A TAROM Avions de Transport Regional ATR-42-500, registration YR-ATF performing flight RO-638 from Satu Mare to Bucharest Otopeni (Romania) with 22 passengers and 4 crew, landed on Otopeni's runway 08L but burst all main tyres. The aircraft came to a stop on the runway and was disabled.
On Jul 18th 2019 Romania's CIAS reported the occurrence was rated a serious incident and is being investigated. The landing was normal until brakes were applied.
On Sep 12th 2019 an internal investigation report by TAROM became known indicating, all four tyres (not just three as initial information had suggested) had burst and all 4 wheels' rims were damaged. The aircraft landed with the park brakes applied.
On Jul 9th 2020 Romania's AIAS released their final report concluding the probable cause of the serious incident was:
Incorrect position of the emergency/parking brake handle, moved from the "OFF" position, upon aircraft runway contact during landing.
Contributing factors were:
- In-flight use of the emergency/parking brake handle, for non-compliant purposes/maneuvers;
- Defective/inefficient CRM by superficial execution of Checks and Cross checks for landing;
- Crew failure to fully comply with the standard operating requirements according to the Company Operations Manual, by ignoring in some cases the "sterile cockpit" concept under FL100.
The AIAS analysed the first officer was pilot flying, the captain pilot monitoring on their 4th sector of the day. The captain's headset had failed, the crew was therefore using the cockpit speakers and hand held microphones for radio calls during the last three sectors.
The flight was more or less uneventful, the first officer however noticed the PARK BRAKE indication went on and off during the flight but did not communicate this to the captain. The indication had been caused by the captain randomly handling the park brake lever, which the captain admitted in post occurrence interviews. It had become common practise in the airline to move the park brake lever out of the OFF position to have the light illuminated as a reminder that checklist items were still open.
The first officer reported that he considered the check of instruments other than PFD and ND to be task by the pilot monitoring and did not pay attention to the panels, the AIAS considered this attitude non-compliant with CRM.
In addition the sterile cockpit below FL100 concept was not adhered to causing distraction to the standard operating procedures. As result the crew alert panel was not effectively monitored.
The investigation commission considered the behaviour of the pilots as "overconfident".