Aviation safety investigations & reports

Traffic management occurrence involving Airbus A320, VH-VQS and Beech Aircraft Corporation BE 76, VH-EWL at Ballina/Byron Gateway Airport, NSW on 14 January 2016

Investigation number:
AO-2016-003
Status: Completed
Investigation completed

Final Report

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What happened

On 14 January 2016, whilst taking-off from Ballina/Byron Gateway Airport, Airbus A320, registered VH-VQS (VQS) and operated by Jetstar Airways, came in close proximity to Beech Aircraft Corporation BE-76 Duchess, registered VH‑EWL (EWL). The Duchess was conducting navigation training in the vicinity of the runway and was noticed by the flight crew of VQS during the take‑off roll and below the maximum speed from which they could stop. The take-off was continued and while manoeuvring to maintain separation from EWL, the crew of VQS received master warning/caution alerts regarding the aircraft’s configuration. The crew also commenced flap retraction at low altitude and turned contrary to operator-prescribed departure procedures before departing for Melbourne. There were no injuries or damage to equipment recorded during the occurrence.

What the ATSB found

The ATSB found that despite an increase in passenger numbers and a mixture of traffic, Ballina/Byron Gateway Airport operated without the support of air traffic information and/or services. While recognising that a direct comparison between airports is difficult, Ballina also experienced a higher number of incidents relating to communication and separation issues compared to airports with similar traffic levels. The ATSB also found that a number of non‑standard operating practices and procedures led to a breakdown of crew resource management and the ability to adequately manage the dynamic situation by the crew of VQS. Finally, the ATSB found that the level of communication between the crews of VQS and EWL was inadequate to develop a shared mental model of what each crew was intending to do to ensure separation.

What's been done as a result

Following a recommendation by the Civil Aviation Safety Authority (CASA), the operator of Ballina/Byron Gateway Airport implemented a certified air/ground radio service (CA/GRS) to provide weather services and traffic information at the airport. This service commenced in March 2017 and operates daily between 0800 and 1800 local time. The CASA Office of Airspace Regulation is planning a post‑CA/GRS implementation review in mid-2017 to assess its effectiveness.

Additionally, Jetstar Airways have proposed to increase their annual audit schedule of common traffic advisory frequency operations, reviewed their jump seat policy when operating in such aerodromes to assist in distraction management, and altered their training matrix to further include exercises pertaining to levels of assertion and upwards managing by first officers.

Safety message

Operations at non‑controlled airports remain a safety watch priority for the ATSB. This occurrence highlights that traffic separation in that environment relies on a clear and shared plan between involved aircraft.

Adherence to standard operating practices and procedures promotes a shared understanding of crew’s actions by making them ordered and predictable to the other pilots. As well as reducing the likelihood of task omission or duplication during times of high workload, standardised practices and procedures decrease the mental demand on flight crew when carrying out a set of complex steps, allowing for better processing of unexpected events.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

Safety Issue

Go to AO-2016-003-SI-01 -

Air traffic facilities at Ballina/Byron Gateway Airport

Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area.

Safety issue details
Issue number: AO-2016-003-SI-01
Who it affects: All aircraft operations that utilise Ballina/Byron Gateway Airport
Status: Adequately addressed
General details
Date: 14 January 2016   Investigation status: Completed  
Time: 14:04 EDT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Ballina/Byron Gateway Airport    
State: New South Wales   Occurrence type: Separation issue  
Release date: 19 May 2017   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Airbus  
Aircraft model A320-232  
Aircraft registration VH-VQS  
Serial number 2515  
Operator Jetstar Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Ballina, NSW  
Destination Melbourne, Vic.  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 76  
Aircraft registration VH-EWL  
Serial number ME-16  
Operator Air Gold Coast  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Departure point Gold Coast, Qld  
Destination Ballina, NSW  
Last update 14 November 2018