Countdown to Collision: The crash of LATAM Perú flight 2213
On the 18th of November 2022, a routine airport firefighting exercise at Jorge Chávez International Airport in Lima, Perú went horribly wrong when a speeding fire truck slammed into a departing LATAM Perú Airbus A320, sending the airliner sliding down the runway in flames. As stunned firefighters rushed to respond, the 108 occupants aboard LATAM flight 2213 hurriedly evacuated the burning aircraft under the calm command of both the air crew and the fire crew, who maintained their professionalism under pressure despite the shock of the crash. In the end, although 9 passengers were seriously injured and the plane was a write-off, everyone aboard flight 2213 escaped with their lives. The firefighters, however, were not so lucky: of the three personnel on board the demolished truck, two were declared dead on the scene, and the third would eventually succumb to his injuries after a 7-month hospital battle.
Now, one year after a tragedy that shook the airport fire rescue community, the release of the final report on the accident has illuminated a series of organizational and communications breakdowns that led to the crash, building up through meetings and telephone calls in the days, hours, and minutes before the chain of events reached its fiery crescendo. The findings prove that the accident was much more complex than anyone initially realized, reaching far beyond the simple question of who had permission to enter the runway. Instead, the crash presents a case study in how the failure to disseminate information within and between organizations can lay the groundwork for disaster, while also conveying lessons for all of us about how we should — and shouldn’t — behave when we begin to suspect that we don’t know what’s going on.
◊◊◊
Opened in 1960, Jorge Chávez International Airport is the busiest in Perú, the destination of nearly all international flights to the country, and the hub for several major Peruvian domestic airlines. Located close to the center of Lima, Perú’s capital and by far largest city, the airport processes an annual passenger turnover of more than 18 million people, equivalent to more than half the population of the entire country. And until 2023, it did all of this with only one runway, making it the 10th-busiest single-runway airport in the world as of 2015.
For these reasons, in 2012 authorities announced a massive project to expand the airport west toward the coastline, with plans for a new terminal, new support infrastructure, a new control tower, a new commercial development, and — of course — a new runway. Although it was originally scheduled to begin construction in 2013 with 2017 targeted for opening, the project suffered from a series of punishing delays due to a variety of factors, and construction did not actually begin until 2019, just in time for the Covid-19 pandemic to delay the works even further. As of October 2023, the new runway and control tower have opened, but the new passenger terminal isn’t expected to be ready for use until 2025.
In 2022, as the world emerged from the pandemic, both construction work and air traffic at Jorge Chávez kicked into high gear. But the process of expanding an airport isn’t just about laying pavement and stacking bricks: in fact, behind the scenes, hundreds of people must work to ensure that the new infrastructure is smoothly incorporated into airport procedures; that personnel are trained on its specificities; and that every aspect of the plan complies with regulations. In this case, that was the responsibility of a private limited liability company called Lima Airport Partners, or LAP, which had contracted the construction project and was overseeing its completion. Owned primarily by a German airport services company, LAP is responsible for the day-to-day operation of Jorge Chávez airport, from the concessionaires to facility maintenance to firefighting, but, crucially for this story, not the actual movement of aircraft. That responsibility belongs to the Peruvian Airports and Commercial Aviation Corporation, known as Corpac, a state entity entrusted with the operation of all air traffic control facilities in the country. This type of arrangement is common worldwide, albeit far from universal.
As mentioned above, LAP was in charge of the Airport Rescue and Firefighting service, or ARFF, at Jorge Chávez, and that is where this story begins in earnest.
The purpose of ARFF is to rapidly respond to an emergency anywhere at the airport in order to save lives and protect property, in that order. The normal duties of an ARFF firefighter include a lot of sitting around waiting, interspersed with events like minor fires and fuel spills, but they must nevertheless be prepared to respond to a once-in-a-lifetime accident involving real and immediate danger to potentially hundreds of people. ARFF services worldwide are required to be able to reach the scene of an aircraft accident anywhere on any runway, and begin applying extinguishing agent, within three minutes or less — and not only that, but they have to regularly prove it, too. Several times a year, ARFF personnel will carry out response time exercises, simulating an emergency response to a crash at the farthest end of the most distant runway, in order to ensure their continuous readiness to meet the three-minute requirement.
At Jorge Chávez, with its single runway, this was relatively simple. Designated 16 or 34 depending on the direction, the runway was 3,600 meters long and 45 meters wide, with the airport fire station located east of the strip abeam the displaced threshold of runway 34, about 700 meters from the start of the paved surface, as shown above. To carry out a response time exercise, firefighting vehicles would exit the fire station onto aircraft taxiway Foxtrot/Alfa, which runs parallel to the runway along its east side for its entire length, and then proceed all the way down Foxtrot to the opposite end, by the threshold of runway 16. ARFF personnel would coordinate in advance with Corpac controllers to ensure that no planes entered taxiways Foxtrot and Alfa during the exercise, and with the route completely clear, it was trivial to achieve a response time under three minutes. (It’s also worth noting that while controllers at some airports declare a “ground stop” during ARFF drills, halting all aircraft and vehicles on the entire airport surface, this was not the policy at Jorge Chávez.)
However, with the addition of a second runway to the west of runway 16/34, it was obvious to the airport planners that the old location of the fire station was unsuitable. Standard practice at multi-runway airports is to place the fire station as close to the center of the airport as possible, so with the old station located at what would become the far southeastern corner of the field, the ARFF service would not be in a position to respond within three minutes to an emergency at the far end of the soon-to-be-completed runway 16 Right, which would be nearly five driving kilometers away from the station. For that reason, a new fire station was being constructed in between the two runways, where the most distant runway end — the head of the existing runway 34 — would be only 3 driving kilometers away, as shown above.
Along with the new control tower, which was located immediately next door, the new fire station was one of the first buildings constructed during the airport expansion project and was essentially complete by the summer of 2022. Prior to construction, simulations had predicted an estimated response time of two minutes and 42 seconds from the new fire station to the head of runway 34, but now that the new station was done, the ARFF service would need to prove that this response time was actually achievable under real world conditions, and that meant organizing another response time exercise.
Although the ARFF schedule already featured response time exercises from the old fire station in February, April, June, and October of 2022, a test from the new fire station was added as a fifth, supplementary exercise to be held in August. During the August exercise, controllers cleared the runway of traffic, and several fire trucks proceeded from the new fire station to the runway via a Vehicle Service Road called VSR4, which was specifically built to provide emergency vehicles with unimpeded runway access. After receiving authorization from air traffic control, the vehicles then turned right and proceeded down to the head of runway 34, recording a response time of 2 minutes and 48 seconds.
Following the exercise, a meeting was held between the management of LAP-NEWLIM, the division overseeing the expansion project, and the LAP safety management team, during which it was decided that a second response time exercise from the new station should be held before the scheduled opening of the new runway in January 2023. The reasons for arranging a second exercise were manifold, including simple caution, but the fact that the theoretical response time was not achieved, falling short by 6 seconds, might also have played a role. This exercise was preliminarily scheduled for November 17.
To understand the events that followed, it helps to be familiar with the organizational hierarchy of both the LAP ARFF and the Corpac control tower.
At the top of the ARFF hierarchy is the Fire Chief, who attends meetings and engages in other high-level deliberations with other divisions of LAP that may impact the ARFF service. In day-to-day operations, the Fire Chief is assisted by three General Rescue Supervisors who rotate 12-hour shifts. Each General Rescue Supervisor organizes and monitors the activities of a group of 12 firefighters, with the assistance of a lower-ranking Rescue Team Supervisor. This entire apparatus is subordinate to LAP management and works in parallel with other departments, including Construction, Security, and more, while a LAP-NEWLIM Aeronautical Specialist ensures that activities related to the expansion project are carried out in a manner harmonious to the concurrent operation of aircraft.
Meanwhile in the Corpac control tower, operations are overseen by the Tower General Coordinator, whose primary duty is to ensure that the tower functions smoothly and provides safe and efficient air traffic services to all airport users. Below the General Coordinator, the controller staff are organized into five “duty teams,” each of which is headed up by a Duty Supervisor. Each Duty Supervisor is in turn responsible for a group of about a half a dozen controllers, who work in two-hour blocks while rotating through four “operational positions” over the course of a 12-hour shift. The highest-ranking operational position is the Shift Supervisor, which may be filled by the Duty Supervisor or any qualified controller. This position oversees the three positions that talk directly to aircraft, consisting of Clearance Delivery, which provides information to planes awaiting departure from the gate; Ground Control, which handles all moving traffic on aprons and taxiways; and Local or Tower Control, which is responsible for takeoffs, landings, and all other operations on the runway itself.
Although this is a lot to remember, most of these relationships will be revisited shortly, as we begin to piece together the fatal events of November 18th.
◊◊◊
On the morning of November 17th, the day originally planned for the response time exercise, the LAP-NEWLIM Aeronautical Specialist placed a phone call to the Corpac Tower General Coordinator in order to arrange a time window for the exercise that would result in the least impact to air traffic. This conversation apparently led to the conclusion that the best time for the exercise would actually be between 15:00 and 16:00 the following day, which the Tower General Supervisor later conveyed in an email addressed to the Aeronautical Specialist. This email was also forwarded to the usual Duty Supervisor for Duty Team №1, who would be overseeing the tower during the proposed exercise, so that he could pass it on to his staff.
Meanwhile at LAP, on the evening of the 17th, the ARFF Fire Chief sent an email to, among many others, the General Rescue Supervisor and Rescue Team Supervisor who would be on duty on November 18th, informing them that the exercise would take place on the afternoon of that date, and that air traffic control would provide “facilities for free transit from the new station along the VSR4 service road to the current runway for the ARFF units involved in the exercise.” However, no Corpac employees were among the recipients.
The following morning, two of the controllers on Duty Team №1 arrived to find that their other four colleagues, including the Duty Supervisor, had called off work for various reasons. According to the line of succession, one of the regular controllers became acting Duty Supervisor, while four replacements were brought in to help cover the 7:00 to 19:00 shift, including three from other Duty Teams who were working overtime, and one who had been assisting the Tower General Coordinator. As an unintended side effect of this situation, knowledge of the response time exercise was lost, because the only team member who knew about it was the usual Duty Supervisor who had called in sick.
Over the course of the day, the acting Duty Supervisor, four regular controllers, and a trainee worked the four operational positions through a series of two-hour blocs. At the end of each bloc, they would all swap positions, with each periodically receiving empty blocs so as not to exceed 8 hours on duty during the 12-hour shift. However, the acting Duty Supervisor worked the first four blocs continuously without a break, and at one point he was observed sleeping at the Shift Supervisor position.
Meanwhile, as the scheduled time for the exercise approached, the ARFF personnel began to gather with their vehicles at the new fire station. In command was the General Rescue Supervisor, assisted by the Rescue Team Supervisor, while six of the twelve on-duty firefighters were recruited to drive the ARFF vehicles. The exercise plan called for the involvement of two Rosenbauer Panther firefighting vehicles, consisting of a six-wheel model designated Rescue 1, and a four-wheel model designated Rescue 3, each of which would be manned by a driver, a co-driver, and an equipment operator. The General Rescue Supervisor and the Fire Chief would follow along behind at the wheel of Rescue 7, a modified Nissan Frontier pickup truck. Finally, once all this was in place, all that remained was to confirm the exact time of the exercise, which had to be coordinated with air traffic control.
