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When VH-CZM was transferred to the arrivals controller, the aircraft was observed to turn left at Wonthaggi and track 298 degrees towards BAYSI instead of 320 degrees towards Plenty. The controller subsequently radar vectored VH-CZM to Plenty. There was no breakdown in separation. By replaying the communications tape it was discovered that at 14.04.35 EST, the sector three controller had issued the following clearance: "Charlie Zulu Mike, STAR clearance Plenty One arrival, runway 34, maintain flight level 370." The pilot read back: "Charlie Zulu Mike BAYSI One arrival, runway 34, flight level 370." When the pilot read back a different clearance, the controller failed to notice the pilot's error. When the aircraft turned left, the pilot genuinely thought that he had been cleared for a BAYSI one arrival. Significant Factors The following factors were considered relevant to the development of the incident: 1. The pilot misheard the Plenty One clearance and read back BAYSI One. 2. The controller misheard the pilot's incorrect clearance read back.
Download Final Report
[ Download PDF: 14KB]
General details
Date: 13 July 1995 Investigation status: Completed 
Time: 14:25 EST  
 Investigation type: Occurrence Investigation 
 Occurrence type: Operational non-compliance 
Release date: 15 August 1995 Occurrence class: Airspace 
Report status: Final Occurrence category: Incident 
Aircraft details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737-377 
Aircraft registration: VH-CZM 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Hobart TAS
Destination:Melbourne VIC
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Last update 21 October 2014