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ASN Wikibase Occurrence # 225969
Last updated: 23 June 2019
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Date:22-SEP-2018
Time:07:04
Type:Silhouette image of generic SF34 model; specific model in this crash may look slightly different
Saab 340A
Owner/operator:Western Air
Registration: C6-KID
C/n / msn: 136
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Nassau-Lynden Pindling International Airport (NAS) -   Bahamas
Phase: Take off
Nature:Domestic Scheduled Passenger
Departure airport:Nassau-Lynden Pindling International Airport (NAS)
Destination airport:Freeport-Grand Bahama International Airport (FPO/MYGF)
Investigating agency: AAID Bahamas
Narrative:
A near mid-air collision occurred over runway 14/32 at Nassau-Lynden Airport, Bahamas when two aircraft simultaneously departed the same runway, from opposite ends, headed toward each other.

At 07:04:41 a Piper PA-23-250 Aztec E (C6-JEF) was given instructions to depart runway 27 from Kilo intersection at Lynden Pindling Intíl Airport, and continue on course to its destination of Great Harbor Cay, in the Berry Islands. Eight seconds later a Saab 340A (C6-KID), operating as flight WST701, was given instructions to depart from the threshold of runway 14, with instructions for a left turn after departure, destination Freeport, Grand Bahama.
Despite acknowledging instructions for a runway 27 departure, C6-JEF taxied onto runway 32, from intersection Lima, contrary to issued instructions.
Both aircraft eventually commenced takeoff roll headed toward each other. C6-JEF became airborne first after commencing takeoff at about 07:04:24.
At 07:04:46 C6-KID was passing taxiway Echo commencing his take off roll, from the opposite direction, on runway 14. C6-KID rotated just prior to taxiway Delta, at 7:04:53. By the time C6-KID rotated and became airborne, C6-JEF had already passed overhead.
Aircraft separation height over the runway is unknown. Neither aircraft was aware of their close proximity or conflict possibility until advised by ATC.


The poor decision making exercised by the pilot of aircraft C6-JEF in not following directions issued by ATC, despite advising he understood the instructions given, has been determined by the AAID as the probable cause of the near mid-air collision.
Also contributing to this near mid-air collision was the actions of the air traffic controller by losing visual on the aircraft he issued instructions to, and the failure on the part of the crew of C6-KID for not observing that another aircraft was on the same runway at the same time before commencing their take-off roll.
The AAID believes this loss of visual contact on the aircraft by the controller, may have been as a result of distraction due to the ongoing shift change at the time, and the fact that the controller was manning two separate radio frequencies3 during a time of high traffic volume, while using a system that required additional training and frequent data input so that all systems can function properly with adequate current information.
The AAID also believes the failure to notice the aircraft by the crew of C6-KID may be the result of distractions or preoccupation with completing final checks while on the runway, before takeoff.
Pilot training, qualification and air traffic controller training, licensing and record keeping practices has been investigated and while not directly contributing to the incident were noteworthy and required action.

Sources:

AAID Bahamas

Accident investigation:
cover
  
Investigating agency: AAID Bahamas
Status: Investigation completed
Duration: 8 months
Download report: Final report


Images:


Graphic: AAID Bahamas

Revision history:

Date/timeContributorUpdates
09-Jun-2019 17:54 harro Added

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