Aviation safety investigations & reports

Runway undershoot involving Beechcraft B200, VH-FDO, at Cairns Airport, Queensland, on 9 July 2020

Investigation number:
AO-2020-034
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final report

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What happened

On 9 July 2020, at about 0005 Eastern Standard Time, a Beechcraft 200 aircraft, registered VH‑FDO and operated by the Royal Flying Doctor Service, Queensland Section, was on approach to Cairns Airport, Queensland. On board the aeromedical flight were the pilot in command under supervision, supervisory pilot, flight nurse and two patients.

The Cairns runway 15 threshold was temporarily displaced due to runway works. During the approach, the flight crew sighted an airport safety officer’s car with its headlights directed at what appeared to be a row of lights across the runway, illuminating the displaced threshold. The aircraft passed above the row of lights and touched down beyond it. However, the aircraft had landed short of the actual displaced threshold and struck an unseen temporary runway end light. 

What the ATSB found

The ATSB found that the airport safety officer's car headlights were directed at reflective witches’ hats that marked the works limit line, which was in front of the displaced threshold. To the flight crew, this appeared as a row of lights across the runway. As a result, the flight crew misidentified the aerodrome works limit line as the displaced runway threshold lights. The actual displaced threshold lights were also indistinguishable from the taxiway lights that remained illuminated during the approach. This resulted in a runway undershoot as the aircraft landed short of the displaced threshold.

The works and airport safety officers laid out the aerodrome works lighting, but did not ensure it was arranged such that the location of the displaced threshold was unambiguous to the flight crew. The requirement that lighting was not confusing to pilots was stipulated in the Civil Aviation Safety Regulations Part 139 (Aerodromes) Manual of Standards. However, the Cairns Airport procedures for temporary runway works lighting and markings were inconsistent and did not ensure they were laid out in accordance with the required standards.

What has been done as a result

After the incident, the following safety actions were taken by Cairns Airport for the remaining runway works:

  • no vehicle headlights were to be directed towards the active runway
  • the works limit line was marked by a single amber light on the side of the runway
  • taxiway lights were only illuminated after an aircraft had landed
  • witches’ hats with reflective tape were not to be used
  • the notice to airmen was amended to advise that taxiways were not available, and of temporary blue taxiway edge lighting
  • green temporary displaced threshold lights were replaced with solar lighting that did not require electricians to wire.

Safety message

Aerodrome works can pose a hazard to aircraft, particularly where there are unusable portions of a runway and a displaced runway threshold. Aerodrome works markings and lighting must be unambiguous and laid out in accordance with relevant standards, to minimise the likelihood of confusion for flight crew and the potential for a runway undershoot or excursion.

Download final report
[Download  PDF: 671KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety actions

Sources and submissions

General details
Date: 09 July 2020   Investigation status: Completed  
Time: 00:15 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Cairns Airport   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Runway - Other  
Release date: 03 February 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model B200  
Aircraft registration VH-FDO  
Serial number BB-2020  
Operator Royal Flying Doctor Service of Australia (Queensland Section)  
Type of operation Aerial Work  
Sector Turboprop  
Damage to aircraft Nil  
Destination Cairns, Queensland  
Last update 05 February 2021