable to detect the damage while taxiing after landing, a conclusion reached during the investigation by simulating the crew’s field of view from the aircraft toward the damaged area.
The investigation also noted that the crew did not properly conduct a standard departure briefing, and this was identified as a contributing factor to the accident. Specifically, the report states that during flight preparation there were significant discrepancies in the performance data entered into the calculation applications. Because the crew skipped or failed to follow a proper departure briefing, those errors went unnoticed. The absence of the briefing meant that incorrect parameters were entered into the Flight Management and Guidance System, and there was no cross-check to catch them.
The investigation revealed multiple procedural lapses and human factor issues. The crew failed to adhere to standard departure briefings and operational cross-checks, leading to incorrect inputs in performance calculations. The captain exerted pressure on the first officer, who did not challenge the decision to depart from the shorter intersection. Compounding the problem, the aircraft was not configured optimally for the shortened takeoff distance, and the reduced thrust setting (FLEX 33°C) was used instead of maximum power from the outset.
Upon landing back in Belgrade, fire crews followed the aircraft during taxi to the gate and took action to contain fuel leaking from the left wing. Foam was applied to prevent fire risk, and passengers disembarked via a jet bridge safely. However, the investigation points out that the aircraft was initially parked at gate C2, at the passenger terminal, despite the fuel leak and structural damage. Only later, after a preliminary inspection, was it towed to a remote stand (B3). The airport’s Emergency Plan has since been revised, requiring such an aircraft to be directed to an isolated parking position immediately, away from terminal operations. Shortly after the accident Air Serbia severed all ties with Marathon Airlines.
Both the 58-year-old captain and the 44-year-old first officer underwent alcohol testing, with results returning negative. During the investigation, the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) were removed from the aircraft and sent for readout and analysis in cooperation with the aircraft manufacturer. The Serbian Civil Aviation accident investigation agency emphasised that the event underscored the need for stricter adherence to performance calculations, intersection takeoff procedures and CRM training. The extensive structural damage to the aircraft and ground equipment, combined with the near loss of control during takeoff, mark this as one of the most serious recent incidents at Belgrade Airport.
The 43-page report, in Serbian, can be viewed here (PDF document).
Seeing those photos, we were a centimeter or two away from a real disaster
ReplyDeleteMiracle no one was even injured.
DeleteIf you open up the report the scary ones show up...
DeleteA huge miracle. What happened to the pilots? Are they flying again? How can you not do a proper departure briefing? That's totally negligent... unbelievable
DeleteIn the report, it shows a photo where you can see the two pilots actually input competely different data in CRM and they didn't cross check.
DeleteSorry I meant in the Flight Management and Guidance System, not CRM.
DeleteIs Marathon down to just one aircraft?
ReplyDeleteNo, operating 3 - one for Skyalps and 2 for Aeroitalia
DeleteThanks
DeleteWhat happened to the pilots?
ReplyDeleteThey fled the country.
DeleteWonder if they are still flying.
DeleteThat would be interesting to know
DeleteIt is crazy with how little runway they tried to depart from.
ReplyDeleteThis is a textbook case of poor CRM. The captain overruled the tower and the FO just went along with it. It’s lucky this didn’t end in tragedy.
ReplyDeleteWhat happened to the aircraft? Was it repaired?
ReplyDeleteNo, I believe it is written off.
DeleteIt was.
DeleteI sometimes wonder where AirSerbia would be without that accident...at 7-10 E jets?
ReplyDeleteMost likely, They would have had at least 5 by the end of last summer season.
Deleteshows how resilient these Embraers are.
ReplyDeleteOr how weak ILS antennas are.
DeleteThe localizer antenna is designed to be frangible, as it's located directly in the overrun area. You don't want it to be very rigid, or even built on top of reinforced concrete, like it was in that Korean accident not too long ago.
DeleteDidn't know that two pilots had only one test flight with instructor at that day earlier, which makes it even more scary.
ReplyDeleteThe ground handling part is also worrying. Parking a leaking, structurally damaged aircraft at the terminal should never have happened. Good that procedures were updated after.
ReplyDelete+1
DeleteAgain, embarassment for the airport fire crews. The report states they didnt see any technical issues or damage indications, at which point one must ask, are they legally blind??? Pure luck saved the people involved from a more serious incident
ReplyDeleteThat one seems extremely strange to me too.
DeleteJust happy nobody was hurt.
ReplyDeleteThe report reads like a case study for flight schools. Wrong intersection, wrong calculations, no proper briefing and ignoring ATC… almost every mistake possible in one takeoff.
ReplyDeleteExactly. And even not applyng full thrust after having realized they are being left with no runway. Bizzare.
