Date:	Saturday 18 May 2024
Time:
Type:	BAe Jetstream 32
Owner/operator:	SARPA - Servicios Aéreos Panamericanos
Registration:	HK-4411
MSN:	870
Year of manufacture:	1989
Fatalities:	Fatalities: 0 / Occupants: 5
Other fatalities:	0
Aircraft damage:	Minor, repaired
Category:	Serious incident
Location:	Bonaire-Flamingo International Airport (BON/TNCB) -   Caribbean Netherlands
Phase:	Take off
Nature:	Ambulance
Departure airport:	Bonaire-Flamingo International Airport (BON/TNCB)
Destination airport:	Rionegro/Medellín-José María Córdova Airport (MDE/SKRG)
Investigating agency:	Dutch Safety Board
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
During take-off from Runway 10 at Bonaire International Airport (TNCB) in Caribbean Netherlands, the nose landing gear hit several runway edge lights. The aircraft suffered minor damage to a tire of the nose landing gear.

The aircraft departed on an ambulance flight to José María Córdova International Airport in Rionegro, Colombia. During the takeoff roll, the aircraft struck three runway edge lights along the right side of the runway, causing minor damage to the nose landing gear. The flight crew did not detect the contact with the lights and proceeded to their destination without further incident.

The sequence of events leading up to the misaligned takeoff began during the taxi and line-up phase. The aircraft had taxied from the general aviation apron and Taxiway B via the runway to the turn pad at the southern end of Runway 10. Instead of following the yellow taxi line leading to the centre of the runway, the captain opted for a different path, citing concerns about propeller clearance near the edges of the turn pad. As a result, he initiated the turn earlier than he would have if he had followed the taxi line.
After completing the turn, the aircraft was positioned along the right edge of the runway rather than the centre line. The absence of runway turn pad lighting at night made it difficult to maintain accurate visual reference, and the captain misidentified the white runway edge lights as centre line lights.
As the aircraft accelerated for takeoff, the first officer, who was the designated Pilot Flying, noticed that the aircraft was not aligned with the centre line. The first officer’s workload was high during the line up as he was managing air traffic control communications and performing checklists, which may have delayed his recognition of the misalignment. He called this out to the captain three times with increasing urgency.
The captain acknowledged the concern and stated that he was correcting the alignment, but his adjustments were minimal. The captain believed that the aircraft was correctly positioned and did not fully grasp the extent of the misalignment. The cockpit environment, influenced by the training relationship between the two pilots, played a role in how the situation had developed. The first officer, being under supervision, did not take further action despite recognizing the problem. The presence of an authority gradient likely influenced his decision not to intervene more assertively. The extent to which these factors contributed to the occurrence could not be determined due to the unavailability of cockpit voice recorder data.
The contextual and environmental conditions at Flamingo International Airport further contributed to the situation. The absence of runway centre line lighting meant that pilots had to rely on other visual cues for alignment. The design of the turn pad, optimized for larger aircraft, created a wider, less defined space that may have made alignment more challenging for a smaller aircraft like the Jetstream 32. The night time conditions also reduced visibility of ground markings, even though weather conditions were clear.
Furthermore, the air traffic controller on duty did not have a clear view of the aircraft’s alignment due to the distance and lighting conditions.
After a flight of approximately two and a half hours, the aircraft landed in Rionegro.
During a post-flight inspection, maintenance personnel discovered that the right nose landing gear tire was deflated and that both nose landing gear tires had sustained cuts,
consistent with impact damage. The right wheel rim of the nose landing gear was also damaged. The captain documented the deflated tire in the aircraft’s technical logbook and reported the incident to the operator’s safety department. Meanwhile, airport authorities at Bonaire conducted a routine runway inspection and found three broken runway edge lights. The damage pattern, along with the location of the tire marks on the runway, confirmed that the aircraft had rolled along the right edge rather than the centre line during takeoff.
The combination of human, environmental, and infrastructural factors led to the misaligned takeoff. The large 270-degree turn, the early deviation from the taxi line, the absence of turn pad lighting, and the misidentification of runway edge lights as centre line lights resulted in the aircraft departing from the incorrect position. Within the cockpit, the authority gradient, workload distribution, and communication dynamics
likely influenced the crew’s ability to detect and correct the misalignment in a timely manner. While the first officer identified the issue and called it out multiple times, the captain’s perception that he was making the necessary corrections prevented more decisive action.
The airport operator and regulatory authorities reviewed the necessity of runway turn pad lighting but concluded on the basis of a safety assessment that, given the low traffic volume requiring its use, it was not essential. Following this incident, procedural changes were introduced at Flamingo International Airport. As of 26 September 2024,
intersection takeoffs from Runway 10 have been permitted for Code A and B aircraft, including the Jetstream 32, eliminating the need for backtracking.
This incident highlights broader considerations for night time operations at airports where centre line lighting is absent. Enhanced cockpit training on the risks of misaligned takeoffs, improvements in runway visual guidance, and a review of Crew Resource Management training to encourage more decisive interventions in abnormal situations could help prevent similar occurrences in the future

TNCB 190155Z: Wind from 090° at 13 knots, visibility 10 kilometres or more, scattered clouds at 1,500 feet, broken clouds at 1,900 feet, temperature 29 °C, dew point 25 °C, QNH 1013 hPa

https://bonaire.nu/2024/05/20/sarpa-neemt-deel-baanverlichting-mee-bij-opstijgen-vanaf-bonaire/
https://bonaire.nu/2024/06/06/flamingo-luchthaven-bevestigt-eindelijk-incident-met-jetstream-sarpa/
https://onderzoeksraad.nl/wp-content/uploads/2024/08/Quarterly-Aviation-Report-Q2-2024.pdf

Date/time	Contributor	Updates
22-Aug-2024 18:45	ASN	Added
22-Aug-2024 18:45	ASN	Updated [Location, ]
29-Aug-2025 05:49	ASN	Updated [Registration, Total occupants, Destination airport, Narrative, Accident report, ]