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Taxiway Takeoff Pilots Were Distracted by a ‘Sudden Surge in Cockpit Workload’ During Line-Up

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Taxiway Takeoff Pilots Were Distracted by a ‘Sudden Surge in Cockpit Workload’ During Line-Up ONRECORD Taxiway Takeoff Pilots were distracted by a ‘sudden surge in cockpit workload’ during line-up. BY MARK LACAGNINA The following information provides an aware- responsibility for taxiing solely to pilots-in- ness of problems that might be avoided in the command and “did not provide a sufficiently future. The information is based on final reports robust process for the verification of the de- by official investigative authorities on aircraft parture runway before commencement of the accidents and incidents. takeoff roll.” The passenger terminal is on the east JETS side of the Hong Kong airport and between parallel east-west runways, both 3,800 m Controller Called for Abort (12,467 ft) long and 60 m (197 ft) wide. Airbus A340-300. No damage. No injuries. The south runway was closed for scheduled he flight crew had been instructed by air traf- maintenance, and the A340 flight crew was fic control (ATC) to expedite their departure told to taxi to Runway 07L for their departure Tand were completing a variety of tasks when to Helsinki, Finland. Visual meteorological they inadvertently turned onto a parallel taxiway conditions (VMC) prevailed, with 10 km (6 and began a rolling takeoff. The A340 was ac- mi) visibility. The report did not specify the celerating through 75 kt when the air movements number of people aboard the A340. controller told the crew to stop. The pilots re- The aircraft was about 1,400 m (4,593 ft) jected the takeoff and, after waiting for the brakes from the end of the outer parallel taxiway, to cool, departed without further incident. Taxiway B, when the air movements controller The serious incident occurred at Hong Kong confirmed that the crew was ready for de- International Airport the night of Nov. 27, 2010. parture and asked them to expedite their taxi The final report by the Accident Investiga- and to line up on Runway 07. Another aircraft tion Division of the Hong Kong Civil Aviation was on an 18-nm (33-km) final approach to Department said that a causal factor was “a Runway 07L, and the controller planned for combination of a sudden surge in cockpit work- the A340 to depart before the other aircraft load and the difficulties experienced by both the landed. The A340 was nearing the end of captain and the first officer in stowing the EFB Taxiway B when the controller cleared the [electronic flight bag] computers at a critical crew for takeoff. point of taxiing shortly before takeoff, [which] When the aircraft reached the end of distracted their attention from the external Taxiway B, the captain made a right turn onto environment [and] resulted in a momentary Taxiway A1, which crosses the inner taxiway, degradation of situation awareness.” Taxiway A, and leads to Runway 07L. Instead of The report also faulted company standard taxiing the aircraft onto Runway 07L, how- operating procedures (SOPs) that delegated ever, the captain turned onto Taxiway A and FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2012 | 57 ONRECORD transferred control to the first officer, who changes in the lighting, marking and signage began a rolling takeoff, per company procedure. at the hot spot. “This abnormal maneuver was detected by The report noted that information in the the ground movements controller on the ad- Hong Kong Aeronautical Information Publica- vanced surface movement guidance and control tion about the hot spot had not been incorpo- system,” the report said. The ground controller rated in the A340 operator’s airport briefing. alerted the air movements controller, who radi- Among the recommendations generated by the oed the crew to “stop rolling.” investigation were that the operator ensure that The crew brought the aircraft to a stop 1,400 safety-significant information is incorporated m from the west end of the taxiway at 0124 local in airport briefings in a timely manner and that time, or about 14 seconds after initiating the Hong Kong ATC managers ensure that clear- rejected takeoff. After waiting about 50 minutes ance for takeoff on Runway 07L is not issued at for the wheel brakes to cool, the crew departed night until ensuring that the aircraft has passed from Runway 07L. Taxiway A or has entered the runway. Investigators found that neither the captain, the first officer nor the relief pilot stationed in Approach to a Closed Runway an observer’s seat realized until the controller’s Boeing 777-300. No damage. No injuries. call that the takeoff had been initiated on the n route from Narita, Japan, with 117 pas- taxiway. While turning the aircraft onto the sengers and seven crewmembers, for a taxiway, the captain had made a public-address E50-minute flight to Kansai International announcement for the flight