What happened
During the taxi and takeoff phase, the pilot of VH-FDL, an aircraft operating on runway 15, departed without the runway lighting being activated. The incident occurred during a period of high workload for the pilot, who was managing communications with both air traffic control and a cabin medical crew regarding an unsecure cabin. Because the aircraft was not required to stop before takeoff, the pilot did not have a dedicated opportunity to visually inspect the runway environment without the interference of bright landing lights.
The investigation
The investigation focused on why the runway lights remained inactive and why the error was not detected by either the controller or the pilot. Investigators examined the air traffic control interface, specifically the INTAS system, and found that a 'LIGHTS' memory prompt was being used as a passive risk control. This prompt remained on the screen continuously from dusk until dawn, regardless of the actual status of the runway lights. Furthermore, the workflow did not force the controller to interact with this prompt when moving flight progress strips from the taxiway to the runway.
Regarding the pilot, the investigation found that the reflection of the aircraft's own landing lights off the inactive high-intensity runway lights (HIRL), combined with other ambient aerodrome lighting, created a visual environment that masked the lack of runway lighting. As the aircraft rotated, the change in light direction caused the reflection to vanish, creating an illusion that the lights had extinguished once airborne.
Findings
- The air traffic controller failed to activate the runway lighting controls prior to the aircraft entering the runway.
- The continuous display of the 'LIGHTS' prompt in the INTAS system likely led to user desensitisation, meaning the controller did not process the prompt as an actionable task.
- The pilot's workload was significantly increased by simultaneous communications with medical crew and air traffic control.
- The controller's reliance on the expectation that the pilot would report lighting issues contributed to the oversight.
- The presence of reflected light from the aircraft's landing lights prevented the pilot from noticing the inactive runway lights during the taxi and takeoff roll.