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Factors influencing misaligned take-off occurrences at night

Summary

On 3 July 2009, the Australian Transport Safety Bureau (ATSB) was notified that a SAAB Aircraft Company 340B (SAAB), registered VH-ZLW, had commenced its take-off roll along the runway 25 left edge lights at Sydney Kingsford Smith Airport, New South Wales. This was one of three occurrences over the previous 2 years that involved aircraft commencing takeoff on the runway edge lighting.

In addition, within the previous 2 years the ATSB investigated two other occurrences involving pilot misidentification of runway alignment cues or lack of those cues during takeoff. All five Australian misaligned take-off and landing occurrences involved aircraft with weights greater than 5,700kg and three of the six occurrences involved scheduled regular passenger transport (RPT) operations. The remaining two occurrences involved charter operations.

This research investigation examined each of these occurrences and relevant international occurrences to identify the common factors associated with misaligned take-off and landing occurrences.

After reviewing the Australian and international occurrences, eight common factors were identified that increased the risk of a misaligned take-off or landing occurrence. The factors included: distraction or divided attention of the flight crew; confusing runway layout; displaced threshold or intersection departure; poor visibility or weather; air traffic control clearance/s issued during runway entry; no runway centreline lighting; flight crew fatigue; and recessed runway edge lighting.

To foster safety awareness, knowledge and action, the ATSB developed a pilot information card to help flight crew identify factors that could increase the risk of a misaligned take-off or landing.

Download Complete Document: ar2009033 [PDF: 1.29MB]

Type: Research and Analysis Report
Investigation Number: Ar-2009-033
Publication Date: 30/06/2010
ISBN: 978-1-74251-073-6
Publication Number: Jun10/ATSB104