attendants to be Airport the night of Aug. 30, 2010, the flight seated, activated the weather radar system and crew had briefed for the instrument landing transferred control to the first officer. Both system (ILS) approach to Runway 24L. Near- pilots completed the “Line-Up Checklist,” and ing Kansai, however, the crew accepted an both had difficulty stowing their EFBs. During offer by ATC to expect a visual approach to the turn, the first officer disengaged the air- the runway. conditioning packs and checked the fuel load The report by the Japan Transport Safety just before setting thrust for the company- Board said that although VMC prevailed, “a visu- preferred rolling takeoff. The relief pilot was al approach to the airport is very difficult at night looking down during the turn, trying to make due to a lack of light in the vicinity.” The longer, ‘No queries were sure that his EFB was stowed and that there parallel runway, 24R, was closed for maintenance, were no loose items on his tabletop. but its approach lights and precision approach ever raised among “Both [operating] pilots stated that they path indicator (PAPI) lights were on. the three pilots saw the red stop bar lights perpendicular to the Soon after the approach controller issued centerline but dismissed them as part of the a heading of 100 degrees, a vector to establish concerning the lighting system leading to the displaced runway the 777 on a right downwind leg for Runway threshold,” the report said. “No queries were 24L, the crew reported that the runway was in correct positioning ever raised among the three pilots concerning sight. The approach controller cleared the crew the correct positioning of the aircraft.” for a visual approach and instructed them to of the aircraft.’ Taxiway A1 was a known hot spot. Prior establish radio communication with the airport to the incident, three other flight crews had traffic controller. initiated takeoffs on Taxiway A, rather than When the crew reported that the aircraft was on Runway 07L. These incidents also had established on downwind, they were cleared to occurred after midnight, with good visibil- land on Runway 24L. The first officer, the pilot ity and light traffic, and after the crews were flying, disengaged the autopilot, turned onto a cleared for takeoff before reaching Taxiway right base leg and told the captain to perform A1. The previous incidents had led to several the landing checklist. He then saw runway and 58 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2012 ONRECORD PAPI lights, and turned onto final approach to Transport Canada subsequently issued an what he thought was Runway 24L. airworthiness directive requiring compliance Both pilots noticed Both pilots noticed that their navigation dis- with a Bombardier service bulletin that in- plays showed abnormal indications for the ILS formed CRJ operators about the accident and abnormal indications approach to Runway 24L and realized that they recommended replacement and rerouting of the were on final approach to Runway 24R. Almost oxygen line. for the ILS approach simultaneously, at 2155 local time, the airport to Runway 24L traffic controller advised the crew that they were Gust Spoils Landing Dassault Falcon 10. Substantial damage. No injuries. approaching the closed runway and asked if they and realized that could make a left turn to align the aircraft to he flight crew had to circumnavigate several land on 24L. thunderstorms during the flight to Sellers- they were on At the time, the 777 was about 3 nm (6 km) Tburg, Indiana, U.S., the night of March 23, from Runway 24R, and the crew decided that 2011. The airport’s automated weather observa- final approach to side-stepping to Runway 24L would be difficult. tion system was reporting VMC, with surface Runway 24R. They conducted a go-around and subsequently winds from 310 degrees at 19 kt, gusting to 27 landed the aircraft on Runway 24L without fur- kt. Nearing the airport, the crew canceled their ther incident. During the go-around, the lights instrument flight plan and conducted a visual for Runway 24R were turned off. approach to Runway 36, which was 5,500 ft (1,676 m) long and 100 ft (30 m) wide. ‘Electrical Anomaly’ Ignites Fire “The captain [the pilot flying] reported Bombardier CRJ200. Substantial damage. No injuries. that the landing reference speed (VREF) was hortly after external electrical power was 110 kt, which included a 5-kt gust factor,” the applied to the CRJ in preparation for its de- NTSB report said. “As the airplane touched Sparture from Tallahassee (Florida, U.S.) Re- down on its main landing gear, it encountered gional Airport the morning of Feb. 28, 2009, the a wind gust that raised the left wing. The captain and a flight attendant, the only people captain corrected with a left roll input as he aboard the airplane, heard a hissing sound and simultaneously reduced the airplane’s pitch detected smoke and signs of a fire.
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