Two Skywest AT72 and Sunstate DH8D at Gladstone on May 16th and May 17th 2012, takeoff in night conditions without runway lights

Last Update: October 29, 2012 / 12:20:14 GMT/Zulu time

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Photo of Skywest Airlines VH-FVL, ATR ATR-72-200 — Skywest Airlines VH-FVL, ATR ATR-72-200 (Photo credit: Alec BHX/KKC / Flickr / License: CC by-sa)

Incident Facts

Date of incident
May 16, 2012

Classification
Report

Airline
Skywest Airlines

Flight number
XR-1718

Departure
Gladstone, Australia

Destination
Brisbane, Australia

Aircraft Registration
VH-FVL

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A Skywest Airlines Avion de Transport Regional ATR-72-500 on behalf of Virgin Australia, registration VH-FVL performing flight XR-1718/DJ-1718 (May 16th) from Gladstone,QL to Brisbane,QL (Australia), was preparing for departure from runway 10 in darkness, last daylight at 17:43L (sunset at 17:06L). The runway lights had been activated by pilot activation at about 17:17L (run time 30 minutes) verified to be on at 17:27L by a surveillance video. At 17:37L the common traffic advisory frequency (CTAF) broadcast the automatic call that the runway lights would extinguish in 10 minutes. The ATR began taxiing at 17:45L, entered the runway for backtracking at 17:46L. At 17:47L the runway lights extinguished, confirmed by video surveillance. At 17:53L the crew made their departure call on the CTAF noting an airborne time from runway 10 at 17:51L. A Dash 8 beginning taxi at 17:51L and entering the runway at 17:52L for backtracking activated the runway lights at 17:52L.

A Skywest Airlines Avion de Transport Regional ATR-72-500 on behalf of Virgin Australia, registration VH-FVU performing flight XR-1718/DJ-1718 (May 17th) from Gladstone,QL to Brisbane,QL (Australia), was preparing for departure from Gladstone's runway 10. The runway lights had been activated by the crew of another aircraft, the 10 minutes remaining automatic call happened at 17:45L. The AT72 began taxiing at 17:48L, broadcast they had entered and were backtracking the runway at 17:50L and reported rolling at 17:54L. The runway lights extinguished at 17:54L.

A Sunstate Airlines de Havilland Dash 8-400 on behalf of Qantas, registration VH-QOK performing flight SSQ-2307/QF-2307 (May 17th) from Gladstone,QL to Brisbane,QL (Australia), began taxi at 18:04L, entered the runway at 18:04L and reported rolling on runway 10 at 18:06L. The runway lights however were turned on again only at 18:11L.

All aircraft continued their flights for safe landings at destination.

The Australian Transportation Safety Board released their final report into the three takeoffs without runway lights without conclusions however a safety message reading:

Runway and taxiway lighting serves many important functions for a departing aircraft. For example, it provides:

- navigational guidance around the airport
- directional guidance during the take-off roll
- an indication of the location of the end of the runway
- necessary guidance for approach and landing if required due to an emergency shortly after takeoff

The incident highlights the potential hazards associated with change blindness, inattention blindness and expectation bias.

Change blindness occurs when a person does not notice that something is different about the visual environment relative to before the change. Research has shown that in some cases, quite dramatic changes are not detected, particularly if changes occur when the observer is not looking at the relevant part of the visual environment at the time. In this instance, the crews did not notice the difference between the airport lighting when they were boarding the aircraft versus when they taxied out for departure. At the time the airport lighting was turned off, the aircraft was parked on the apron and the crew were onboard the aircraft facing away from the runway lighting and looking into a brightly lit terminal.

Inattention blindness occurs when a person does not notice an object which is visible, but unexpected, because their attention is engaged on another task. In this instance, the absence of airport lighting was noticeable, if looked for, and the crews probably had an assumption or expectation that the lighting was on.

In simple terms, expectation bias is Â‘seeingÂ’ what you expect to see even when it is not there. In this case, runway lighting being on.

Defining a specific place for PAL tasks in the crewÂ’s sequence of procedures, such as when the pre-taxi CTAF call is made and incorporating this into a pre-taxi checklist, could potentially ensure more reliability in performing these tasks.

As an immediate safety action Skywest issued a company memo remining flight crew of their standard operation procedure requirements to cycle the runway lighting prior to engine start and the requirement to verify runway lights are illuminated. Sunstate changed their policies to require activation and verification of runway lights prior to taxi, conducted a review of the runway verification drill during line up and approached aerodrome operators, with the assistance by CASA, to encourage runway lighting left activated during peak times of aircraft activity. Gladstone Airport considers to install a reflective sign reading "Are the runway lights turned on?" before aircraft would enter the airport maneouvering areas.

The ATSB quoted statements by all flight crew, that neither flight crew had noticed anything unusual or problematic with the airport lighting or environmental conditions at the aerodrome. They had no problems maintaining directional control of their aircraft. Neither flight crew was aware that the runway lights had gone off between boarding their aircraft and departure until they had been contacted by the ATSB. All crew explained they did not hear the 10 minutes remaining automatic call on CTAF probably because of being distracted with cockpit tasks.

Neither flight crew recalled seeing the windsock lighting flash, but all flight crew commented the windsock was difficult to see during taxi. There was higher ground behind the windsock with bright lighting making the windsock difficult to see. All crew were therefore using the unlit windsock near the threshold of runway 10 for reference of wind.

Gladstone runway 10, runway lights on, in twilight (Photo: ATSB):