DeleteThis could have been a disaster.
ReplyDeleteSomeone was looking after those 111 souls that day.
DeleteIt really is a miracle how that did not lead into a disaster.
DeleteThat same somebody could have avoided this whole accident altogether.
DeleteThe only one looking positive after this near catastrophe in Embraer and how strong and good they have designed and build their aircraft.
ReplyDelete+1
DeleteJU should also think about who they contract with. They just can’t blame Marathon and its pilots.
ReplyDeleteThe pilots are the most responsible. Read the report past the headline. But I guess you think it is a conspiricy which also involved Embraer which did the read out of the voice recorded.
Delete^ some people have full sympathy for the pilots because their hate for JU and/or Serbia is stronger. Simple as that.
DeleteSo Aeroitalia and Sky Alps which are currently contracting with Marathon should also think twice? Why aren't you outraged that Marathon is operating flights every day from Mostar?
DeleteJU chose the cheapest partner in Marathon. It is an airline that before JU I do not think they had operated flights for any other airline in Europe.
DeleteBut even that could not prepare anyone (including Marathon management) about the captain's repetitive BIG mistakes.
How do you know it was the cheapest partner? You have access to how much it cost to wet lease with them? You compared it to others that were available at the time to provide wet lease capacity and concluded it was the cheapest?
Delete@Anon 09:51: Don't forget to take into account the level and the quality of the training they received throughout their career, and the company culture - all of which have significant impact on how pilots perform in the real world.
Delete@Anonymous 10:41
DeleteExactly. This things should have been checked before we went to business with them and allowed them to carry the Air Serbia logo on their airplanes.
No, regulators do those checks. In this case the European Union Aviation Safety Agency.
DeleteIf you allow any outfit to sport your logo and represent you you check the basic things yourself too.
DeleteAny sensible airline will audit airlines, from which they wet lease the aircraft from. Marathon are under the oversight of the Greek CAA, not EASA.
DeleteHow do you know Air Serbia didn't audit the airline? What would display in the audit that this would happen? Both pilots were experienced. One was even an instructor on the Embraer. Both had clear records. The airline is audited by EASA and fully complied to EASA standard. Use that little brain of yours.
Delete@10.53 refer to comment @9.55.
DeleteAlso to add, Sky Alps and Aeroitalia currently have contracts with Marathon Airlines. Both Sky Alps and Aeroitalia made agreements with Marathon Airlines after this accident. And all three airlines are from the EU.
DeleteClearly the JU audit of Marathon was a failure since this report discovered how they disregarded proper procedures before and after the flight.
DeleteIf Marathon was not to blame but only the two pilots why shortly after the accident Air Serbia severed all ties with Marathon Airlines?
DeleteWell, for PR reasons maybe.
Delete@11.06 I know you have a very big need to blame JU but I will repeat again
DeleteWhat would display in the audit that this would happen? Both pilots were experienced. One was even an instructor on the Embraer. Both had clear records. The airline is audited by EASA and fully complied to EASA standard.
JU should have had a crystal ball? I hope you are not advocating for that codeshare between Air Serbia and American Airlines seeing as the AA plane crashed earlier this year and it seems pilots didn't follow procedure.
In which accident did the AA pilots did not follow procedures?
DeleteSurely not on the Washington crash with a helicopter over the Potomac river. That was none of their fault.
^ are you the one that was arguing that control tower assigns gates at airports?
DeleteThere were even some people on this website claiming that JU should not have severed ties with Marathon, that all would have been forgotten quickly, etc. Hopefully this report makes it clear that JU made the absolutely correct decision to cut all ties right away with no ifs and buts. And if Mostar Airport can't secure anyone better to fly to their airport, that is quite frankly their problem to deal with
DeleteBelgrade Airport are as much to blame as the Marathon pilots!
ReplyDeleteYes, Belgrade Airport didn't inoput correct data in the log, Belgrade Airport ignroed clear warnings from ATC, Belgrade Airport put preassure on the copilot to ingore warning, Belgrade Airport didn't increase speed on departure run... Oh, I forgot you didn't even read the article.
DeleteIt was too long for him.
Delete
DeleteI think the airport and the control tower are nowhere near as responsible as the captain who made so many criminal mistakes one after the other.
But BEG also gets the rightful blame in the report for allowing a damaged aircraft leaking aviation fuel (it is very flammable) to go to a jet bridge gate at the terminal, next to other aircraft with passengers and disembark as if everything was normal.
Different level of responsibility for the airport compared with the pilots for sure but it made a big mistake in allowing that too.
Not exactly sure why you bring the control tower into it as they didn't do anything wrong. They followed procedure, even offered pilot to taxi back. If a pilot says that based on system calculations they can safely depart, ATC can't overule the pilot, especially since they don't know the weight of the aircraft.
DeleteThe control tower shouldn't have allowed that aircraft to taxi to a stand at the terminal after the emergency landing. The report is very clear.
DeleteNo, the report does not say that. I suggest you actually read it. It is crazy that you think that someone from the control tower can see and conclude that there is structural damage to the aircraft.
Delete@Anonymous10:31
DeleteThe report is clear indeed, you just need to stop argue with its findings.
"The airport’s Emergency Plan has since been revised, requiring such an aircraft to be directed to an isolated parking position immediately, away from terminal operations"
It has absoolutely nothing to do with ATC. In fact the ATC is praised for its actions in the report.
DeleteNobody blamed the ATC but the tower.
DeleteYou have the link to the report in the article.
DeleteControl tower has nothing to do with assigning parking stands to any aircraft.
DeleteThe tower can not see if fuel is leaking from the plane at nighttime nor can it asses the damage to the aircraft.
DeleteThe tower knows that an aircraft has struck something and is attempting an emergence landing.
DeleteYou do NOT allow such an aircraft to go to the terminal building next to other aircraft.
Thankfully the investigators identified that mistake and measures and change in procedures have been taken since to prevent it from happening again in the future,
Even some "experts" here disagree.
^ the real expert is you who thinks that that tower assigns parking stands.
DeleteWho gave them permission to go to gate C2? The Holy Spirit? Maybe the Marathon CEO in Greece? Eurocontrol from Switzerland? 🤔
Delete^ I would highly recommend that you stop embarassing yourself. Gate assignments and parking are managed by the Airport Operations Control Center (AOCC). The AOCC (located in a room on the first floow of BEG) coordinates the use of gates, stands and terminal space.
DeleteBut ATC gives clerance to take off. They should not have given Clear to take off or did pilots just took off without clearance? I mean 1.2 km Runway even ATC controller should know it's not enough
DeleteNo, that's not how it works and please don't comment on things you clearly don't know how they work. ATC did everything according to procedure.
DeletePilot have the last word, atc can not deny if pilot says he controlled and wants to fly
DeleteMarathon is currently flying out of Mostar every day for Sky Alps.
ReplyDeleteNo one seems upset about it. Odd.
DeleteNot even so called "expert".
DeleteI wouldnt fly with them..
DeleteAnd?
DeleteThat right there highlights the difference between doctors and pilots: the latter are always investigated, and if found at fault, they are held accountable. Hopefully, the captain’s either out of the cockpit or demoted to FO.
ReplyDeleteIt is strange though that we have on idea what happened to the pilot. Is he going to be prosecuted by us or from some other country's authorities?
DeleteProsecuted for what? Noone had died, nor was injured.
Delete111 people did not die for centimeters!
DeleteProsecuted for repeatedly braking correct procedures and managing to nearly crash a perfectly working aircraft.
No criminal justice without consequences, pal.
DeleteHave you seen the pictures pal?
DeleteYes, there is damage, but I don`t think pilots used to be prosecuted for that. Lloyd will cover, that`s for sure.
DeleteI’d be really surprised if he still has a job. And good luck getting an no-incident report from your company.
DeleteI’ve seen plenty of demotions in my company for issues far less serious than this.
Probably flying for some lo co airline in India, Indonesia or sub Saharan African Airline. For sure not Ethiopian though, they are a serious company.
DeleteHow comes that security guard at same airport’s gate was arrested after that incident back in January, after getting tricked by some guy who then drove his car around the airport runways? What was his criminal act?
DeletePure luck separating that flight from catastrophy.
ReplyDeleteAbsolutely!
DeleteHad it been A340-600 they would have made it
ReplyDeleteThe report itself is not a Holy Grail. Some findings are not casting enough light into preventing future similar incidents. Please, don't get me wrong. I'm not pointing a blame at anybody, just trying to illuminate some aspects, which were not covered in report well enough or not at all. I am active air traffic controller with 30+ years experience in both TWR and APP/ACC, I'm very familiar with safety cases as I work on air traffic control applications and systems as well (as designer). The report has put all the blame on the crew. But I don't want to use this term, as blame is punishment and without an oversight, it stays stationary, doesn't take into account other contributing factors and possible solutions. I've heard arguments, that air traffic controllers did everything they could to prevent this incident. They didn't. We ATCOs as any operational staff have a leverage to act upon unique events according to own decision making process, not necessarily prescribed (in form of order, law, instructions etc). This in reality mean, that we have very strictly prescribed tasks (to prevent collisions between aircraft in the air and on the ground with other aircraft, vehicles and other obstacles) and to prevent collision with terrain. Also techniques how to achieve that are usually prescribed, sometimes even as part of aviation law.
ReplyDeleteHaving said this, I can state that BEG TWR controllers didn't do everything they could. They could do more, they could have prevented take-off from wrong intersection. I know, many will jump in the air, saying how, when captain's is the last. Well, If I can prevent captain from taking off from wrong RWY, taxiing on wrong TWY, I can also prevent him from taking off from intersection, which even report states as being inadequate. It was recognised as such by my BEG colleges as well, they warned the crew, but didn't exercise their right (and I would also say duty), to force them to taxi to more suitable intersection. You can shout as loud as you want, that they can't know the required TORA for every aircraft type...give me a break! One must be beyond stupid as ATCO not recognising TORA of 1200 m for E190 with almost 2 hrs flight ahead as ADEQUATE! One of the most important parts of our job is to recognise unsafe situations, before they become dangerous. This is textbook example of such situation. All they had to do is to instruct them to taxi to another intersection and not giving them take-off clearance. Captain's is last, but only in operating the aircraft. ATCO has all the right and duty to INCREASE safety margins. By instructing them to line up and take off from inadequate position, they did the opposite of that. They passively observed a possible catastrophe unveiling in front of their eyes.
continued:
DeleteAre they to blame? No, they didn't do anything wrong, but they also didn't do everything at their disposal to prevent it.
And here we come to the part where parties should be blamed. First one is airport and CAA. Whenever there are construction works going on at the airport, chances of confusion are rising exponentially. What at least CAA should do is to forbid taking off from the intermediate parts of the runway. This is very unpopular with operators, as taxing times are longer, but you know that famous saying that what doesn't matter in aviation is fuel you don't have, runway behind you and altitude above you. During my TWR days, all aircraft except general aviation were instructed to take off from the beginning of the RWY, with max TORA. Taking off from intermediate distances is unsafe and it can become dangerous very quickly. It is taking into account that there is little chance of something going wrong. In 99% of the cases this logic works out without consequences, but...
The other one to blame is airline or better said its company safety pilot. He (or she) should not allow taking off from certain TORA, or since works in progress, he or she should prescribe using max TORA available.
Is this passive assertion of situation by the ATCOs ok or not, I leave it with them. I know that this is not uncommon among many of colleges of mine, who think, they have no saying in this. How wrong they are. We do have a saying and we should enforce the power instilled in us by the state, to operate air traffic in safe manner.
I know, that what I wrote will infuriate many, but if you don't know how ATC operates and what tools and powers we have at our disposal, please don't argue with that.
Again this guy
DeleteAs I could understand, everyone is guilty who followed their procedures, except those two idiots who didn't?
Delete@OP - Well said my friend. 100% agree. They just sat there and watched the show
Delete+1 15:26
Delete15.26, where did I say that? Show some proof of you being aviation pro. I can send my licence to admin
DeleteBEG ATCOs didn't follow the basic rule: prevent accident from happening. If they truly believe 1200 m is enough TORA for E190, then they are incompentent. Sorry.
Delete^ the self proclaimed expert has spoken!
Delete18:24
DeleteYou can issue 100 more zama licences, but that will not change official CINS report which clearly accuses responsible for this mess and clearly release those who isn't. Read it again, but slowly, with understanding
@18:51 Is it true that pilots at Vrapče Airport don't have to do any calculations - ATC does it all for them?
Delete"Taking off from intermediate distances is unsafe and it can become dangerous very quickly. It is taking into account that there is little chance of something going wrong. In 99% of the cases this logic works out without consequences, but..."
DeleteWhat a load of nonsense. Intersection takeoffs are perfectly safe, and tens of thousands of flight every day depart from intersections rather than full takeoff length. You often have more stop margin doing an intersection takeoff at a light weight than you do when departing at maximum weight from full length - which one is less safe?
This accident was the culmination of many many different failures, including the pilots. Sheer dumb luck prevented this from being a disaster.
ReplyDeleteIs there also a report from Brazil (the manufacturer’s country and Europe (the place of registration and the destination?). There are usually three different agencies investigating.
ReplyDeleteLuckily, it wasn't their day to drink from the silver cup.
ReplyDeleteFirefighters and the rest of the airport crew should have gone above and beyond their duty once fuel leak was noticed, and use their better judgment to direct damaged aircraft to the remote location instead of being parked at the gate, even though regulations at the time didn't explicitly call out fuel leak as one of the mandatory conditions for remote location use.
Really? And they needed so much to establish that!???
ReplyDelete