Final Report


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.

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions