ASN Wikibase Occurrence # 172733
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Date: | Tuesday 19 March 2013 |
Time: | 02:08 |
Type: | Boeing 727-281 Adv. (F) |
Owner/operator: | Kelowna Flightcraft Air Charter |
Registration: | C-GKFJ |
MSN: | 21455/1316 |
Year of manufacture: | 1978 |
Fatalities: | Fatalities: 0 / Occupants: 3 |
Aircraft damage: | None |
Category: | Incident |
Location: | Hamilton International Airport, ON (YHM/CYHM) -
Canada
|
Phase: | Take off |
Nature: | Cargo |
Departure airport: | Hamilton International Airport, ON (YHM/CYHM) |
Destination airport: | Winnipeg International Airport, MB (YWG/CYWG) |
Investigating agency: | TSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:A Kelowna Flightcraft Air Charter Boeing 727-281 (registration C-GKFJ, serial number 21455), operating as KFA273, was departing on runway 30 at Hamilton Airport, Ontario, at 02:08 local time during the hours of darkness destined for Winnipeg International Airport, Manitoba. Two snow sweepers were working near the departure end of runway 30. During the take-off roll, air traffic control instructed the aircraft to abort the take-off, and the flight crew rejected the take-off. The aircraft came to a stop at approximately the halfway point of the 10 006-foot-long runway, separated from the snow sweepers by approximately 1200 feet (365 m). There was no damage, and there were no injuries.
Findings as to causes and contributing factors
1. The blocked-runway indicator on the controller's extended computer display system display went unnoticed or unheeded, resulting in a take-off clearance being issued to KFA273 when the runway was not clear of vehicles.
2. During issuance of the take-off clearance, vehicles were observed on the runway, and the controller instructed the aircraft to stand by rather than using standard phraseology to cancel the take-off clearance.
3. The flight crew began to read back the take-off clearance before the controller released the push-to-talk button and, in doing so, did not hear the controller's instruction to stand by.
4. The controller's attention was focused on other tasks when KFA273 began the take-off roll, resulting in the aircraft movement going unnoticed for 22 seconds before the instruction to abort take-off was issued.
5. The air traffic control instruction to abort take-off, which was simultaneous with other sensory input and was not sufficiently compelling to alter the crew's mental model of the situation or their expectation of an uneventful take-off, initially went unnoticed. As a result, the rejected take-off was not initiated until 9 seconds after the instruction.
Findings as to risk
1. If personnel scheduling practices include counter-clockwise shift rotations and short shift changes, there is an increased risk of fatigue and performance impairments during night shifts occurring at the end of the shift rotation.
2. If the practice of working the combined air–ground position is employed for extended periods of time at night, there is an increased risk of controller errors due to fatigue.
3. If a blocked-runway indicator is routinely unheeded, there is an increased risk of aircraft being authorized to use a runway that is unavailable.
4. If airlines systematically plan flights with similar call signs to operate in close proximity to one another, there is an increased risk of call sign confusion.
5. If air traffic control transmissions are incomplete, not heard, or insufficiently compelling to alter the crew's preconceived perception of the situation, then the risk is increased that the transmission will go unheeded.
6. If aircraft depart before the advisory times in the brake-cooling schedule, then there is an increased risk of brake overheating or tire fuse plug release.
Accident investigation:
|
| |
Investigating agency: | TSB |
Report number: | A13O0049 |
Status: | Investigation completed |
Duration: | |
Download report: | Final report |
|
Sources:
http://www.tsb.gc.ca/eng/rapports-reports/aviation/2013/A13O0049/A13O0049.asp
History of this aircraft
Other occurrences involving this aircraft
16 July 2011 |
C-GKFJ |
Kelowna Flightcraft Air Charter |
0 |
St. John's International Airport, NF (YYT/CYYT) |
|
min |
Runway excursion |
Revision history:
Date/time | Contributor | Updates |
06-Jan-2015 19:28 |
harro |
Added |
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