Background
An incident involving an aircraft identified as FDL occurred when the runway lights were not activated during a takeoff. The investigation focused on the actions of both the air traffic controller and the pilot.
Air Traffic Control Actions
The controller used the ‘LIGHTS’ memory prompt in the INTAS system as a passive risk control measure. This prompt remained on the screen from last light to first light, regardless of whether the runway lights were on or off. Additionally, the workflow for departing aircraft did not require the controller to pass the flight progress strip through the ‘LIGHTS’ prompt when moving it from the taxiway to the runway. Continuously displayed prompts that do not require action may lead to user desensitization, potentially preventing the controller from processing the prompt during workflow.
The controller typically conducted a visual scan of the INTAS display and the airfield before clearing an aircraft to enter the runway. The controller recalled completing this scan but did not notice the runway lights were off and did not take action to activate them. The controller also expected the pilot to report any issues with the runway lights.
Pilot Actions
During taxi, the pilot faced high workload, particularly in a single-pilot cockpit, requiring divided attention among several tasks. The pilot received a notification from the cabin medical crew indicating the cabin was not secure for takeoff, leading to a request for an extended backtrack on runway 15. Additional communications with the medical crew and ATC further increased workload while the aircraft was moving on the taxiway and runway.
Once aligned on the runway for backtrack and takeoff, the pilot’s view included strong aircraft landing lights reflecting off the inactive high intensity runway lights (HIRL). This reflected light, combined with other light sources from a well-lit aerodrome, presented significant light during the pilot’s visual scan. The presence of this reflected light and the absence of a specific check for runway lights resulted in the pilot not realizing the runway lights were inactive before starting the takeoff. When the aircraft rotated, the landing lights were directed away from the runway, causing an illusion that the runway lights extinguished as the aircraft became airborne.
Sequence of Events
A review of clearances showed the aircraft was not required to stop at any point before takeoff. The pilot noted that not stopping at the holding point eliminated an opportunity to visually check the runway without the landing lights shining on it. The pilot added that the increased workload should have prompted a pause and reassessment before takeoff, but an additional pause when lined up would likely have been ineffective due to the expectation that the lights would be on and the presence of reflected light.