C1/2002L Incident on take-off roll in Oulu on 11 December 2001

On Tuesday December 11, 2001, at 3.23 o’clock there was an aircraft incident at Oulu Airport, when a Piper Chieftain, owned and operated by Turku Air Oy, initiated its take-off roll in fog to a wrong direction against its air traffic control clearance. The Accident Investigation Board, Finland, initiated an investigation into the incident and appointed Tarmo Kulmala and Arto Nissinen as investigators.

The pilot-in-command intended to fly a solo cargo flight from Oulu to Rovaniemi in poor visibility at night. The pilot had difficulties to perceive the location and heading of the aircraft soon after starting to taxi on the apron. He stopped for a moment on the taxiway to clarify the heading and set the directional gyro 180 degrees wrong. This led him to initiate his take-off roll to a wrong direction on the runway. The air traffic controller noticed the situation and ordered the aircraft to stop. The aircraft stopped well before the end of the runway.

The chain of events started when the pilot did not check his taxi route from a taxiway map or recognisable outside objects before starting taxi. During taxi he also set a wrong heading to the directional gyro and did not follow the signs leading to the runway holding points. He did not cross-check the reading of the left directional gyro with that of the magnetic compass or the right directional gyro. The contributing factors were inadequate knowledge and system familiarity of the pilot, virtually unfamiliar airport as an operating environment, prevailing foggy weather, and physiological matters related to the actions of the pilot. The investigators also discovered deficiencies in the operating procedures and instructions of Turku Air Oy, in those parts of the manual which cover poor visibility operations and calculating of the required runway length and obstacle clearance.

The investigators recommended that the pilots shall observe the effect of their circadian rhythm, rest and eating on their alertness. In addition, the investigators presented three recommendations to Turku Air Oy; to compose standard operation procedures, to change their procedures to always use the full length of the runway in poor visibility, and to change the type-specific take-off technique to correspond with the original flight manual and to train the procedures to their flight crews.

The Accident Investigation Board requested comments to the report and safety recommendations from the pilot, Turku Air Oy and Flight Safety Authority of the Finnish Civil Aviation Administration. The comments from the pilot were not received in due time. Turku Air Oy and Flight Safety Authority did not present changes to the report.

C1/2002L Report (pdf, 0.31 Mt)

 
Published 1.1.2002