Jetstar A320 at Hobart on Dec 14th 2012, night takeoff without runway lights
Last Update: May 30, 2013 / 15:44:23 GMT/Zulu time
Date of incident
Dec 14, 2012
ICAO Type Designator
Australia's ATSB released their bulletin releasing following safety message:
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
This 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.
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. However, the crew 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.
The ATSB reported that the older type PAL required three clicks on the radio transmit button with 1 second between each click to activate the runway lights, a newer type was installed at Hobart however that required three clicks on the radio button with 1 second in between clicks and the whole sequence completed in 5 seconds, the successful activation would be confirmed by an automatic broadcast on CTAF. The system was operating normally throughout the incident night, logs of the runway lighting system confirmed the lights were not active during departure of JQ-710.
The captain had 18,000 hours of flying experience, the first officer 14,000 hours of flying experience, however, neither pilot had operated PAL at night for several years. The crew, fully aware of the necessity of activating the runway lights operating at an uncontrolled airfield, reverted to the older PAL system and failed to activate the runway lights and failed to detect the runway lighting was off while turning onto the runway.
The captain reported that they were arriving at Hobart already outside tower opening hours. They employed the older procedure of PAL, heard the transmission that the runway lights would extinguish in 10 minutes (PAL activates the runway lights for 30 minutes, 10 minutes prior to the lights being turned off this fact is being announced by an automatic broadcast on CTAF) and believed they had successfully activated the lights. While taxiing out for departure the captain saw the wig wag lights at the runway holding point and believed this was confirming the runway lights were on. Both flight crew commented that they did not notice anything unusual during the departure roll and had no difficulty maintaining directional control.
Jetstar took an immediate safety action remining their flight crew of two different PAL systems being in use. Hobart Airport changed their runway lights schedule keeping the runway lights active until after the last known scheduled commercial flight operation (including out of schedule operations).
Aircraft Registration Data
Date of incident
Dec 14, 2012
ICAO Type Designator
This article is published under license from Avherald.com. © of text by Avherald.com.
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