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ASN Wikibase Occurrence # 238448
Last updated: 10 February 2021
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Date:09-JUL-2020
Time:00:15 EST
Type:Silhouette image of generic BE20 model; specific model in this crash may look slightly different
Beechcraft B200 King Air
Owner/operator:Royal Flying Doctor Service
Registration: VH-FDO
C/n / msn: BB-2020
Fatalities:Fatalities: 0 / Occupants: 5
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Cairns Airport, QLD (CNS/YBCS) -   Australia
Phase: Landing
Nature:Ambulance
Departure airport:Kowanyama, QLD
Destination airport:Cairns Airport, QLD (CNS/YBCS)
Investigating agency: ATSB
Narrative:
The Royal Flying Doctor Service (RFDS) Beechcraft King Air 200 aircraft with a pilot in command under instruction, a supervisory pilot, a flight nurse and two patients on-board, landed on Cairns Airport’s runway 15 shortly after midnight. Due to on-going night runway works, runway 15’s threshold was displaced.
While the runway was closed at night for normal operations during the works, a portion of the runway was available to the RFDS with prior notice, with the runway 15 threshold temporarily displaced by 1,856 metres.
The flight crew were unaware that their aircraft had struck anything on landing with the broken temporary runway end light – which had been taped to be unidirectional to aircraft using the reciprocal runway 33 and was therefore not visible to flight crew when they landed on runway 15 – discovered later that morning by an airport safety officer. An inspection of the aircraft identified a scuff mark on the right main landing gear tyre.

During the approach, the flight crew sighted an airport safety officer’s car with its headlights directed at what appeared to be a row of lights across the runway, illuminating the displaced threshold. The aircraft passed above the row of lights and touched down beyond it. However, the aircraft had landed short of the actual displaced threshold and a tyre struck an unseen temporary runway end light.
Contributing factors
- The flight crew misidentified the aerodrome works limit line for the displaced runway threshold lights, resulting in a runway undershoot and collision with an unseen portable runway end light.
- The works and airport safety officers did not ensure the aerodrome works lighting was arranged such that the location of the displaced threshold was unambiguous to the flight crew.
- Cairns Airport procedures for temporary runway works lighting and markings were inconsistent and did not ensure lighting was not confusing to pilots

Sources:

https://www.atsb.gov.au/publications/investigation_reports/2020/aair/ao-2020-034/

Accident investigation:
cover
  
Investigating agency: ATSB
Status: Investigation completed
Duration: 7 months
Download report: Final report


Revision history:

Date/timeContributorUpdates
21-Jul-2020 10:34 Petropavlovsk Added
21-Jul-2020 12:17 harro Updated [Time, Total fatalities, Other fatalities, Destination airport, Source, Damage]
21-Jul-2020 19:26 RobertMB Updated [Aircraft type]

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