C9/2010L Serious incident: Jetliner Collision with Runway Edge Lights at Take-off in Oslo on 23 October 2010

An Embraer 190 jetliner on Finnair scheduled flight FIN658M collided with three runway edge lights during take-off at Oslo Gardemoen airport on Saturday, 23 October 2010. There were 4 aircrew members and 31 passengers onboard.

During take-off the tyres on the left (LH) main gear and nose gear collided with the runway edge lights. The tyres sustained minor damage and the runway edge light fragments were flung into the right (RH) engine, causing strike damage. According to the observations of the pilots, the aircraft and its engines operated normally at take-off. The take-off run was continued and the aircraft's course was corrected to the runway centre line. Once airborne, the flight crew told the air traffic control that they thought that they might have collided with the runway edge lights. Three damaged runway edge lights were found in a subsequent runway inspection. This information was relayed to the flight crew. The flight was continued to Helsinki-Vantaa airport, the destination. The damage to the main gear tyre was detected during a post-landing inspection, but the damage to the nose gear tyre and the engine was only discovered after the aircraft had been taken to the maintenance hangar for the main gear's tyre change. The damage was so substantial that the engine and both tyres had to be replaced.

This was by no means an isolated event as numerous similar incidents have occurred around the world. Even though the root cause of this occurrence was attributable to human error, comparable contributing factors with other events could be identified, such as darkness, inadequate Crew Resource Management (CRM), pilots focusing their attention to things other than taxiing as well as the flight crew's inadequate knowledge and observation of airport lighting arrangements. The common factors also included the special characteristics of the taxiways, the runway and the runway shoulder areas as well as shortcomings in ATC procedures, especially in radiotelephony.

In addition, the investigation revealed ambiguities in the company's Operations Manuals Part A (OM-A) and Operations Manuals Part B (OM-B). In Norway there are no regulations published by the authorities or airport operator instructions as regards reporting and documenting foreign object debris found in the movement area.

The cause of the serious incident was the fact that the flight crew mistook the left runway edge lights for the centre line lights as they were lining up. Because of this, they commenced the take-off run on top of the elevated runway edge lights, resulting in damage to the lights and the aircraft. Inadequate CRM was a contributing factor.

Other possible contributing factors included darkness as well as the special characteristics of the taxiways, runway and runway safety areas. Unsatisfactory radio phraseology and ATC clearances as well as a rapid rate of speech may have caused subconscious haste of the flight crew.

The investigation commission issued six safety recommendations. Two were directed to the Finnair Group. They deal with confirmation of the correct runway and take-off position as well as flight crews' readiness for departure while taxiing into position. Four of the recommendations were issued to Avinor AS . The recommendations concern the rate of speech in radiotelephony, aerodrome Hot Spot comments, the reporting of foreign object debris in the movement area to pilots/operators as well as to create a guide for the documentation of foreign object debris in the movement area.

In addition, suggestions were given to Finnair to update their training curriculum with regard to stopping the cockpit voice recorder, brushing up on airport lighting arrangements, revising the content of the Operations Manual Part B and the visual check of the aircraft. Suggestions were given to Avinor AS to add a remark into Oslo Gardemoen's Ground Overview Hot Spot Chart.

C9/2010L Report (pdf, 0.73 Mt)