Finnair E190 at Oslo on Oct 23rd 2010, struck runway edge lights during takeoff

Last Update: January 22, 2013 / 19:53:09 GMT/Zulu time

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Incident Facts

Date of incident
Oct 23, 2010

Classification
Incident

Airline
Finnair

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

Onnettomuustutkintakeskus, the Accident Investigation Board of Finland (AIBF), released their final report concluding the probable cause of the serious incident was:

The serious incident was caused when the flight crew mistook the left runway edge lights for runway centre line lights while lining up. This resulted in a misaligned take-off over the elevated runway edge lights as well as damage to the runway lights and the aircraft itself. Inadequate Crew Resource Management was a contributing factor.

Other possible contributing factors included darkness as well as the special characteris-tics of the taxiways, the runway and the runway shoulder areas. Unsatisfactory radio phraseology and air traffic control clearances as well as the rapid rate of speech may have caused subconscious haste of the flight crew.

Weather was good with visibility at 9km, winds calm, few clouds at 300 feet, temperature -2 deg C and dew point -3 deg C. Taxiways and runways were clear and dry.

The captain (43, ATPL, 8,973 hours total, no hours on type provided) was pilot flying, the first officer (30, ATPL, 2,672 hours total, no hours on type provided) was pilot monitoring. The aircraft had taxied to Alpha South next to runway 01L for de-icing. Following de-icing, which took about 7 minutes, the crew requested taxi instructions from Alpha South and received "... taxi to 01 Left and 01 Left, cleared take-off, wind calm." 13 seconds later the aircraft left Alpha South, the taxi checklist was processed including takeoff briefing, loadsheet information, trim and flap setting. The line up checklist, usually processed after receiving line up clearance, was subsequently processed. 53 seconds after leaving Alpha South the TOGA button was pushed for departure from runway 01L.

The captain said in post flight interviews that he had checked the approach to his left being clear of other traffic while lining up, which required him to turn backwards to see traffic on short final due to the acute angle of the taxiway to the runway. To ease seeing the traffic he had veered left off the taxiway center line, which the AIBF reasoned made it more difficult to judge the position relative to the runway center line. After lining up the captain asked the first officer whether he was ready for departure, the first officer replied he was still seeking the standard instrument departure chart as he was trying to bring the chart up on his cockpit laptop, the first officer thus had difficulty monitoring the progress of taxi.

The AIBF reported according to Oslo's ground radar the aircraft lined up aligned with the left hand edge lights of the runway.

The aircraft accelerated along the left runway edge until about the 4th edge light, at which point the captain recognized they were not on the runway center line and steered the aircraft to the right onto the center line. The AIBF stated they could not establish how the captain recognized they were travelling along the left runway edge. However, both pilots heard a clunk almost simultaneously with the course correction which they felt was the sound of the nose gear travelling over a recessed center line fixture. The takeoff continued normally thereafter.

About 2 minutes after becoming airborne the crew concluded they might have collided with runway edge lights and reported to ATC.

A subsequent runway inspection found 3 runway edge lights and fixtures had been run over, lamps #1, #4 and #5. No debris from the aircraft was found.

The finding was reported to the crew. In absence of any abnormal indication the crew discussed possible damage to the aircraft and decided to do a full flaps landing at Helsinki in order to minimise landing speed. The landing was without further event.

The captain concluded in his air safety report filed after landing that he may have mistaken the left runway edge lights for the runway center line lights.

The aircraft sustained damage to the inner left main gear tyre as well as the right hand nose gear tyre. Both tyres were replaced. Strike marks were found on 5 fan blades of the right hand engine, one of the blades showed a 25mm (one inch) long crack parallel with the fan blade chord. Dents were found on the second and third stage compressor blades, the damage exceeded the maximum permissable values, the engine was replaced.

The AIBF stated following a simulator test: "When approaching the runway from TWY A1, the green taxiway centre line lights are straight ahead and the green runway threshold lights are on the left. These lights can confuse the pilot, especially if his gaze moves from the front sector, for example, towards the final approach. Moreover, the green runway entry point centre line lights on taxiways A1 and A2 made it more difficult to discern the right runway edge lights." and later continued "Due to its location, it was difficult to spot the runway designation marking (01L) on the runway centre line. This is true irrespective of the taxi route: i.e. whether one enters the runway along the TWY centre line lights or takes the route used in this occurrence." and finally stated "The view from the LH runway edge lights was noticeably abnormal. The RH runway edge lights were not clearly visible. The runway centre line lights could easily be mis-taken for the RH edge lights, and the LH edge lights for the centre line lights. However, there were no lights on the left side of the aircraft that could have been interpreted as edge lights. When the PAPI lights were on they provided a quite clear indication of being to the left of the centre line. Their effect only intensifies as the take-off run progresses."

The AIBF analysed that the nose gear ran over the #1 edge lights before turning to line up, the aircraft was then steered slightly left to the edge lights in order to prevent the nose gear running over what the captain assumed were the runway center line lights. When he corrected the aircraft heading by about 3 degrees to steer the aircraft to the center line, the right hand nose tyre went over the 4th edge light probably causing the clunking sound heard. The inner left hand tyre then ran over the 5th edge light. It is probable, that debris of the collision between right hand nose gear tyre and the 4th edge light flung parts of the 4th light fixture into the right hand engine.

The AIBF analysed: "The pilots said that the aircraft did not handle abnormally, nor were the engine values outside the normal range. The take-off run was continued and the flight eventually land-ed in Helsinki. The investigation commission believes that the justified decision would have been to abort the take-off. This was because the aircraft was clearly on top of the runway edge lights and even partly outside the runway strip. When the captain noticed that the aircraft was misaligned it would have been safe to reject the take-off because the speed was still low."

The AIBF analysed that the combined taxi and takeoff clearance, deviating from standard phraseology, should not have occurred. Instead a taxi to holding point runway 01L should have been issued and while the aircraft was approaching the holding point the line up and takeoff clearance should have been issued.

The AIBF stated that the Accident Investigation Board Norway had issued a safety recommendation (editorial note: along safety recommendations issued by other investigation authorities) in 2006 and 2010 stating: "The AIBN recommends that Avinor considers implementing a procedure where take-off clearance is not issued before the air traffic controller has verified that the aircraft has passed a point where the only remaining possibility for departure is on the intended runway."
Incident Facts

Date of incident
Oct 23, 2010

Classification
Incident

Airline
Finnair

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

This article is published under license from Avherald.com. © of text by Avherald.com.
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