Aviation safety investigations & reports

Runway Event involving Fokker F28, VH-JFB at Williamtown Airport, NSW on 26 August 2013

Investigation number:
AO-2013-133
Status: Completed
Investigation completed

Summary

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On 26 August 2013, about 2 hours after last light on a dark night, an Alliance Airlines Fokker F28 aircraft, registered VH‑JFB, was taxiing at Williamtown Airport, New South Wales.

As the captain taxied the aircraft onto the runway, air traffic control (ATC) issued departure instructions and a take-off clearance. The captain then momentarily looked down to confirm that the correct departure heading had been entered into the aircraft’s flight management system. As he looked up, he believed he had almost overshot the runway centreline as he observed the threshold markings in front and under the nose of the aircraft, and a line of recessed lights to his left. The captain determined that the recessed lights were runway centreline lights.

Shortly after, the captain commenced the take-off run. Immediately after, the captain noted that the ground area to the left of the runway centreline lights ahead was a different colour than that on the right. He then realised that he had lined up on the runway edge lights. The captain rejected the take-off and steered the aircraft to the right, toward the actual runway centreline.

An internal investigation conducted by Alliance Airlines found that the design of the operational readiness platform (ORP) recessed lighting and obscured centreline markings caused visual confusion during the line-up procedure. This was further compounded by an unserviceable aircraft taxi light and the distraction caused by the requirement for the crew to enter the heading issued by ATC as part of the departure instructions at a critical time. As a result of this occurrence, Alliance Airlines have released an operational notice to crews to increase pilot awareness of ORPs at military airports, and as part of the operator’s accident prevention program, a Take-off Misalignment Hazards publication has been issued.

The Department of Defence also advised the ATSB that scheduled remediation works, which consisted of repainting the runway centreline markings and refreshing the taxiway lead in lines with black contrast lines to highlight the markings had been completed.

In 2010, a research report published by the ATSB identified eight factors common to misaligned take-offs at night, and developed a pilot information card to assist crews in identifying factors that increase the risk of a misaligned take-off.

Aviation Short Investigation Bulletin - Issue 24

Download final report
[Download  PDF: 386KB]
 
 
 
General details
Date: 26 August 2013   Investigation status: Completed  
Time: 18:40 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Williamtown Airport    
State: New South Wales   Occurrence type: Runway - Other  
Release date: 10 December 2013   Occurrence class: Operational  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Fokker B.V.  
Aircraft model F28  
Aircraft registration VH-JFB  
Serial number 11521  
Type of operation Charter  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Williamtown, NSW  
Destination Sydney, NSW  
Last update 14 November 2018