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| Date: | Monday 1 March 2021 |
| Time: | 22:43 LT |
| Type: |  Beechcraft 400A Beechjet |
| Owner/operator: | Fly-Coop Air Service |
| Registration: | HA-YFJ |
| MSN: | RK-254 |
| Engine model: | PWC JT15D-5 |
| Fatalities: | Fatalities: 0 / Occupants: 4 |
| Other fatalities: | 0 |
| Aircraft damage: | Minor, repaired |
| Category: | Incident |
| Location: | Budapest Ferenc Liszt International Airport (BUD/LHBP) -
 Hungary
|
| Phase: | Take off |
| Nature: | Training |
| Departure airport: | Budapest Ferenc Liszt International Airport (BUD/LHBP) |
| Investigating agency: | TSB Hungary |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Beechjet 400A damaged the first, second and fourth runway edge lights on the northern edge of the runway, south-east of the J4 intersection, while taxiing from the B1 waiting point to the 31L threshold.
The crew apparently did not notice that they lined up on the left-hand runway edge and performed the take-off from runway 31L.
There were four persons on board. A type rated pilot (who was company rated PIC and FO) was seated in the right pilot seat as PM, and a pilot without type rating was seated in the left pilot seat as PF. A TRI pilot was seated in the passenger seat behind the cockpit bulkhead, rearward facing in the passenger compartment, but rotatable 90 degrees inwards, and was assigned to supervise the non-type rated pilot in the left cockpit seat in an instructor capacity. In addition to him, there was another pilot in the cabin as a passenger.
Root Causes
The root cause of taxiing on the runway edge and knocking down the edge lights was identified as human error, where the crew's lapse in focus and attention attested during taxiing led to a compromised situational awareness, causing them to misidentify the edge lights as centerline lights while backtracking to threshold 31L.
Contributing Factors
The safety investigation identified the following contributing factors that influenced the runway centerline misidentification and why the crew never identified the error.
Factors influencing the misidentification:
- The AIP did not provide comprehensive information regarding the difference in the operation of the centerline lighting system of Runway 13R/31L compared to Runway 13L/31R; and marked both runway’s centerline lights “bidirectional”. Additionally, the AIP did not include a visual representation of the taxiway centerlines continuing as taxi lines crossing the runways, to help pilots understand in advance the complexities of the area around intersection J4 and prepare them for the initial left turn of the taxi line leading right from B2.
- Inadequate execution of flight training procedures (PAX1, acting as instructor, was seated in the passenger compartment).
- PAX1’s lacking pre-flight briefing, without highlights regarding the expected difficulties during taxi, such as an unexpected initial turn of the yellow taxi line after B2, the visual differences out of a low-built cockpit and peculiarities of runway lights and markings at the J4 area).
- Undefined and overlapping responsibilities regarding pilot roles: two PIC’s on board (CM2 and PAX1) will in all likelihood undermine flight deck synergy (CRM) and erode decision making efficiency.
- Relatively little experience of both pilots in this aircraft with a low-built cockpit and at this particular intersection at night. With the AIP deficiencies referred to earlier, familiarity with this runway’s peculiarities, particularly in the B2-B1-J4 area is crucial for processing and properly interpreting the complex visual pattern at this intersection at night. Regretfully, the pilot with local knowledge and experience with this intersection was seated in the passenger compartment.
- The deterioration of the crew’s situational awareness could be fostered by pilots’ personal relationship and their relatively high flight experience, where none of them regarded each other as ‘novice’ or ‘trainee’. Their high overall familiarity with the airport also likely reduced their attention during taxi.
- The crew’s compromised situational awareness likely triggered an automatic response known as confirmation bias. Influenced by their prior experience, they inadvertently searched for centerline lights and took the first opportunity to find them in the runway edge lights.
- As inferred from their interviews, the pilots regarded this flight as a mere formality to conclude CM1’s type rating, which probably contributed to letting their guard down during taxiing.
- The corporate culture observed at the operator and ATO, as detailed in section 2.1.4, reflects a more lenient approach to regulations. This leniency directly contributed to none of the crew members being legally qualified for their assigned roles in the incident flight. Specifically, CM1, without a valid type rating, should only have flown with an instructor in the other seat; CM2, as PIC, should have refused to fly with a non-type- rated co-pilot; and PAX1 should have occupied a pilot seat to operate as an instructor).
Factors contributing to the crew not recognizing their oversight throughout the backtrack to threshold 31L:
- The centerline lights in their current northwesterly configuration were not visible to the crew taxiing southeast.
- Information about the above fact was not available in the AIP or taxi charts.
- The outer edge of the shoulder was outside the main beam of the aircraft’s taxi lights.
- The different shades of grey between the shoulder and runway were perceptible but not obvious.
- With the frangible couplings’ low yield force and the engine noise drowning out the tires impacting the lights at low speed made the impacts’ physical perception from the cockpit practically undetectable
Accident investigation:
 |
|
Sources:
TSB Hungary
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 08-Oct-2024 09:29 | ASN | Added |
| 08-Oct-2024 09:31 | ASN | Updated [Other fatalities, Location, ] |
| 08-Oct-2024 10:10 | ASN | Updated [Other fatalities, Narrative, Accident report, ] |
| 08-Oct-2024 10:12 | ASN | Updated [Other fatalities, ] |
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