Aviation safety investigations & reports

Collision on ground - Townsville Aerodrome, Queensland, 11 February 2009, VH-SBW, Bombardier DHC-8-315

Investigation number:
AO-2009-007
Status: Completed
Investigation completed

Summary

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On 11 February 2009 at about 1922 Eastern Standard Time, a Bombardier Inc DHC‑8‑315 commenced the take-off roll on runway 01 at Townsville Aerodrome for Cairns, Queensland. During the takeoff, the pilot in command realised that the aircraft was aligned with the left runway edge. The aircraft was manoeuvred to the centre of the runway and the takeoff rejected. It was later determined that the aircraft's left mainwheel had damaged a runway edge light. There were no injuries to the 34 passengers or five crew members and no damage to the aircraft.

The investigation found a number of factors that may have led to the pilot in command not aligning the aircraft on the runway centreline for the takeoff. Those factors included misinterpreting the normal runway cues, time pressure to depart, the weather conditions at Townsville Aerodrome and the associated delays during the aircraft's arrival, landing and departure.

Following this occurrence, the operator amended their operational procedures to ensure aircraft were aligned on the centreline of the assigned runway. In addition, the Australian Transport Safety Bureau (ATSB) has released an Aviation Research and Analysis Report (AR-2009-033) that examined a number of domestic and international occurrences in which pilots commenced the takeoff while aligned with the runway edge lighting. In that examination, eight common factors were identified that increased the risk of a misaligned takeoff or landing occurrence, including: the distraction or divided attention of the flight crew; a confusing runway layout; the presence of a displaced threshold or the conduct of an 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.

The ATSB has developed a Pilot Information Card that will alert pilots of the increased risk of a misaligned takeoff as a result of those factors, which will be distributed to relevant parts of the industry and will be available from the ATSB on request.

Download Final Report
[Download  PDF: 996KB]
 
 
Alternate: [Download  DOC: 5.31MB]
 

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Safety Issue

Go to AO-2009-007-SI-01 -

Takeoff procedures

The operator did not have procedures to assist the crew to ensure that the aircraft was lined up on the runway centreline in preparation for takeoff.

Safety issue details
Issue number: AO-2009-007-SI-01
Who it affects: Operator and operator’s flight crew
Status: Adequately addressed
General details
Date: 11 February 2009   Investigation status: Completed  
Time: 1922 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Townsville Aerodrome    
State: Queensland   Occurrence type: Collision with terrain  
Release date: 28 January 2011   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Bombardier Inc  
Aircraft model DHC-8  
Aircraft registration VH-SBW  
Serial number 599  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Townsville, Qld  
Destination Cairns, Qld  
Last update 14 November 2018