Greenland DH8B at Kangerlussuaq on Mar 2nd 2017, took off occupied runway without clearance
Last Update: May 11, 2017 / 14:01:15 GMT/Zulu time
Incident Facts
Date of incident
Mar 2, 2017
Classification
Report
Airline
Air Greenland
Flight number
GL-235
Departure
Kangerlussuaq, Greenland
Destination
Sisimiut, Greenland
Aircraft Registration
OY-GRO
Aircraft Type
De Havilland DHC-8-200 Dash 8
ICAO Type Designator
DH8B
Denmark's Havarikommissionen HCL released their bulletin as final report into the serious incident concluding the probable causes were:
OY-GRO departed from an engaged runway at BGSF without an ATC take-off clearance.
To the AIB, the following combined conditions had an influence on the sequence of events:
- The actual flight was approximately one hour behind the scheduled time of departure.
- An over-motivated flight crew acted from their expectations rather than the factual reality.
- Runway downslope prevented the flight crew from spotting the three runway snow clearing vehicles.
- Soft safety barriers like the applied ATC phraseology and the flight crew standard operating procedures on use of landing lights did not provoke or raise the attention of the flight crew in such a way that their decision making process changed.
No safety recommendations were released as result of the investigation, the HCL reasoned: "The AIB safety investigation did not reveal systemic flight safety lapses."
The HCL analysed:
On 2-3-2017, the scheduled duty period of the flight crew was 10:30 hours.
At the time of the serious incident, the actual flight was approximately one hour behind the scheduled time of departure.
The AIB finds it possible that the flight crew of OY-GRO eagerly tried to catch up on time in order not to exceed the maximum daily duty period of 10:30 hours (seven sectors), which might mentally have provoked the flight crew to act from their expectations rather than the factual reality (over-motivation).
...
The downslope at the far end of runway 27 prevented the flight crew - when lining up the aircraft on runway 27 - from spotting the three runway snow clearing vehicles. To the flight crew, the runway seemed free.
...
The applied ATC phraseology was in accordance with ICAO Doc 4444.
However, the AIB finds that use of the optional additional word “WAIT” in this particular case (an engaged runway) would have made the ATC lineup clearance more attention-demanding. An attention-demanding clearance might have strengthened the situational awareness of the flight crew.
Incident Facts
Date of incident
Mar 2, 2017
Classification
Report
Airline
Air Greenland
Flight number
GL-235
Departure
Kangerlussuaq, Greenland
Destination
Sisimiut, Greenland
Aircraft Registration
OY-GRO
Aircraft Type
De Havilland DHC-8-200 Dash 8
ICAO Type Designator
DH8B
This article is published under license from Avherald.com. © of text by Avherald.com.
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