The General Rescue Supervisor decided that the task of coordinating with ATC would be delegated to the Rescue Team Supervisor, and at 13:58, the latter called the landline for the Duty Supervisor position at the control tower to inquire about the timing of the exercise.
Picking up the phone, the acting Tower Duty Supervisor responded, “Tower.”
“Hello sir, good afternoon, this is XX XX, Rescue Station Team Supervisor,” the caller said. (Real names are redacted from the transcripts.) “A favor with Mr. AA?”
“Mr. BB BB. The same,” the Duty Supervisor replied, obliquely informing him that the regular Duty Supervisor, Mr. AA, was not in that day.
“How are you sir?” said the Rescue Team Supervisor. “I called because today we are going to test the new rescue station… to the head of 34. So, we are looking at doing them between a window that we have between three and four in the afternoon. We coordinate with you, I think the time window, more or less, is between 3:00 and 3:20 on average.”
“What are they going to do, or what do you want to do, to begin with?” the Duty Supervisor asked. He was just now finding out about the exercise for the first time, although the ARFF personnel were unaware of this.
“Now, what we are going to do is from the new rescue station,” the rescue Team Supervisor explained. “We’re going to do a kind of… a response time, okay, practically towards the head of 34. It’s a test, it’s not a response time.”
“Yes, yes, of course, of course,” said the Duty Supervisor.
“We are passing within that time, correct? So for that, obviously, we are going to request authorization via 121.9, okay?” said the Rescue Team Supervisor, referring to the Ground Control frequency.
The Duty Supervisor was trying to visualize in that moment what route the fire trucks would take from the new fire station to the head of runway 34. “Do I understand that they are going to travel through the new taxiways, Quebec, Romeo, and Lima?” he said, referring to recently constructed taxiways on the west side of the runway.
The Rescue Team Supervisor had no idea where any of those taxiways were, but he must have figured the controller knew better than him, so he replied, “That’s how it is.”
“Aaaand are you going to go near the head, or do you request to enter the runway?” the Duty Supervisor asked.
“We request to enter the runway, at the head,” said the Rescue Team Supervisor.
At this point, we should stop and consider the route that was being discussed. Earlier in this article, it was mentioned that the exercise route would follow VSR4 to the runway, and then the vehicles would proceed down the runway itself to the head of runway 34, and this was still the plan. But the Duty Supervisor, who had not been present for the previous exercise in August, imagined that this exercise would be like the ones from the old fire station, where the fire trucks proceeded along a parallel taxiway to the head of the runway. He therefore assumed that the vehicles would proceed along either taxiway Quebec or taxiway Romeo, which run parallel to VSR4 in the vicinity of the new fire station, and then turn right onto taxiway Lima, paralleling the runway on the west side until they reached the end. (These two conceptions of the route are shown above.) Furthermore, although the Rescue Team Supervisor had received the earlier email explaining that VSR4 would be used, he was not familiar with the official names of any of the roads or taxiways in the newly constructed area, many of which had just been completed within the past few weeks. He therefore did not recognize that the Duty Supervisor was conveying an incorrect picture of the route, and although the General Rescue Supervisor and the Fire Chief were both listening to the call on speakerphone, they inexplicably made no attempt to interject with the correct information.
In fact, had the Duty Supervisor been fully aware of the status of the construction project, he would have known that the route he imagined was not even usable. Taxiways Quebec and Romeo were blocked off by the fence surrounding the work site and couldn’t be accessed from the new fire station, and moreover, it was not possible to enter the head of runway 34 from the end of taxiway Lima, because the last 50 meters of the taxiway hadn’t been built yet. However, nobody corrected him on this matter either.
Now, let’s return to the call. By this point the acting Duty Supervisor had acquired an incorrect picture of the route that the fire trucks would take, and the Rescue Team Supervisor had also incorrectly confirmed that the trucks would request entry to the runway only upon reaching the head of runway 34. Expounding upon this erroneous interpretation, the Duty Supervisor then said, “Now, depending on the traffic, the person who is on the Ground frequency will coordinate with the person who is at the Tower [frequency] for entry.” This was standard procedure for ground vehicles that wanted to enter the runway, because ground vehicles normally remained in contact with the Ground controller, while the runway was the responsibility of the Tower controller, therefore coordination between them would have to take place. Continuing his explanation, the Duty Supervisor then added, “Depending on the traffic, because you can see a window in terms of arrivals, but maybe we have departure traffic.”
“That’s exactly what we wanted to coordinate with you,” said the Rescue Team Supervisor.
“Yes, yes, yes, correct,” said the Duty Supervisor. “You call us and depending on that traffic we allow you entry to the runway. There is no problem if there is no traffic.”
“Yes, and there is even coordination with the [Tower General Coordinator], …(unintelligible)… to do precisely today’s test,” the Rescue Team Supervisor added.
Being a last minute replacement, this was news to the Duty Supervisor. “Yeah, when did you coordinate with him?” he asked.
“Eeeehh, there’s an email involved, just a moment…” the Rescue Team Supervisor said. In the background, the voice of either the General Rescue Supervisor or the Fire Chief could be heard saying, “Yesterday!”
“…Yesterday, yesterday,” the Rescue Team Supervisor repeated.
“Well okay, he omitted to inform, but well, that’s the least of it,” said the Duty Supervisor.
“If not, send me an email and I will forward it to you,” said the Rescue Team Supervisor.
“No, there is no problem, oral coordination for me is the most important thing at this moment that I am responsible,” said the Duty Supervisor.
“Now, ready hermano, then, please, I ask you this… we can, what’s it called, we coordinate it eh, my General Supervisor is going to be communicating any news with you,” the Rescue Team Supervisor concluded.
“Yes, correct, ready, okay,” said the Duty Supervisor.
“Thank you very much,” said the Rescue Team Supervisor.
The Duty Supervisor signed off with “Ciao,” and the call ended.
Seconds later, the Duty Supervisor walked over to where the Ground and Tower controllers were seated in order to explain the situation to them. “In a while there will be a test, an exercise by the firefighters,” he said. “They are going to leave the new rescue base, they are going to go through Quebec, Romeo, Lima to the head of 34.”
“From that path, will you able to see all the way there?” the Tower controller asked.
“I don’t know!” said the Duty Supervisor. “And they will see, depending on the traffic, whether or not they are allowed to enter the runway.”
The tower controller laughed. “Negative, up to the holding point, nothing more!” she said. “They can go from … (unintelligible) … if there is traffic, no! They go to the holding point.” In this context the “holding point” refers to the place at the end of a taxiway where aircraft wait before entering the head of runway 34.
The Duty Supervisor replied that he had no problem clearing the trucks to the enter the runway if traffic permitted.
Subsequently, the Duty Supervisor and the General Rescue Supervisor had a conversation on their personal cell phones, which was not recorded, during which they allegedly agreed that the exercise would take place at 15:10. The General Rescue Supervisor then gathered the ARFF personnel participating in the exercise and informed them that it would happen at the aforementioned time, and that he would signal the start of the exercise by activating the sirens on Rescue 7, because the new fire station was not yet hooked up to the emergency alarm button in the control tower. He also briefed the route they would take, first along VSR4, followed by a right turn onto the runway, which they would follow to the head of 34. However, he did not use the identifier “VSR4,” as he appeared to be unaware of it, and neither he nor the Rescue Team Supervisor recognized that this was not the route they had conveyed to the Tower Duty Supervisor just over 30 minutes earlier.
◊◊◊
Meanwhile, at parking area №9, the last passengers had just finished boarding LATAM Perú flight 2213, bound for the city of Juliaca. LATAM Perú is the flag carrier of Perú and a subsidiary of the LATAM Airlines Group, which originally formed from the 2011 merger of LAN Chile, the former flag carrier of Chile, with TAM Airlines, the second largest airline in Brazil. The name “LATAM” is a double entendre, combining “LAN” and “TAM,” while also invoking “Latin America,” in an expression of its broad regional ambitions. LATAM Airlines, as the company is collectively known, is today the largest airline in Latin America and has subsidiaries in most major South American countries, including LATAM Chile, LATAM Brazil, LATAM Perú, LATAM Colombia, LATAM Ecuador, and LATAM Paraguay.
LATAM Airlines was also among the early customers when Airbus introduced its latest, re-engined Airbus A320 variant, the A320neo (“New Engine Option”) in 2016. Casual readers may recall the A320neo as the model that spurred Boeing to develop the ill-fated 737 MAX. Unlike its competitor, however, by November 2022 no A320neo had been destroyed in an accident. Certainly no one at Jorge Chávez that day could have predicted that that was about to change.
Flight 2213 to Juliaca on November 18th was assigned to an A320neo registered in Chile as CC-BHB, which would be partially filled with a moderate load of 102 passengers. Also on board were six crewmembers, including four flight attendants and the two pilots, consisting of an experienced Captain with about 8,200 hours and a First Officer with about 3,300 — although none of that experience was going to help them avoid what was coming.
At 14:55, with all the passengers on board and all checklists complete, flight 2213 was cleared by the Ground controller to push back from the gate. However, another aircraft belonging to SKY Perú was in the way, and further movement was delayed for seven minutes.
During those seven minutes, at 15:00, a new two hour bloc shift began in the control tower, and all the controllers swapped positions. The Duty Supervisor, having completed eight hours on duty, left for the day; the previous Tower controller took over the position of Shift Supervisor; a controller that had been on break since 13:00 assumed the role of Tower controller; and a totally new controller, who had just showed up to work at 14:30, took over Ground control, while the previous Ground controller went on break. Therefore, the new Shift Supervisor was the only person in the tower for the 15:00 to 17:00 shift who had been present when the Duty Supervisor discussed the ARFF exercise.
Subsequently, at 15:02, the new Ground controller cleared flight 2213 to taxi to the threshold of runway 16 for takeoff, and handed off the flight to the Tower controller, who was using a frequency of 118.1. The crew taxied without incident to the runway, and at 15:09 the First Officer radioed that they had reached the holding point. The Tower subsequently instructed them to hold short of runway 16 until another A320 had landed, which it did moments later, at 15:10.
Meanwhile, at 15:03, the General Rescue Supervisor was putting the final preparations in place for the exercise. One of the last remaining tasks was to remove a row of cones that blocked entry to the runway from VSR4. Therefore, he called Ground on a frequency of 121.9, transmitting, “Ground control, Rescue 6,” although he was actually in Rescue 7.
“Rescue 6, Ground,” the controller replied.
“Ground control, permission to remove the cones that block us from the main runway?” he asked.
“Position?” the Ground controller asked, unsure what he was talking about.
“In front of LAN,” the General Rescue Supervisor said, using the callsign for LATAM Airlines.
Still uncertain what he was referring to, the Ground controller asked again, “Advise position?”
“In front of the LAN hangar,” said the General Rescue Supervisor.
The intersection of VSR4 and the runway was directly opposite a LATAM hangar, but this was not clear from his transmission. “Confirm, close to taxiway Alfa?” the Ground controller asked, believing that he was on the east side of the runway, immediately in front of the hangar.
“Nooo eeeh, in the new project,” the General Rescue Supervisor said, again failing to specify his exact position. “I am here to remove those cones, to do the exercise.”
“Copy standby,” the Ground controller said, before picking up his binoculars to search for the cones. With the help of the Tower controller, he managed to spot them after a few seconds. “Rescue 6, authorized approach 90 meters from the runway axis, the cones on the vehicular route, Whiskey side,” he said. Since the cones appeared to be more than 90 meters from the centerline of the 45-meter-wide runway, they were not the responsibility of the Tower controller, and it was okay to enter the area even if the runway was in use. He did not recognize that cones were on VSR4, nor did he understand the reason why the cones were being removed, but neither did he ask.
