Final
Report № AIFN/0010/2018, issued on 10 January 2022
25
was predominantly fixated inside the cockpit and did not effectively perform external peripheral
view. He was probably preoccupied with something other than the
before takeoff checklist.
Even though the Operator had specific risk mitigation in place including: General taxi
guidance, line-up and positive runway identification, takeoff and landing runway verification and
crosscheck, and the
before takeoff checklist
for both pilots to confirm the correct take-off runway;
critical elements were lapsed by the flight crew which degraded their situation awareness.
The Operator had identified hazards of takeoff from incorrect runway, and appropriately
developed mitigations. However, it is probable that the Commander did not scrutinize the trainee
Copilot performance due to his confidence that she will carry a routinely successful intersection
takeoff on runway 12 from Bravo 6 intersection as he witnessed earlier on days 1 and 2 of their
four-day pairing.
The communications with Tower, the air traffic information system (ATIS), weather
reports, and the operational flight plan (OFP) had all confirmed that runway 30 was in use, which
should have been reached by a left turn from taxiway Bravo 14 holding point. The Investigation
believes that the Copilot took the other direction referring to her previous experience for takeoffs
from runway 12 by right turns from Bravo 6 intersection.
The external visual barriers that should have led to runway 30 were multiple:
The illuminating lead-on lights towards runway 30 after the stop bar at Bravo 14
holding point.
Bravo 14 holding point signage;
Bravo 14 taxiway lead-on yellow centerline for runway 30; and
The illuminating runway 30 uni-directional edge lighting.
Another cue to the flight crew that they had entered the wrong runway was the runway 30
white double touchdown zone markings and runway 30 aiming points, which would have been
visible at such a short distance. All the above directional references were overlooked by the flight
crew.
The Investigation could not determine how many intersection takeoffs the Commander
had performed using Bravo 14 for runway 30 prior to the Incident, and when was his last takeoff
using the same intersection. However, based on the two
months’ OMSJ intersection departure data
prior to the Incident, 85.5 percent of the intersection departures were performed from Bravo 14. The
Commander had, most likely, performed several intersection takeoffs from Bravo 14 for runway 30,
and he should have been familiar with the taxiways and runway maps because OMSJ was his home
base.
The Investigation concludes that because OMSJ was the home base of both flight
crewmembers, it is possible that they performed the take-off checklist out of habit without assertive
read and challenge communication. The three previous takeoffs conducted by the Copilot from
runway 12 added to that habitual behavior.
2.3.4
Take-off decision
It took the Commander about six seconds to mentally process the information of the
approximate position of the Aircraft on the runway, Aircraft speed, perception of remaining runway
available, take control of the Aircraft, decide to continue the takeoff, and advance both thrust levers
to TOGA detent.
