CRJ2, Dubai UAE, 2011

Summary: 

On 9 May 2011, a Bombardier Challenger 850 began a positioning flight night take off from Dubai aligned with the right hand edge of runway 30 for which take off clearance had been given. The error was not detected until a collision with a lighting installation after which a high speed rejected take off was made. The Investigation noted that the Captain had lined up the aircraft on the runway edge in good visibility before passing control for the take off to the low-experience First Officer. It was concluded that the crew failed to sufficiently prioritise their external situational awareness.

Event Details
When: 
09/05/2011
Event Type: 
Day/Night: 
Night
Flight Conditions: 
On Ground - Normal Visibility

19201

Flight Details
Operator: 
Type of Flight: 
Public Transport (Non Revenue)
Take-off Commenced: 
Yes
Flight Airborne: 
No
Flight Completed: 
No
Phase of Flight: 
Take Off
Location
Location - Airport
Airport: 
General
Tag(s): 
Copilot less than 500 hours on Type, Inadequate Aircraft Operator Procedures
HF
Tag(s): 
Authority Gradient, Distraction, Procedural non compliance, Ineffective Monitoring - SIC as PF
RE
Tag(s): 
High Speed RTO (V above 80 but not above V1)
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): 
Aircraft Operation, Air Traffic Management, Airport Management
Investigation Type
Type: 
Independent

Description

On 9 May 2011, a Bombardier Challenger 850 being operated by Gama Aviation on a positioning flight from Dubai to Dammam Saudi Arabia with just the flight crew and one cabin crew on board inadvertently attempted to take off at night in normal visibility aligned along the right hand edge of runway 30 for which take off clearance had been given. The error was not detected until a collision with a lighting installation after which a high speed rejected take off was made. There were no injuries but damage was caused to the right hand wing by impact with the fixed lighting which was also damaged.

Aircraft wing damage - reproduced from the Official Report

Investigation

An Investigation was carried out by the Air Accident Investigation Department of the GCAA. The records of flying experience for the two pilots showed that the 50 year old Co-Pilot had little time on the aircraft type (145 hours) and low total flying experience (2650 hours) compared to that of the 49 year old aircraft commander (12275 total flying hours including 3800 hours on type) thus creating a potentially steep authority gradient between the two pilots. It was established that the First Officer had been PF but because taxiing was exclusively a left hand seat duty, transfer of control was required once the aircraft had been lined up on the departure runway by the aircraft commander. The rejected take off was only initiated following the collision with the ground lighting unit and was from 90 knots after a call to that effect by the aircraft commander. It was noted that Runway 30 was 60 metres wide and 4090 metres in length.

A number of findings were made including the following:

  • The transfer of control between the captain and co-pilot happened twice: one from the Captain to the Co-pilot at the beginning of the takeoff roll and the other from the Co-pilot to the Captain after the “stop” call-out. In both cases, the transfer of control was not as required in the Company Operations Manual since the terms used in the first transfer were not consistent with those in the Manual and the second transfer was “not explicit”.
  • The Operations Manual does not include a check item of the meaning “check the aircraft position in relation to the runway centre line”.
  • There were no indications that fatigue was affecting the crew performance.
  • The taxiway and runway marking lines and lights were in compliance with GCAA Regulations and in conformance with the relevant SARPS for ICAO Annex 14.
  • The intensity of the runway and taxiway lightings had no influence on the cockpit runway visibility.

It was noted that “although the company procedure in the “Before Takeoff Checklist” was according to the minimum standards of the Civil Aviation Regulations and recognised SOP, the procedure did not protect the crew from mistake line up of the aircraft. On the other hand, taxiway to runway lead-in lines and lights were obvious enough (and) if they were tracked properly, they would have led the Aircraft to the runway centreline.

The Investigation found that the Probable Cause of the Serious Incident was:

“The impact with the runway nearest Visual Approach Slope Indicator Systems light after incorrect line-up with the runway edge line instead of centreline. The incorrect line-up was due to the crew confusion between the runway centre and edge lights.”

Contributing Factor was also identified as:

“Neither of the two pilots realised the misalignment situation due to their situational awareness (being) overwhelmed by activities not enabling them to have adequate peripheral vision outside the cockpit.”

Four Safety Recommendations were made:

  • that the Aircraft Operator should enhance his procedure to ensure that situational awareness of the pilots is more coherent with the actual case; pilots’ lookout should be more relying on peripheral vision with minimised distraction by other cockpit activities that could be done at different times and situations.

[SR 12/2011]

  • that the Aircraft Operator should enhance (their) policy and procedure to assure proper transfer of controls between the Captain and Co-pilot.

[SR 13/2011]

  • that the (Dubai) Air Traffic Control Management should forward advisory material to tower controllers highlighting the availability (of) the SMR as an augmentation tool for the surveillance of aircraft and vehicles on the manoeuvring areas, particularly when the method of direct visual surveillance may be insufficient to ensure correct positioning or safe operation of aircraft or vehicles and based on the controller’s situation’s risk assessment.

[SR 14/2011]

  • that the Dubai Airports Company conducts a safety risk assessment on the influence of the floodlights on the crew sight ability.

[SR 15/2011]

The Final Report of the Investigation]was issued on 22 November 2011.

Further Reading

SKYbrary Partners:

Safety knowledge contributed by: