Event 1: Unauthorized Takeoff on 3 January 2017
On 3 January 2017, Blue Panorama flight BPA2331 (Boeing 737-800) operating from Tirana to Milan Malpensa was cleared to taxi to runway 17 with instructions to back-track and report ready for takeoff. The flight crew entered the runway and commenced takeoff without obtaining clearance. The tower controller observed the takeoff and after the aircraft became airborne informed the crew that they had departed without clearance. The pilot acknowledged the error, citing forgetfulness and misunderstanding. The investigation found that the flight crew did not correctly read back the taxi instruction and failed to report ready for takeoff. The controller did not require a correct readback and did not monitor the aircraft's movement on the runway in a timely manner. Due to the absence of other traffic, this event was not classified as an incident.
Event 2: Runway Incursion on 13 April 2017
On 13 April 2017, around 09:40 local time, Blue Panorama flight BPA2247 was cleared to taxi while runway 17 was in use for departures. The approach controller requested to bring a SwiftAir flight MDF9030 in to land on runway 35. The tower controller initially denied the request but later approved the landing, intending for SwiftAir to land while BPA2247 proceeded to the holding point. However, BPA2247 entered the runway as SwiftAir was on final. The SwiftAir crew queried the tower, received a landing clearance, and landed with hard braking, stopping approximately 500 meters from the Blue Panorama aircraft. The event was classified as a runway incursion. Causes included the BPA2247 crew not adhering to instructions, failing to monitor radio communications for situational awareness, and not scanning the runway for traffic before entering. Contributing factors were the tower's decision to use both runway directions, insufficient focus on both aircraft, and lack of traffic advisories.
Event 3: Navigation Error on 7 June 2017
On 7 June 2017, Blue Panorama flight BPA2227 (Tirana to Rome) was cleared to depart runway 35 with the Dires 2B SID, which required a right turn after takeoff. The crew, consisting of a captain (acting as instructor), a first officer under training, and a safety pilot, instead turned left after departure. The controller queried the turn, and the captain corrected the course, explaining the error was due to forgetting the instruction. The investigation determined that the training pilot and the safety pilot did not adequately monitor the actions of the pilot undergoing training, and that the trainee should have been better prepared for potential changes to departure instructions.
Conclusions
OKIIA concluded that Blue Panorama flight crews demonstrated a lack of seriousness and attention to operating rules and ICAO standards at Tirana Airport. Air traffic controllers also failed to enforce strict compliance with procedures. The agency noted that the relatively low traffic density at the airport may have led to complacency. Recommendations included improved crew training, better coordination between ATC sectors, clear assignment of clearance positions, and installation of runway holding point markings.