[Peetwo]

One for the search 4 IP archive -

Possible candidate for the Hoody Hall of Shame & Shambolic ATSB pointless investigation archives? Couple of days ago I noticed this ATSB (apparently...WTF )  newsworthy investigation in their 'News items' webpage:

Take-offs without runway lighting highlights the hazards with change blindness

These incidents demonstrate the impact workload stress can have on operations.


On 19 August 2016, a JetGo Australia Embraer EMB-135LR, registered VH-JTG, operated scheduled passenger flight JG65 from Tamworth, New South Wales, to Brisbane, Queensland. At 2104 Eastern Standard Time, the aircraft began to taxi from parking bay 1 to runway 30 right (30R) with the taxiway and runway lights not activated. The captain taxied the aircraft onto the runway and immediately began the take-off run. During the take-off run, at a speed of about 70 knots, the first officer detected the runway lights were not illuminated and activated them using the pilot activated lighting.

On 28 August 2016, the same aircraft operated scheduled passenger flight JG65 from Tamworth to Brisbane. At 1937, the aircraft began to taxi from parking bay 1 to runway 30R. As the aircraft taxied, the runway and taxiway lights extinguished. The flight crew continued to taxi and lined up on runway 30R. The aircraft began the take-off run and departed runway 30R with the runway lights not activated.

No persons were injured and the aircraft was not damaged in the incidents.

These incidents demonstrate the impact workload stress can have on operations.
These incidents demonstrate the impact workload stress can have on operations. The short taxi created a high workload situation which impacted on the flight crews’ ability to detect the extinguished runway lighting.

The incident on the 28 August also highlights the 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 incident the flight crew did not detect the runway lights extinguish during taxi prior to departure.

Read the full investigation report AO-2016-108
 



Last update 19 January 2017

 
So for 'shits & giggles' I went to the SIB investigation webpage and read this report?? :

What happened

On 19 August 2016, a JetGo Australia Embraer EMB-135LR, registered VH-JTG (JTG), operated scheduled passenger flight JG65 from Tamworth, New South Wales (NSW), to Brisbane, Queensland (Qld). At 2104 Eastern Standard Time (EST), the aircraft began to taxi from parking bay 1 to runway 30 right (30R) with the taxiway and runway lights not activated (Figure 1). At 2107, the captain taxied the aircraft onto the runway and immediately began the take-off run. During the take-off run, at a speed of about 70 knots, the first officer detected the runway lights were not illuminated and activated them using the pilot activated lighting (PAL) (Figure 2). The flight crew continued the take-off.

Figure 1: Taxi path overview (both incidents)


Source: Airservices Australia, modified by ATSB

Figure 2: Take-off run of JTG on 19 August showing runway lights not activated (left) and then activated (right)


Source: Airport Operator

On 28 August 2016, the same aircraft operated scheduled passenger flight JG65 from Tamworth to Brisbane. At 1937, the aircraft began to taxi from parking bay 1 to runway 30R. As the aircraft taxied, the runway and taxiway lights extinguished (Figure 3). The flight crew continued to taxi, lined up on runway 30R and selected the aircraft landing lights on. At 1940, 48 seconds after lining up, the aircraft began the take-off run and departed runway 30R with the runway lights not activated.

No persons were injured and the aircraft was not damaged in the incidents.
Figure 3: JTG taxiing on 28 August with runway lights illuminated (left) and then extinguished (right)


Source: Airport Operator

Runway and taxiway lighting

The taxiway and runway lighting at Tamworth Airport was controlled by a PAL system combined with an aerodrome frequency response unit (AFRU), known as AFRU + PAL. To activate the lights, pilots were required to transmit a sequence of three transmissions on the common traffic advisory frequency (CTAF). Each transmission was to have a maximum duration of 1 second with the break between transmissions being a maximum of 1 second. On receipt of the appropriate transmission sequence, the airport lights were activated and the AFRU broadcast the automatic message: ‘Tamworth Airport CTAF, runway lighting on’ on the Tamworth CTAF.

Once the AFRU + PAL system was activated, the airport lighting remained on for 30 minutes. If it was reactivated during this period, the lighting would remain on for 30 minutes from the time of reactivation. 10 minutes prior to the end of the 30-minute activation period, the primary wind indicator (windsock) lights commence flashing to warn users that the airport lighting is about to extinguish (Figure 4). In addition, an automated message ‘Tamworth Airport CTAF, lights 10 minutes remaining’ was broadcast on the CTAF to advise 10 minutes of runway lighting remaining.

Figure 4: Flashing primary wind indicator showing the windsock illuminated when the runway lights were active (left) and not illuminated (right)


Source: Airport Operator

On 19 August, at 2039, the AFRU broadcast ‘Tamworth Airport CTAF, lights 10 minutes remaining’, the lights then extinguished at 2049. At 2107, during the take-off run of JTG, the first officer broadcast an AFRU + PAL activation sequence on the Tamworth CTAF and the runway lights illuminated.

On 28 August, at 1928, the AFRU broadcast ‘Tamworth Airport CTAF, lights 10 minutes remaining’, the lights then extinguished at 1938. At 2007, an AFRU + PAL activation sequence was broadcast by another aircraft and the runway lights illuminated.
There was no indication that the AFRU + PAL system was malfunctioning on the nights of the incidents.

Captain comments

The same pilot was operating as captain of JTG during both incidents. The captain provided the following comments:

• The captain did not notice that the runway lights were extinguished during either incident and were not aware until notified after each incident.
  
• The taxiway lights at Tamworth are of the recessed centreline type. The taxi from bay 1 to runway 30R is over a rise. Therefore, only three to four taxiway lights are normally visible from the point at which you turn onto the taxiway. The captain remarked that the raised type taxiway side lights found at other airports are more easily visible.
  
• Wind information for pre-flight planning is obtained through the flight crew electronic flight bag or automatic weather information service (AWIS). Therefore, they will only observe the windsock as a back-up, if it is available and close.
  
• During turn-around between flights, the flight crew do not wear headsets and will not hear the 10 minutes remaining broadcast if it occurs during this time.
  
• The responsibility for ensuring the airport lighting would be active was not assigned to either flight crewmember. There was no procedure for ensuring the airport lighting would be illuminated for the departure.
  
• Both incidents occurred at the end of long duty days, so fatigue may have been a factor.
  

First officer comments – 19 August

The first officer of the 19 August incident provided the following comments:

• The tiller in the Embraer 135 is located on the captain’s side. Therefore the first officer always acts as pilot monitoring[1] (PM) during taxi. The taxi from bay 1 to runway 30R is short and a period of intense workload. During this time, the first officer did not look outside the cockpit.
  
• The first officer did not look outside of the cockpit until the aircraft began moving during the take-off run. Once they looked outside, they immediately felt that something was not right. About five seconds later, the first officer detected that the runway lights were not illuminated.
  
• The first officer was PM for this flight. As PM, they were able to quickly activate the PAL and resolve the issue, and did not consider aborting the take-off.
  
• The first officer used the take-off data card for wind information and did not look at the windsock prior to departure.
  

First officer comments – 28 August

The first officer of the 28 August incident provided the following comments:

• The first officer did not notice that the runway lights were extinguished and was not aware until notified after the incident.
  
• The primary wind indicator at Tamworth is situated so that it is illuminated by light from the adjacent apron lighting and a red obstacle light is located above the windsock. On subsequent flights to Tamworth, the first officer has observed that this gives the appearance of the windsock being illuminated when the runway lighting is extinguished (Figure 4).
  

Aircraft lighting

The Embraer 135 is fitted with three landing lights and two taxi lights. The combination of these lights provides a substantial amount of illumination in front of the aircraft.

The taxi lights are used from the beginning of taxi until after departure. Prior to commencing the take-off run, the landing lights are also selected on. The landing lights provide considerably more illumination than the taxi lights.

All flight crew described the aircraft lighting as extremely effective at illuminating the runway ahead of the aircraft and reported no controllability issues during the take-off runs.

Parking apron lighting

Prior to both incidents, the aircraft parked at bay 1 for the embarkation of passengers (Figure 5). This bay is substantially lit by apron floodlights. These lights are not part of the PAL system and remain illuminated when the PAL system extinguishes the runway and taxiway lights.

All three flight crew commented that the apron lighting degraded night-vision and the short taxi from bay 1 to runway 30R did not allow time for eyes to adjust to the dark surrounds of the runway.

Figure 5: JTG parked at bay 1

Source: Airport Operator

Environmental conditions

Last light[2] on 19 August 2016 occurred at 1757, three hours and ten minutes before the take-off. At 2017, the moon was 19 degrees above the horizon and about 99 per cent visible. There was a clear sky.

Last light on 28 August 2016 occurred at 1802, one hour and 38 minutes before the take-off. The moon was below the horizon and the sky was clear.

ATSB comment

Two different PAL systems exist at Australian airports, PAL and AFRU + PAL. The activation sequence for each system is different.

CTAF recordings for the period surrounding each incident showed multiple unsuccessful attempts by other aircraft to activate the AFRU + PAL using the sequence of transmissions for a PAL system.

