Final
Report № AIFN/0010/2018, issued on 10 January 2022
27
for the crew reaction came from the Commander, who described the state of the Copilot as
“startled
and frozen.
”
The Copilot
’s degraded awareness led her to maintain a nose down pressure until rotation
at 122 knots CAS. This action was not as per standard take-off technique. The standard procedure
requires the pilot flying to apply nose down input immediately after commencing the take-off roll.
Then the copilot must start releasing the nose down input gradually at 80 knots until it is completely
released at 100 knots.
Similar to the actions by the Commander, the European Aviation Safety Agency (EASA)
states “Startle and surprise effects can influence pilot performance in many detrimental ways. At
the very least, these effects serve as a distraction which can disrupt normal operation and erode
safety margins. On a more critical level, they can lead to inappropriate intuitive actions or hasty
decision making.”
2
Based on the FDR data, the Investigation found that the Commander had not applied the
procedure of taking over side-stick controls.
From the time the Commander decided to continue the takeoff, and during the climb, the
crew resource management was ineffective as the cockpit became a single-pilot operation. Based
on the Investigation interviews, there were no inputs or monitoring tasks accomplished by the
Copilot after the Commander took control. In such situation, and with a passive Copilot role, the
Oper
ator’s policy required the pilot flying to “Land as soon as practicable after considering all
pertinent factors
…”
Based on his conclusion that the Copilot cannot assume her responsibilities due to her
affected mental state after takeoff, the Commander decided to continue the flight instead of
returning to OMSJ.
The Commander’s decision to continue the training flight was not based on appropriate
risk assessment of the situation of the degraded performance of the Copilot. The Investigation could
not determine why the Commander did not report the Incident to the OMSJ Tower and inform the
operation control center.
2.4
Aerodrome
– Taxiway and Runway
Sharjah International Airport was in compliance with the requirements of the
Civil Aviation
Regulations
concerning taxiway and runway markings, lighting, stop bars, and signage. The
Investigation confirmed that the lead-on lights were functional and the centerline marking was
visible from runway holding point Bravo 14 to runway 30, and if followed, would correctly lead to
the planned take-off runway.
According to
Part IX
of the
Civil Aviation Regulations,
(Appendix 11, 11.4.1.5) “An
intersection take-off sign shall be provided when there is an operational need to indicate the
remaining Take-off Run Available (TORA) for intersection take-
offs.” The Investigation was not
provided with a study prepared by the airport for determining the operational need for intersection
take-off sign indicating the TORA.
2
Reference: EASA Startle Effect Management NLR-CR-2018-242
