AT72, Dresden Germany, 2002
AT72, Dresden Germany, 2002
Summary
On 5 March 2002, an ATR72-202 departed from runway 22 at Dresden in good visibility at night aligned with the edge lights of the runway without the crew apparently being aware of their error. Damage to both the edge lights and the aircraft was subsequently discovered. The Investigation attributed the error to the crew, concluding that a contributing factor had been that the correctly promulgated and lit runway width represented a reduction from a previously greater width with the surface now outside the runway being of a similar appearance to the actual runway surface.
Event Details
When
05/03/2002
Day/Night
Night
Flight Conditions
On Ground - Normal Visibility
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Actual Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Take Off
Location
Location - Airport
Airport
HF
Tag(s)
Flight Crew Visual Inspection,
Ineffective Monitoring,
Ineffective Monitoring - PIC as PF
RE
Tag(s)
Continued Take Off
Outcome
Damage or injury
Yes
Aircraft damage
Minor
Non-aircraft damage
Yes
Non-occupant Casualties
No
Off Airport Landing
Yes
Ditching
Yes
Causal Factor Group(s)
Group(s)
Aircraft Operation
Safety Recommendation(s)
Group(s)
Airport Management
Investigation Type
Type
Independent
Description
On 5 March 2002, following the departure from runway 22 at Dresden in good visibility and light winds at night of an Aerospatiale ATR 72-200 being operated by an unrecorded airline on a domestic scheduled passenger fight from Dresden to Stuttgart, the airport operator found a number of damaged runway edge lights. Inspection of the aircraft after the flight disclosed damage to both nose landing gear tyres, one of which was deflated, and also found evidence of glass fragment impact with the fuselage and propellers, glass splinters in all landing gear bays and noted that the lower anti-collision light had been destroyed. There was no reported awareness of an incident on the part of the 27 passengers and two cabin crew.
Investigation
An Investigation was carried out by the German BFU. The aircraft DFDR was available but the Cockpit Voice Recorder (CVR) was not downloaded (possibly because it was had only a 30 minute recording and had been overwritten).
It was noted that the 2508 metres long runway 22 at Dresden was of concrete construction and had a marked and lit surface width of 51 metres with adjacent unmaintained shoulders of similar but un-maintained concrete construction of 14.5 metres on each side. In effect, an original width of 80 metres had been reduced. All taxiways and runways were marked and lit in accordance with ICAO Annex 14 but the lighting intensity could not be varied by ATC. It was noted that the white centerline lights were hardly visible in a perpendicular direction from the edge of the runway to the centerline.
Damage to the left hand runway edge omni-directional lights, which were positioned at 60 metre intervals and elevated except at taxiway access points, was confined to three successive lights. These were calculated to have been at the position which the aircraft would have been in just before rotation for take off. All three lights were “knocked off (their supports) into a direction of approximately 220°”.
It was established that both flight crew had been familiar with operations at Dresden and that both were experienced on the aircraft type, although with a significant difference between the two pilots in this latter respect with the aircraft commander having been operating the type for ten years prior to the event investigated. It was found that “when taxiing to runway 22 the crew was never under stress or pressure”.
The First Officer had been designated PF for the flight but, as the aircraft was not fitted with a steering tiller for the pilot occupying the right hand seat, it had been necessary under a prescribed SOPs for the aircraft commander to taxi the aircraft into position on the runway and commence the take off roll before handing over control once sufficient rudder authority was available to allow directional control in to be maintained. It was noted that the crew had been aware of some bumps from the nose landing gear as the aircraft accelerated down the runway for take off and then, at around V1, two or three more significant bumps, the first of which had felt “especially heavy.” After take off, the aircraft commander had advised TWR ATC that during the take off run, the aircraft “had obviously collided with an object on the runway”.
The flight crew stated during the Investigation that the aircraft had been correctly lined up on the runway centre line. However, a comprehensive review of all the available evidence concluded that “….the take off run was performed on the left runway edge lighting”. It was also found that a contributing factor was that “due to the (lack of) contrast between the runway surface and the surface of the adjacent side strip it was difficult for the crew to recognize their error of having incorrectly taxied onto the runway.”
The formal Conclusion of the Investigation was that:
“The Incident happened because the pilot-in-command confused the centre line lighting of runway 22 with the left runway edge lighting. This confusion was not noticed by the co-pilot."
The Final Report: BFU 5X005 - 2/02 was published in December 2003 and contained one Safety Recommendation made during and as a result of the Investigation as follows:
- That the particularities of flight operations at Dresden Airport should be described in the AIP Germany, EDDC AD 2.23, under Additional Information AD 2. In addition, AD 2, EDDC 2-5 should contain a reference to the Additional Information under AD 2, EDDC AD 2.23. (12/2002)
It was noted that this recommendation had been implemented on 16 May 2002