AIP ERSA INTRO paragraphs 23.4 and 23.5 detail the differences between the two systems and the correct transmission sequence to activate each system.
While this did not contribute to the incidents, pilots are reminded to be familiar with the identification and use of the different systems.

Safety Analysis

The illumination provided by the aircraft taxi and landing lights made it difficult to detect that the PAL was not activated. Due to the rise on the taxiway, the crew would only have been able to see a few lights ahead of the aircraft, and these would have been illuminated by the aircraft lights. Adding to this, both crew did not have an expectation that the lights may have been extinguished as the cues available did not assist. The auditory 10-minute PAL extinguishing warning could not be heard without headphones, and the windsock flashing light warning was not noticed as the crew obtained wind information using the flight crew electronic flight bag or AWIS.

As the company standard operating procedures did not assign a task of ensuring the runway lights were selected on to a specific role prior to taxi, there was also no procedural prompt to the crew.

The short taxi with a high workload further reduced the chance of detection.

Findings

• The crew did not activate the airport lighting and did not detect that the lighting was off prior to the take-off run.
  
• Available lighting from the aircraft taxi and landing lights, a lack of crew expectation, a short taxi with high workload, and no assigned role or procedure to check for runway lighting resulted in the crew not detecting the lack of runway lights.
  

 
I initially thought WTF are they thinking investigating such a 'something nothing' incident, that I would hazard a guess most reasonably experienced pilots have had happened to them from time to time. But then I also thought, well at least the potential safety issue was responsibly acknowledged & addressed by the operator (& apparently without any punitive murmurings from the regulator), so all's well that ends well...

Safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to these occurrences.

Aircraft operator

As a result of these incidents, the aircraft operator has advised the ATSB that they are taking the following safety actions:

Changes to procedures

• When activating the aircraft taxi lights the pilots must ensure that they confirm the status of the PAL.
  
• When conducting night operations at an unmanned airport, the pilots must activate the PAL or AFRU + PAL by keying the microphone on the appropriate frequency unless the aircraft immediately ahead has already done so. For example, if the aircraft 10 minutes ahead has turned the lights on it will not be necessary to activate the lights again as the lights will normally remain on for a period of 30 to 60 minutes depending upon the installation.
  
• If no traffic is evident then the pilots must activate the PAL prior to taxi for departure and within 15 nm of the aerodrome and whilst above the lowest safe altitude for arrival.
  

Then I read the 'Safety Message' and again I was left thinking WTF drugs were the ATSB on trying to make mountains out of molehills and paint associations with the excellent Transport Canada publication 'Deadly Omissions':

Safety message

These incidents demonstrate the impact workload stress can have on operations. The short taxi created a high workload situation which impacted on the flight crews’ ability to detect the extinguished runway lighting.

The incident on the 28 August also highlights the 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 incident the flight crew did not detect the runway lights extinguish during taxi prior to departure.

The Transport Canada article Deadly Omissions includes further information on change blindness, inattention blindness and expectation bias.

  
Maybe it's just me but I just find that so disingenuous and a WOFTAM of an investigation...
Then I saw one of the latest reported incidents that the ATSB has decided to investigate:

Aviation safety investigations & reports
Investigation title
Pre-flight preparation event involving Airbus A320, VH-VNC, Cairns Airport, Qld, on 21 January 2017
 
Investigation number: AO-2017-008
Investigation status: Active
 

• Summary
  

The ATSB is investigating a pre-flight preparation event involving Tiger Airways Airbus A320, VH-VNC, at Cairns Airport, Queensland, on 21 January 2017.

The flight crew lined the aircraft up for take-off from an incorrect taxiway intersection on the runway. Air traffic control alerted the flight crew who then backtracked the aircraft to the correct intersection prior to commencing take-off.  

As part of the investigation, the ATSB will interview the flight crew, review air traffic control communications and gather additional information.
A report will be released within several months.
 
General details
Date: 21 Jan 2017
 
Investigation status: Active
 
Time: 15:16 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Cairns Airport
 
Occurrence type: Navigation - Other
 
State: Queensland
 
Occurrence class: Operational
 
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Jan 2017 

Aircraft details

Aircraft manufacturer: Airbus
 
Aircraft model: A320-232
 
Aircraft registration: VH-VNC
 
Serial number: 3275
 
Operator: Tiger Airways Aust.
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Cairns, Qld

Destination: Brisbane, Qld
 
 
 


Last update 24 January 2017

  
Now being a former ATCO Hoody would well know that again this incident is a "something nothing" but yet his mob have decided to expend time, money and limited resources on investigating - WTD?? 

MTF...P2

Ps Q/ I wonder if the two investigations above reflect the fact that neither operator is not affiliated with QF, Jetstar or mainstream Virgin? - just saying...