Aviation safety investigations & reports

Procedures related event - Boeing 777-31H/ER, A6-EGG, Melbourne Airport, 30 November 2011

Investigation number:
AO-2011-161
Status: Completed
Investigation completed

Summary

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At about 0349 Eastern Daylight-saving Time, the Melbourne aerodrome controller cleared an Emirates Airlines, Boeing Company 777-31H/ER aircraft registered A6-EGG for takeoff on runway 16.

The crew believed that the runway lights were on a low setting and conducted the takeoff. Once airborne the pilots advised the approach controller that they believed that the lights were on a low intensity. A subsequent check of the airport lighting system revealed that runway 16 lights were turned off.

Had the crew queried the status of the runway lights, the aerodrome controller would have been able to identify that they had not been turned on as believed and corrected the situation.

This incident highlights the potential hazards associated with skill based human error and the need for increased vigilance when working in isolation in a safety critical environment.

Airservices Australia, advised the ATSB that they were in the process of standardising the operation of runway lighting controls at Towers and would propagate a national ATC instruction pending the related change effective 28 June 2012.

Download Final Report
[Download  PDF: 3.57MB]
 
 
 
General details
Date: 30 November 2011   Investigation status: Completed  
Time: 0349 EDT    
Location   (show map): Melbourne Airport   Investigation type: Occurrence Investigation  
State: Victoria   Occurrence type: ANSP info/procedural error  
Release date: 03 August 2012   Occurrence class: Airspace  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 777  
Aircraft registration A6-EGG  
Serial number 41070/965  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Last update 14 November 2018