Queensland Rail should note the safety deficiency identified in
this document and take appropriate action.
The Bureau simultaneously issues SAN980117 to alert the Civil
Aviation Safety Authority to this safety deficiency.
SUBJECT - LIGHTS NEAR GLADSTONE AIRFIELD
INTRODUCTION - REGIONAL AIRLINES SAFETY STUDY
Between October 1995 and July 1997 the Bureau of Air Safety
Investigation undertook a study of the safety of Australian
regional airlines. The objectives of this study were to:
(a) identify safety deficiencies affecting regional airline
operations in Australia; and
(b) identify means of reducing the impact on safety of these
deficiencies.
For the purposes of the survey, regional airlines were grouped
according to the number of passenger seats fitted to the largest
aircraft operated by that airline in January 1997. The groups are
defined as follows:
(a) group 1: 1-9 seats;
(b) group 2: 10-19 seats; and
(c) group 3: more than 20 seats.
The study involved analysing data obtained from:
(a) responses to a survey of Australian regional airline
employees;
(b) discussions with Australian regional airline employees and
managers; and
(c) air safety occurrence reports involving regional airlines over
a 10-year period (1986-1995) from the BASI database.
This Safety Advisory Notice addresses one of the safety
deficiencies identified as a result of this study.
SAFETY DEFICIENCY
The lights in the railway yards near Gladstone airfield may
provide pilots with visual cues which create a false perception of
the alignment of the runway.
Survey Results
In their survey answers, four respondents stated that the
Callemondah marshalling yard lights could 'drown out' the runway
lights and create the illusion of a false runway. The railway yard
was reported as being illuminated by bright lights, which were
adjacent to the final approach path for runway 10 at Gladstone. In
addition, the final approach track for the instrument approach to
runway 10 is slightly offset to the alignment of the runway due to
terrain considerations. As no respondents mentioned any safety
concerns about lights near other airfields, the comments regarding
Gladstone airfield were considered significant.
"At night in poor weather, the runway lighting is totally
overpowered by the adjacent (and almost parallel) railway yards
with very bright flood lighting. More than one aircraft has lined
up on the finals for the railway yards in these conditions when
landing on runway 10."
- Pilot, respondent 472.
The four respondents to this question operated group 3 aircraft
and each had accrued more than 13,000 hours total flying
experience.
Discussion with the chief pilots of the two major regional
airlines that service Gladstone airfield revealed that they were
both aware of the problem, and that the training program for each
company was structured to impart sound local knowledge of the
area.
Discussions with representatives of Queensland Rail revealed that
it could be possible for more shielding to be added to the lights
and that they would be willing to investigate the problem. By
invoking Civil Aviation Regulation 94, the Civil Aviation Safety
Authority (CASA) could require the removal or shielding of any
light likely to endanger the safety of aircraft.
Related Incident
Poor visibility and a night approach were two of the factors
contributing to an incident in 1989, when a Boeing 737 attempted to
land on a main road at Mackay. The air traffic controller alerted
the pilots that they were not aligned with the runway; however, the
aircraft descended to 168 ft AGL before it was established in a
go-around. The crew had misidentified a main road near the Mackay
airfield as runway 14.
ANALYSIS
The lights in the Callemondah marshalling yards, adjacent to the
runway 10 threshold at Gladstone, cause the greatest potential for
harm when a pilot is unfamiliar with the area and/or operating at
night or in poor visibility. The recent publication of runway
approaches may help to alleviate the problem to some extent, as
aircraft should be reasonably well aligned with the runway when
approaching the minimum descent altitude. However, as the yard
lights have been reported as being more visible than the runway
lights, they have the potential to influence the pilot's selection
of a final approach path. This is of particular concern if the
pilot is not accurately maintaining the correct final approach
track. Additionally, as the final approach track for the instrument
approach to runway 10 is slightly offset to the alignment of the
runway, there is an increased potential for pilots to misidentify
the correct location of the runway.
Queensland Rail should note the safety deficiency identified in
this document and take appropriate action.
The Bureau simultaneously issues SAN980117 to alert the Civil
Aviation Safety Authority to this safety deficiency.
Your reference BS/970091 refers to a Safety Advisory Notice No
SAN 980118 concerning lights near Gladstone Airfield.
Discussions have been held with a Mr [name supplied] of your
Bureau, representatives of Sunstate Airlines and Flight West
Airlines in an attempt to identify safety deficiencies highlighted
in your Bureau study. A meeting was convened with the Technical
Services Engineer of the Gladstone City Council who is a technical
representative of the Gladstone Aerodrome Authority.
This organisation was advised that approximately six light towers
in the Callemondah Rail Complex have been identified as having the
potential to interfere with aircraft approaching from a northerly
direction. Advice was also given that plans are being produced to
extend the runway towards the railway to allow for altered flight
paths and this may have a further impact on Queensland Rail yard
lighting. This organisation was unaware of these plans.
The Technical Engineer agreed that no action should be taken at
this point in time until new airport plans are available so that a
proper assessment can be made of any lighting alterations required
to meet airport requirements and ensure the needs of Queensland
Rail in providing a safe workplace for its workers in what is a
major rail terminal supporting export coal facilities at Gladstone
are addressed.
Trusting the action proposed meets your requirements, should you
require any further clarification, please do not hesitate to
contact this organisation.