LAN A343 at Auckland on May 18th 2013, lined up with runway edge lights for takeoff
Last Update: March 24, 2016 / 12:16:41 GMT/Zulu time
Incident Facts
Date of incident
May 18, 2013
Classification
Incident
Aircraft Registration
CC-CQF
Aircraft Type
Airbus A340-300
ICAO Type Designator
A343
While the pilots were conducting last-minute checks and tasks before the take-off, the captain lost awareness of precisely where his aeroplane was in relation to the runway centreline.
Three factors contributed to the aeroplane taking off while it was misaligned:
- the potential illusion created by the illuminated manoeuvre area guidance signs parallel to and along the length of the runway, which, in the absence of a thorough check of aeroplane position, could be mistaken for the runway edge lights
- no other means were used to confirm positively the aeroplane’s position, such as the first officer’s cross-check or the use of on-board navigation systems
- the rolling take-off which reduced the time available for either pilot to realise the error.
The intensities of the taxiway centreline lights and the runway lights at the time of the incident did not meet those recommended by the International Civil Aviation Organization. The Commission was not able to determine whether this safety issue contributed to this particular incident. Nevertheless it is an issue that should be addressed to enhance aviation safety.
The Civil Aviation Authority of New Zealand advisory circular AC139-6, which describes aerodrome design and operating requirements, is based on Annex 14 to the Convention on International Civil Aviation, Aerodromes, Volume 1, Aerodrome design and operations, but contained a number of administrative errors and a different phraseology that may have led to the inconsistent application of this acceptable means of compliance with Civil Aviation Rule 139.51, Aerodrome design requirements. Whilst these errors and differences did not contribute to this incident, the Commission is concerned that they could contribute to accidents in the future.
The captain’s decision to not report the incident to the tower controller as soon as practicable after take-off put the following flights at risk from debris contaminating the runway.
The TAIC reported the captain (ATPL, 32,000 hours total, 10,575 hours on type) was pilot flying, the first officer (CPL, 3,263 hours total, 756 hours on type), two augmenting pilots were completing the flight crew.
The aircraft taxied out for departure 30 minutes before beginning of daylight, there were showers, the runway was damp.
While taxiing to the holding point A1 short of runway 23L, still on taxiway A (runway 05L) the crew performed the before-takeoff checklist, the aircraft's taxilights and runway turnoff lights were on. When the aircraft reached about the runway 05L end the controller asked whether they were ready for takeoff, the first officer affirmed and the aircraft was cleared to line up runway 23L and wait. The captain taxied the aircraft onto the runway and instructed the first officer to complete the remaining checklist items. Before entering the runway the captain looked left to check the approach being clear, the first officer looked right down the runway to check it was clear, too.
As the aircraft was crosing the runway edge the controller cleared the aircraft for takeoff. The captain turned on the landing lights and increased the taxi lights to takeoff intensity. The captain did not recall seeing taxiline lights after turning the landing lights on, but noticed a bright line of lights thinking these were the runway center line lights and steered sharply right to line up with these lights, then applied takeoff thrust without stopping the aircraft. The first officer was working inside the cockpit, saw one line of lights ahead and continued monitoring the instruments.
After travelling for about 1400 meters the captain realized they were lined up with the right hand edge lights, steered the aircraft towards the center line and continued takeoff.
After initial takeoff the captain commented he may have aligned with the right hand edge lights, the first officer hadn't seen anything out of the ordinary, hence the crew decided not to report the concern to ATC. The crew monitoring the tyres for any loss of pressure, but all tyres kept normal pressure.
The TAIC reported that a number of aircraft departed without noticing missing runway edge lights. Only the next scheduled runway inspection, about 2:45 hours later, discovered 7 broken runway edge lights, the runway was closed for 20 minutes to remove the debris, the lights were replaced later the morning.
The aircraft received a cut in the right nose wheel tyre which was noticed by a ground engineer in Sydney. A further inspection revealed another cut in the right hand tyre of the center gear.
The TAIC analysed: "A misaligned take-off is a form of ‘runway excursion’, in which an aeroplane goes off the side or end of the intended runway. It is therefore a ‘serious incident’. These events are rare, but the potential contributory factors identified in the Australian Transport Safety Bureau’s study are often present and some were in this incident. In this case the aeroplane’s undercarriage remained on the strengthened runway shoulder, so there was no damage to the surface and therefore a low risk of major damage to the aeroplane. The principal risk was damage to some of the aeroplane’s tyres and any consequences of that for the take-off and subsequent landing. In addition, the presence of unreported debris created a hazard for following flights. Runway misalignments at Auckland at night have not been common. A database search revealed five events since 2005, mostly involving light, single or twin-engine domestic aeroplanes. Three of these occurred at the other end of the runway, and one on runway 23 Left but at taxiway A2. The fifth occurrence involved a medium-size aircraft at the same entry taxiway as for this incident. Auckland-based pilots of large aeroplanes had not reported through their operators’ safety management systems any concerns for the runway-taxiway entry."
The TAIC analysed: "Once aligned, the runway lights should have appeared as three white lines converging at a single point in the distance. At a glance, it is possible to gain a visual impression that the runway edge lights are the centreline, but only if the line of illuminated movement area guidance signs are mistaken for the right-hand runway edge lights (see Figure 9). It was suggested that this type of illusion was present in the incident at Los Angeles International Airport (see paragraph 3.6.3 above). However, if either pilot had taken the time to make a closer inspection, they would have seen that the relative intensity and spacing of the three lines of lights was not normal when lined up on the edge lights. The rolling take-off reduced the opportunity for either pilot to recognise this mistake. The aeroplane had some navigation system features that could have shown the aeroplane’s position relative to the runway centreline; for example, the localiser beam of the runway instrument landing system could be switched to indicate alignment on the primary flight display. The operator’s flight crew operating manual did refer to the benefits of these cross-checks for take-off in low visibility. However, it was not usual for pilots to use these features when visibility was good, as it was on this night, and neither pilot had them selected for this take-off. The operator subsequently amended its manual to encourage the routine use of on-board systems that show pilots they are lined up in the centre of the correct runway."
The TAIC analysed: "The captain realised that he had aligned the aeroplane on the edge lights as shown by his correction partway through the take-off and his subsequent conversation with the first officer after take-off. However, he did not report the incident to the tower controller. That decision put following flights at risk. Debris from broken edge lights lay scattered on the runway edge for nearly three hours until it was discovered during the next daylight runway inspection. Debris left on runways has contributed to accidents and incidents, so it is essential that any event that may have caused debris to be left on the runway is reported as soon as practicable to air traffic control."
The TAIC analysed: "The intensity of the runway centreline lights was set well above the recommended range. With very low ambient light conditions and good visibility, ICAO recommended that the runway centreline lights be set to between 10 and 20 candela. However, they were set brighter at 177 candela. The recommended setting for the runway edge lights24 was 20-40 candela, but the actual setting on the night was 1,333 candela. Although the intensities of the taxiway lead-in lights and the runway centreline and edge lights were not as recommended by ICAO, the runway edge lights were brighter than the runway centreline lights, as required. Adherence to the ICAO standards provides pilots anywhere in the world with consistent cues for ground manoeuvring, so any variance from the standards can contribute to a pilot making an error. The variances in lighting seen at Auckland Airport are a safety issue that the Commission is recommending that the chief executive of Auckland Airport address."
Incident Facts
Date of incident
May 18, 2013
Classification
Incident
Aircraft Registration
CC-CQF
Aircraft Type
Airbus A340-300
ICAO Type Designator
A343
This article is published under license from Avherald.com. © of text by Avherald.com.
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