“Copy, authorized (unintelligible),” said the General Rescue Supervisor.
One minute and 16 seconds later, having removed the cones, the General Rescue Supervisor called Ground again to report, “Ground control, Rescue 6, we have withdrawn from the area.”
“Copy,” said the Ground controller.
Some ninety seconds after that, the General Rescue Supervisor called again. “Can you confirm if the time for the exercise is still maintained at 15:10 local time?” he asked.
Having just started his shift eight minutes ago, the Ground controller was totally unaware of any exercise. Telling the General Rescue Supervisor to “standby,” he turned to the Shift Supervisor to ask what it was all about. “Rescue 6 is asking me about an exercise,” he explained.
“Have you coordinated with the one you relieved?” the Shift Supervisor asked.
“No,” said the Ground controller. When he took over for the previous Ground controller, she hadn’t said anything about an exercise.
“Ah now, they are going to do an exercise, a response time from the new base,” the Shift Supervisor explained. “To the waiting point for Foxtrot…for the Foxtrot… the parallel to Foxtrot, for Lima,” she said, trying to remember what the new taxiway on the west side of the runway was called. “…to the head of 34. If you do not have traffic, you coordinate so that they enter the threshold.”
“From the new base?” the Ground controller asked.
“From the new base,” the Shift Supervisor confirmed.
“And is he going to go there, to where there are no works?” the Ground controller asked.
“As far as where it doesn’t connect, of course,” said the Shift Supervisor, possibly referring to the end of taxiway Lima, where the final connection to the head of runway 34 still hadn’t been built.
“Ah, yeah,” said the Ground controller.
“But always indicating to him outside the runway,” the Shift Supervisor added.
Turning back to his radio, the Ground controller said, “Rescue 6, Ground.”
“Go ahead, Ground,” came the reply.
“Confirming the exercise,” said the Ground controller.
“Exercise is confirmed at 15:10 local time, copy, thank you,” said the General Rescue Supervisor. The time was 15:08 and 58 seconds.
Approximately one minute later, at 15:10 and 18 seconds, the General Rescue Supervisor announced the start of the exercise over the Ground control frequency of 121.9. “Fire at the head of 34,” he said, and the firefighters stood at attention, waiting for the siren that would signal the start of the three-minute timer.
At that same moment, the pilots of LATAM Perú flight 2213 rattled off the final items on the before takeoff checklist. Moments later, at 15:10 and 40 seconds, the Tower controller transmitted on 118.1, “LAN PERU 2213, wind 190 degrees at 10 knots, runway 16, cleared for takeoff.”
“Cleared for takeoff, runway 16, LAN PERU 2213,” the First Officer replied.
Simultaneously, the General Rescue Supervisor activated the siren, and the exercise began. The firefighters scrambled aboard Rescue 1 and Rescue 3, started the engines, and peeled out of the fire station. “Control, Rescue 6,” said the General Rescue Supervisor. “Units 1, 3, and 6 mobilizing to the head of 34.”
Watching through binoculars, the Ground controller said, “Rescue in sight, entering Quebec.” In actuality, the vehicles were entering VSR4, which ran parallel to taxiway Quebec, but from the tower this was very difficult to discern.
Meanwhile, completely unaware of the exercise — which was playing out on 121.9, a frequency they were no longer monitoring — the crew of flight 2213 steered their plane onto the runway for departure.
“Check takeoff,” said the Captain.
“Check,” the First Officer replied.
The captain advanced the thrust levers to the selected takeoff power setting, and the First Officer called out, “Thrust set.”
Flight 2213 began to accelerate down the runway, gaining speed rapidly. Eight seconds later, the First Officer called out, “100 knots.”
“Check,” said the Captain.
Approaching the runway on VSR4, with Rescue 3 in the front and Rescue 7 in the rear, the firefighters had no idea that an Airbus had just been cleared for takeoff. In fact, as far as the General Rescue Supervisor was concerned, all traffic was being held, because the Ground controller had authorized him to begin the exercise, and they knew that the exercise involved entering the runway — right?
Unfortunately, he was wrong. As the controllers watched the fire trucks speed down VSR4, they expected the convoy to make a right turn onto taxiway Lima to parallel the runway, but to their surprise and horror, they continued straight ahead. With only about 130 meters separating the intersection from the runway, the controller had no time to process this realization and issue a warning. In fact, the Shift Supervisor just barely had time to exclaim, “What are you doing!?”
The pilots of flight 2213 had similarly few options. The Captain spotted the convoy hurtling toward him from the right with just three seconds to spare, leaving him with no time to react. He managed only to shout, “That fucking imbecile! Hey asshole!” before he was interrupted by the sound of a colossal impact.
Traveling at 72 km/h, Rescue 3 hurtled onto the runway, turned sharply to the right, and collided with the aircraft, which was accelerating through 131 knots (243 km/h). The Airbus’s right engine slammed into the left side of the fire truck with tremendous force, instantly tearing the 23-ton vehicle to smithereens. Pieces of the truck and the engine ricocheted off the right wing, breaching the fuel tank and sending a gray mist flying through the air, which immediately ignited into a fireball. Missing its right engine, the plane lurched violently, then the right main landing gear collapsed, sending the aircraft sliding down the runway on its right wing and tail as a plume of fire and smoke trailed behind it.
Witnessing the unfolding events, the pilot of another aircraft transmitted, “Tower, Tower, there has been an accident on runway 16!”
On board the plane, the Captain did everything in his power to keep the crippled aircraft on the runway while hammering the brakes to slow the plane. In the background, the cabin crew could be heard urging the passengers to remain seated with their seatbelts fastened.
“Lima, 302,” another crew transmitted, “the plane landing collided with one of the cars.”
“Hit the callouts,” said the Captain, referring to the rejected takeoff procedures, which both pilots had memorized.
“Reverse,” said the First Officer, activating reverse thrust.
A warning popped up, informing them that only the left reverser had deployed, because the right reverser, along with the entire right engine, was no longer attached to the airplane. “One reverse,” the Captain called out.
Over the radio, the Tower controller said, “Yes, accident, aircraft accident on the runway, aircraft accident on the runway!”
The Ground controller then added, “Rescue, I repeat, Rescue, aircraft crashed on the runway, I repeat!”
Just seconds behind the ill-fated Rescue 3, the crew of Rescue 1 turned onto the runway and began to pursue the burning aircraft. Simultaneously, the crews of Rescue 2 and Rescue 4 launched from the old fire station to join the response.
On board the plane, another warning message popped up informing the crew that the autobrakes had malfunctioned on the right side. “No decel,” the Captain said, reading off the message as he continued to apply full manual braking. And it was working — the plane was slowing down, still under control on the runway, and would soon come to a stop.
“Advise inside? The First Officer asked.
“Yes, ah, no, talk to ATC,” said the Captain.
As another flight crew again reported the accident, the First Officer said, “LAN PERU 2213, stopping runway 16, fire on the right.”
“Yes, the rescue vehicle is being sent immediately, LAN PERU 2213,” said the Tower controller.
Finally, the aircraft ground to a halt, leaning askew, less than 200 meters short of the displaced threshold of runway 34. The First Officer quickly ran through the emergency notifications on their alert display, while the cabin crew broadcast continuous announcements urging the passengers to remain seated and not to grab their belongings.
In the background, the Ground controller said, “Rescue in sight, rescue unit authorized entry to runway.”
“Do you have a fire in the engine? Or not?” the Captain asked.
“Yes, there is a fire in the engine,” said the First Officer. In actuality, the situation was much more serious than that: there was no engine, and the fire was on the airframe itself.
Calling air traffic control, the Captain asked, “Lima, LAN PERU, confirm for me, do you see fire on our airplane?”
“Correct, fire, fire, under the landing gear, correct,” said the Tower. “Two rescue vehicles are approaching at the moment.”
“Emergency evacuation procedure,” the Captain ordered. In the background, the flight attendants continued to shout, “Do not remove hand luggage, do not remove hand luggage!”
“Emer…!” the First Officer started to say.
“Stay calm,” the Captain urged. “Emergency evacuation.”
Hurriedly, the pilots ran through the emergency evacuation procedure, arming the parking brake and calling the cabin crew. “Captain, we have a fire in the back,” a flight attendant said over the interphone.
“I know, I know, I’m aware,” said the Captain.
The pilots shut off the remaining engine, then the Captain announced, “Crew evacuation!”
“Do we open the doors?” A flight attendant inquired.
“Yes, open, open,” the Captain ordered.
By the time the doors flew open and the slides deployed, fire trucks were already pouring foam on the fire raging beneath the aft fuselage. The flight attendants could see flames outside the L4 door in the aft left part of the cabin, so it was not used, and the R1 door at the right front also could not be used because its slide failed to inflate. Nevertheless, the L1 and R4 exits were free, and the crew managed to rapidly evacuate all 102 passengers through them, including some who were suffering from serious injuries. By the time the majority of the passengers left the plane, the fire was essentially extinguished, thanks to the quick work of the fire crews, who were, however ironically, on the scene in record time.
Ultimately, the Captain was — in true maritime fashion — the last to leave the plane, after confirming that no one was left on board. Some of the fire crews remained to tamp down the embers, while Rescue 4 was ordered to drive down the runway to the remains of Rescue 3 to determine the fate of its occupants. As they approached the scene, they probably held out little hope — the entire crew cab portion of the truck had been ripped from the chassis and lay strewn across the runway. There rescuers discovered the lifeless bodies of the 45-year-old driver and 23-year-old equipment operator, but miraculously, the 32-year-old co-driver, who had been seated farthest from the point of impact, was breathing and had a pulse. He was rushed to hospital in a coma with severe skull and facial injuries, and although his prognosis was grim, doctors vowed to do their best to save him.
While early images of the fiery accident led observers to worry that there may have been fatalities on the aircraft as well, this thankfully proved not to be the case. Although exterior damage was extensive, the firefighters managed to extinguish the blaze before it penetrated the cabin, and the passengers did not have to deal with heavy smoke or fire during the evacuation process. In the end, all 108 passengers and crew escaped with their lives, although not without consequence — the final report states that 92 people suffered minor injuries, and 9 were seriously hurt, including some who required lengthy hospital stays, with the last passenger being released only on December 14th. As of this writing, several are still dealing with injuries that require ongoing physical therapy.
Unfortunately, the injured firefighter is not among them. Although people around the world were rooting for his survival, he suffered a traumatic brain injury from which he never recovered, and he died on June 17th, 2023, seven months after the accident, becoming its third and final victim.
◊◊◊
In the immediate aftermath of the crash, chaos gripped Jorge Chávez International Airport. The collision had damaged the runway and left it littered with wreckage, closing down the busiest airport in Perú for nearly 30 hours, while various parties tried to figure out who was at fault. In a move widely criticized by global pilots’ organizations, Peruvian authorities detained the pilots of flight 2213 and held them for over a day, despite a complete lack of evidence of their culpability, as it in fact emerged within hours that the A320 had been properly cleared for takeoff. LAP officials publicly insisted that the fire trucks also had authorization to enter the runway, and continued to do so as late as June 2023, but Corpac vigorously denied this, and the Tower tapes appeared to back them up. So what really happened? Why did the convoy of fire trucks charge straight into the path of a speeding airliner, with fatal consequences? Now, one year later, Perú’s Aviation Accident Investigation Commission, or CIAA, has finally produced a conclusive answer with the release of its final report.
On the most basic level, the accident was caused by the fact that Corpac and LAP personnel had differing mental models of the proposed exercise route. Air traffic controllers believed that the fire trucks would travel via taxiways Quebec, Romeo, and Lima to the head of runway 34, and thereafter request entry. In reality, the ARFF personnel planned to travel via Vehicle Service Route 4 and then proceed down runway itself. So where did this misunderstanding come from?
In the CIAA’s opinion, one of the most important factors influencing these divergent expectations was the fact that neither the controllers nor the ARFF crews had received training on the layout and nomenclature of the new roads and taxiways being constructed under the LAP-NEWLIM expansion project. Everything west of runway 16/34 was considered outside the jurisdiction of air traffic control until such time as it was ready for actual operations, which was not expected to happen until 2023. Construction vehicles moved freely there and controllers were quite happy to leave them alone. Airport maps posted in the control tower didn’t include the newly constructed surfaces, and none of the controllers interviewed by the CIAA were even aware of the existence of VSR4. In fact, due to the uniformly brown terrain in the construction site, the small access road was barely visible from the tower even if one knew it was there, and it probably didn’t even occur to the controllers that it would be possible to travel straight from the new fire station onto the runway without making at least two turns. Furthermore, most of the controllers were unaware that taxiways Quebec and Romeo were still fenced off, or that taxiway Lima hadn’t been finished and didn’t connect to the head of runway 34 at its southern end.
At the same time, ARFF personnel hadn’t received any training on these matters either, and most of them appeared equally unaware of the names of the new service roads and taxiways. For instance, the Tower Duty Supervisor described an incorrect route that he assumed the trucks would use, and the Rescue Team Supervisor didn’t know enough about the nomenclature to correct him. And later, the General Rescue Supervisor was unable to indicate his location with respect to any road or taxiway despite repeated inquiries from the Ground controller. Had he been able to articulate that he wanted to remove the cones on VSR4, the Ground controller might have decided to find out where that road was located, and he might have realized that the only reason to remove the cones was so that vehicles could access the runway via VSR4.
This lack of knowledge provided fertile ground in which the seeds of disaster were planted. But the actual sequence of events probably began during the debrief meeting after the first, uneventful response time exercise in August. Despite the fact that the August exercise was closely coordinated between LAP and Corpac, with representatives of the latter involved at the planning stages, no Corpac representatives were present when the decision was made to conduct a second exercise in November, and there is no evidence that anyone at Corpac was informed of the plan until the morning of November 17th, the proposed day of the exercise. The reasons for this breakdown in communication are difficult to understand, but it’s possible that those responsible for the decision simply forgot to appoint anyone to coordinate. Additionally, the plan for the second exercise was essentially identical to the first, so LAP personnel might have believed that additional coordination was unnecessary. After all, the Tower General Coordinator was heavily involved in the planning of the August exercise, so there might have been an assumption that he would simply convey the already familiar details of the plan to whomever happened to be on duty that day, without any need for closer cooperation.
However, a breakdown in the chain of command at Corpac occurred, because the Duty Supervisor whom the General Coordinator had entrusted with knowledge of the exercise called in sick, and his replacement was never informed. Consequently, the plan for the exercise was transmitted not from organizer to organizer, but between two lower level supervisors, neither of whom was familiar with the details. While speaking to the Rescue Team Supervisor, the Tower Duty Supervisor asked if the exercise would use taxiways Quebec, Romeo, and Lima; the Rescue Team Supervisor erroneously confirmed this due to insufficient knowledge of the taxiway nomenclature; and the incorrect plan was then passed down to everyone else in the tower.
By the time the clock approached 15:10, the General Rescue Supervisor believed that controllers had been informed of the exercise and knew what it would entail, when they in fact had a completely incorrect picture of the situation. Consequently, when the Ground controller — who had only found out about the exercise moments earlier! — authorized it to begin, the General Rescue Supervisor assumed that that confirmation carried implicit permission to access the runway, because it was literally not possible to drive from the new fire station to the head of runway 34 without entering it. He then passed on this false assumption to the rescue personnel under his command, who understood that their supervisor had cleared everything with air traffic control already and that they need not worry about stopping short of the runway to ask for clearance to enter. This might have been consistent with their expectation that they should beat their previous response time of 2 minutes and 48 seconds, which would be difficult to do if they decelerated and stopped at the edge of the runway, given that it took around 30 seconds for the heavy fire trucks to get up to speed.
Nevertheless, every single aviation rulebook in existence, from International Civil Aviation Organization regulations to Peruvian law to the ARFF manual, clearly states that no one is to enter an active runway without receiving express permission from air traffic control. “Express permission” means “Cleared to enter/cross runway X” and never anything else. This permission was never given, and it was a major error on the part of the General Rescue Supervisor to assume that such a thing as an implicit clearance even existed, let alone that he had received one. In fact, the aviation industry established decades ago that a clearance to proceed to some location on the airport surface never includes implicit permission to cross any runways that one might happen to encounter along the way. Therefore, while the General Rescue Supervisor’s assumption had a certain internal logic, it plainly violated one of the fundamental principles of airport surface navigation and he really should have known better.
Once the rescue vehicles were in motion, disaster was virtually assured. The trucks appeared to be going where controllers thought they would go up until the last couple of seconds before the collision. The pilots of the LATAM A320, who were focused on the runway ahead, didn’t see the convoy approaching from the side until three seconds from impact. And the driver of Rescue 3 was not expecting to encounter any traffic, and he might have been looking to his right, toward the area where he was about to turn, rather than toward the aircraft, which was coming from his left.
The crew of flight 2213 had no possibility of taking any sort of evasive action, traveling as they were at 131 knots, and though the collision caused major damage, they kept the plane under control and brought it to a halt within the confines of the runway. With the help of the cabin crew, they then oversaw the safe evacuation of all 102 passengers despite the presence of a large fuel-fed fire under the rear of the aircraft. In total, the actions of all 6 crewmembers during those critical minutes were nothing short of heroic.
In its final report, the CIAA also took the time to commend the firefighters who rushed to extinguish the flames, which no doubt saved lives. Investigators specifically pointed out that the fire crews, especially the crew of Rescue 1, displayed exceptional courage and professionalism in responding swiftly and effectively to the crash despite witnessing the violent deaths of their own colleagues mere seconds earlier. Amid a completely unprecedented situation, they ensured that duty momentarily triumphed over emotion, and did what had to be done.
Not everyone distinguished themselves that day, however. While the controllers were mostly blameless, opportunities to discover the misunderstanding nevertheless may have been missed in the minutes and hours before the crash. First of all, shortly before the accident the Shift Supervisor instructed the Ground Controller to tell the ARFF crews to stay off the runway, but he did not do so and she did not correct him. Secondly, the previous Ground controller, who went off duty at 15:00, did not inform her successor of the planned exercise during the handover briefing, apparently because she thought the vehicles would not enter the controlled areas of the airport. And third, the General Coordinator should have taken action to ensure that the staff on duty knew about the exercise when the original Duty Supervisor called in sick, and the acting Duty Supervisor ideally should have pushed the Rescue Team Supervisor to provide more specific information about the exercise. Investigators also pointed out that several controllers were showing signs of fatigue, and some were observed using their mobile phones while on duty, although they concluded that neither of these factors played any direct role in the accident.
However, the above flaws were quite minor compared to the errors committed by ARFF management. In addition to the General Rescue Supervisor’s dangerously improper assumption that his men had permission to enter the runway, investigators also criticized him and the Fire Chief for failing to correct the Rescue Team Supervisor when he provided false information over the phone, even though they were in the room when it happened. Investigators also criticized high level LAP managers, including the Fire Chief, for failing to coordinate the exercise with Corpac, whether that meant including Corpac personnel in planning meetings, CC’ing them on important emails, or sending an ARFF representative up to the tower during the exercise, as was standard practice during exercises from the old fire station. In fact, ideally they should have done all of the above. Why they didn’t is uncertain, the subject of mere speculation, in part because most of the LAP management appear to have immediately lawyered up and provided only terse, noncommittal statements to the CIAA.
In its conclusion, the CIAA wrote that almost everyone involved, from upper management on down, displayed some level of complacency — the unconscious belief that things will be fine, just because they’ve always been fine, and that vigilance is unnecessary. In this accident, this manifested as a certain incuriosity, where nobody had the whole picture, and many of them knew it, but each declined to rectify their own ignorance. A bit of life advice: when you don’t know what’s going on, don’t assume that everyone else knows better. Because what if you aren’t the only one? What if nobody knows what’s going on? The truth is that such a situation can quickly spiral into disaster if nobody starts asking hard questions, and in fact that’s what happened at Jorge Chávez on the 18th of November 2022.
One way to prevent this kind of communications breakdown is to ensure that personnel are well trained on a comprehensive set of standard procedures for every situation. However, the CIAA noted a number of deficiencies in this area, beyond the already-mentioned lack of training on the new airport zones. ARFF training did not cover procedures for response time exercises, and the description of such exercises in the ARFF manual lacked specificity, leaving unmentioned the need to ask for express permission before entering a runway. Firefighters were also not provided with detailed training on standard radio phraseology, despite the fact that they were expected to use that phraseology whenever they operated vehicles inside the maneuvering areas of the airport. This may have contributed to the General Rescue Supervisor’s failure to obtain express permission to enter the runway, and the rescue drivers’ failure to question his instructions. And lastly, neither ARFF personnel nor controllers were familiar with the International Civil Aviation Organization’s manual for preventing runway incursions, a critical document that explains how runway collision accidents happen and how to avoid them.
In order to correct these deficiencies, the CIAA took the unusual step of not only recommending training improvements, but also drafting their own comprehensive and detailed proposal for how LAP and Corpac could more effectively coordinate the planning, organization, and execution of response time exercises, with built-in safety measures designed to ensure that potential hazards are identified and addressed before being discovered in the line of duty. The genuine commitment to improving aviation safety in Perú expressed in this proposal brings hope that similar accidents might be avoided in the future.
◊◊◊
Looking back on the accident from not so far down the road, its long-term significance is yet to be determined, but the lessons it provides are invaluable, which is why I chose to write such a comprehensive article. But while much went wrong, I think it’s worth concluding with a reminder that a lot also went right. There was a time in the history of commercial aviation when not everyone would have walked off that plane alive. The fact that they did was not a miracle in the divine sense, but rather the very human triumph of modern training and engineering, and an argument in support of the belief that every act of incompetence or ignorance is somewhere overshadowed by corresponding acts of professionalism, skill, and courage. So in the end, do not let this tragedy stir a lack of faith in flying, or in firefighting, but rather let it reaffirm trust in both, as twin pillars of aviation safety that for a brief moment clashed, but nevertheless knelt to pick up the pieces together.
_______________________________________________________________
Don’t forget to listen to Controlled Pod Into Terrain, my new podcast (with slides!), where I discuss aerospace disasters with my cohosts Ariadne and J! Check out our channel here, and listen to our latest episode, featuring Paninternational flight 112. Alternatively, download audio-only versions via RSS.com, or look us up on Spotify!
_______________________________________________________________
Join the discussion of this article on Reddit
Support me on Patreon (Note: I do not earn money from views on Medium!)
Visit r/admiralcloudberg to read and discuss over 250 similar articles
