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FACTUAL INFORMATION When the pilot of the Boeing 727 requested a taxi clearance from bay two for runway 17, the Aerodrome Controller (ADC) issued a clearance to the Surface Movement Controller (SMC) for the Boeing to cross runway 12. The SMC cleared the Boeing to taxi and issued the clearance to cross runway 12. Other traffic requirements then became the priority for both the SMC and Co-ordinator. While the SMC was issuing the Boeing 727 pilot with the clearance, the Cessna 152 pilot reported ready for takeoff to the ADC. As both aircraft were on different frequencies, neither pilots heard the other. After a short delay, the Cessna was cleared for takeoff. Over the 30 seconds following the issuing of the take-off clearance, the ADC became involved in the co-ordination of three other aircraft. He then noticed that the Cessna had not taken off and reissued the take-off clearance. The Cessna pilot replied 'We've got the 727 crossing'. At this point the ADC saw the Boeing crossing the runway and instructed the Cessna to hold position. The second ADC was involved in discussions with surveyors during the entire sequence. Due to the weather conditions, runway 17 was designated for arrivals and departures, while runway 12 was used for circuit traffic. This runway configuration is not often used in Canberra. ANALYSIS The ADC forgot that he had issued the Boeing with the clearance to cross. He was distracted by the presence of visitors in the tower and the busy workload. The non-standard runway configuration may have had some influence on the ADCs procedures, resulting in a runway scan different to that which he normally would use. FINDINGS 1. The ADC issued the SMC with a clearance for the Boeing 727 to cross runway 12. 2. The SMC issued that clearance to the Boeing 727 pilot. 3. The ADC issued the Cessna 152 pilot with a take-off clearance from runway 12. 4. The Cessna 152 pilot reported holding while the Boeing 727 crossed the runway. SIGNIFICANT FACTORS 1. The runway configuration was not standard for Canberra. 2. The ADC was distracted due to a busy workload and the presence of visitors.
Download Final Report
[ Download PDF: 15KB]
 
 
 
 
General details
Date: 18 May 1995 Investigation status: Completed 
Time: 9:50 EST Investigation type: Occurrence Investigation 
 Occurrence type:Loss of separation 
 Occurrence class: Airspace 
Release date: 05 January 1996 Occurrence category: Incident 
Report status: Final  
 
Aircraft 1 details
Aircraft manufacturer: Cessna Aircraft Company 
Aircraft model: 152 
Aircraft registration: VH-CSZ 
Sector: Piston 
Departure point:Canberra ACT
Destination:Canberra ACT
Aircraft 2 details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 727-277 
Aircraft registration: VH-ANA 
Sector: Jet 
Departure point:Canberra ACT
Destination:Sydney NSW
 
 
 
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Last update 21 October 2014