Incident Overview
On 21 July 2023 at 0119 local time, an Airlink Piper PA-31 aircraft, registered VH-XMM, was preparing for a flight from Essendon Fields Airport, Victoria to Bankstown, New South Wales. The pilot received an airways clearance and accepted a departure from runway 26 as requested by air traffic control.
Sequence of Events
After commencing the take-off run, the pilot heard multiple loud noises and rejected the take-off, exiting the runway. Inspection upon return to the apron revealed a damaged main landing gear tyre and brake caliper.
ATSB Investigation Findings
The Australian Transport Safety Bureau (ATSB) determined that during a period of high workload, the aircraft was misaligned with the runway edge lighting, resulting in minor damage during the take-off run. Recorded position data confirmed the aircraft was aligned with the runway edge lighting during line-up. CCTV footage showed an aircraft moving along runway 26 and extinguishing northern runway edge lights as it passed. The damage was consistent with striking the runway lights.
During an interview, the pilot noted that while entering the runway, they checked for approach traffic, filled out departure times, and completed the line-up checklist using a physical checklist. These actions diverted attention from outside to inside the cockpit. The pilot also advised that runway 26 was not a frequently used runway for operations. The ATSB found that a combination of high workload, unfamiliarity with the runway, and night operations increased the risk of runway misalignment.
Fatigue Analysis
Due to the time of the occurrence and the pilot's belief that fatigue was a contributing factor, the ATSB analyzed the pilot's fatigue level. The analysis indicated that, based on known information about the pilot's previous sleep and work roster, it was unlikely the pilot was experiencing a level of fatigue known to affect performance at the time of the incident.
Safety Action Taken
Airlink advised the ATSB of proactive safety actions, including reviews of:
- Fatigue management of aircrew conducting night operations, including mandatory 'out of contact' hours.
- Night proficiency checks for pilots and their frequency.
- Airport familiarisation processes for night operations, with clear procedures for inducting aircrew at new ports.
- Current simulator set-up to determine potential for simulator training and checks supporting practical assessment, including night checks.
- Fatigue management plan improvements for night flights and variances against Civil Aviation Safety Authority Civil Aviation Order 48.1 regulations.
Safety Message
The ATSB highlighted the importance of reducing distractions during critical stages of flight. Pilots should consider implementing a sterile cockpit rule at those times to reduce distraction opportunities. Additionally, checklists during ground operations should, where possible, be completed when the aircraft is stationary.