On 22 March 2007, an Emirates Boeing 777-300ER, started its take-off on runway 05 Right at Auckland International Airport bound for Sydney. The pilots misunderstood that the runway length had been reduced during a period of runway works and started their take-off with less engine thrust and flap than were required. During the take-off they saw work vehicles in the distance on the runway and, realising something was amiss, immediately applied full engine thrust and got airborne within the available runway length and cleared the work vehicles by about 28 metres.
Findings from the Serious Incident investigation led by The New Zealand Transport Accident Investigation Commission (TAIC) identify the following safety issues:
[…] “An information processing error by the pilots led them to believe the full runway length was available for departure when it had been reduced, so they began their take-off with less thrust than required for the available length of runway.
The pilots’ error stemmed from a mindset they had developed from their landing a few hours earlier that the runway length restrictions had been removed, and their insufficiently thorough pre-flight checking process.
The captain’s prompt application of full thrust after the pilots saw the obstruction on the end of the runway ensured a safe outcome to the take-off.
The pilots’ error compromised their ability to reject the take-off or maintain obstacle clearance safely in the event of a loss of engine thrust, and exposed the flight and ground personnel to unnecessary risk.
The current Automatic Terminal Information Service (ATIS) broadcast did not properly fulfill its intended purpose of conveying essential but routine information to the pilots because:
- it was about twice as long as that recommended by International Civil Aviation Organisation (ICAO)
- it contained permanent information
- its words “normal operations” contradicted the reference later in the ATIS that advised “reduced runway length”.
Although the ATIS broadcast contained the correct information about the runway length restrictions, its word choice helped reinforce the pilots’ mindset that the runway length was normal when it was not, and its construction was not robust enough to break that mindset.
The Auckland AIP arrival and departure information inadvertently restricted ATS’s word choice for ATIS broadcasts so that it implied that operations were normal when a non-normal runway restriction was in effect.
The format of the printed version of the ATIS broadcast made it confusing to read, and some interpretation was required to determine the length and content of each sentence. This format contributed to the pilots’ information-processing error.
ATIS broadcasts were the only normal means used to alert pilots to critical runway information, such as when length restrictions were in effect. Had another defensive layer been established that required controllers to use standardised, unambiguous phraseology to warn pilots whenever runway restrictions were in effect, the pilots’ mindset would likely have been broken.”
Six Safety Recommendations were made on 23 October 2007 and are listed below in order of development and not necessarily in any order of priority.
To the Director of Civil Aviation in respect of the ANSP:
- Ensure that ATIS broadcasts at all applicable airports, regardless of the means of format and transmission of ATISs, have clear word and sentence structures, are unambiguous, never imply that things are normal when they are not, contain no permanent information and conform as closely as possible to ICAO-recommended standards.
- Enhance the Auckland International Airport AIP arrival and departure information so the words “normal operations” are not selected for use in ATS communications when any non-normal operations are in effect.
- Enhance ATS procedures so that controllers, in addition to what may be contained in ATIS, always unambiguously warn pilots when runway restrictions are in effect.
- Ensure controllers always confirm that pilots acknowledge receipt of the current ATIS broadcast.
To the New Zealand Director of Civil Aviation that he should instruct Emirates to:
- Educate all its pilots to always strictly apply normal checking procedures, to thoroughly scrutinise all the available flight information, particularly ATIS broadcasts, and to always acknowledge receipt of the ATIS.
To the New Zealand Director of Civil Aviation that:
- Although the runway works did not directly contribute to this incident, he satisfy himself that the aerodrome operating certificate holders for major airports in New Zealand have established adequate procedures and taken the precautions necessary to ensure that the frequency and extent of runway works are such that they do not impose unnecessary risk to aircraft operations.