Lighting the Way for Safety

By Debbie Hersman

On Oct. 19, 2009, a Delta Air Lines Boeing 767 flight
60, en route from Rio de Janeiro to Atlanta, landed on a taxiway instead of a runway at Atlanta Hartsfield-Jackson International Airport (ATL). While this event did not result in fatalities, injuries or damage to the aircraft, there were tremendous opportunities to learn from our investigation.
Our investigators found that one of the three crewmembers was ill and the remaining two pilots conducted the entire night flight without a customary break period. In addition, the flight crew was assigned a number of runway changes with the last clearance to land on runway 27R, not 27L, coming during final approach, always an extremely busy time for pilots.

Importantly, the pilots had not been briefed about runway 27R’s approach and did not know the approach light system and the Instrument Landing System (ILS) were unavailable to help them identify the runway. After accepting the final clearance and sidestepping from runway 27L to 27R, the captain lined up the airplane on what he reported were “the next brightest set of lights” he could see.

Our team’s review of ATL’s lighting found there were several visual cues that could have misguided the captain to align with the taxiway instead of runway 27R. While our probable cause finding was, “The flight crew’s failure to identify the correct landing surface due to fatigue,” one recommendation was that the Federal Aviation Administration direct airport operators to inform air traffic managers of changes to airfield lighting to help prevent the confusion that flight 60’s flight crew experienced.

I am pleased that the FAA acted on this recommendation by modifying not one, but two advisory circulars and today we have closed this recommendation as “Exceeds Recommended Action.” I commend Acting Administrator Michael Huerta and his team for their continuing efforts to improve safety.

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