ATSB report finds pilots and flight crews confused by Adelaide Airport runway works and markings, causing high-risk errors
A Qatar Airways flight was still at ground level approaching the runway’s end after pilots confused temporary markings at Adelaide Airport in a series of near-misses, a report reveals.
Pilots and flight crews were confused by Adelaide Airport runway markings or lights on 13 occasions this year, triggering takeoff errors that put passengers at risk, a report has revealed.
An Australian Transport Safety Bureau report published on Tuesday detailed the incidents, which occurred while taxiway construction works took place at Adelaide Airport between March and May this year.
A temporary start of takeoff (SOT) position was set up for runway 23 during the works period, but on 13 occasions across day and night flights, crews missed the new SOT position and mistakenly commenced takeoff from a landing threshold, reducing the runway by about 500m.
The report detailed the risky occasions, including a Qatar Airways flight en route to Doha from Adelaide on March 31 that was still at “0ft altitude approaching the departure end of the runway”.
ATSB chief commissioner Angus Mitchell said the confusion meant flight crews “used performance parameters for a longer runway … increasing the risk of a runway overrun, especially if a high speed rejected takeoff had been required”.
Runway excursions, which include runway overruns, have the potential to result in fatalities and are classified as high-risk incidents by the International Civil Aviation Organization.
The ATSB report found flight crews had misidentified the runway’s start because of “confusing temporary markings and lights”.
In April, the Adelaide Tower air traffic control manager emailed Airservices’ safety
team, saying there was “a LOT of confusion with pilots as to where the takeoff commences”.
The manager said air traffic controllers were frequently having to spend their time explaining to crews where the temporary SOT position was, as opposed to the displaced landing threshold that was mistakenly being used instead.
Two flight crews interviewed by ATSB said they did not identify the white line indicating the SOT position.
They also failed to see the start of red edge lights, which started at the SOT position, because “it was a bright sunny day”.
The flight crews later realised the error and reported the occurrences.
A spokesman for Adelaide Airport said it had noted the report’s outcomes.
“Adelaide Airport … has taken steps to improve notifications to aircraft operators about changes to takeoff procedures when works are underway on the airfield impacting our runways,” he said.
“We will also review and act on any resultant changes to Civil Aviation Safety Regulations to help ensure safe operations at the airport at all times.”
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Originally published as ATSB report finds pilots and flight crews confused by Adelaide Airport runway works and markings, causing high-risk errors
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