Aviation safety investigations & reports

Loss of separation involving Boeing 737 aircraft, VH-YFN and VH-VZV and Robinson R44, VH-WYR near Essendon Airport, Victoria, on 26 January 2016

Investigation number:
Status: Completed
Investigation completed


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What happened

On the morning of 26 January 2016, the air traffic controllers at Melbourne Airport, Victoria conducted a runway change from runway 16 for arrivals and runway 27 for departures to runway 16 for arrivals and departures. The Melbourne Tower Coordinator and the Melbourne Approach East Controller were required to coordinate the runway change with the Essendon Aerodrome Controller. However, both Melbourne controllers forgot to conduct the coordination.

At Essendon Airport, the pilot of a Robinson R44 helicopter, registered VH-WYR (WYR), had been cleared to operate overhead the airport, not above 1,500 ft, as there were overcast conditions above that level.

At 0705 Eastern Daylight-saving Time, a Boeing 737 was cleared for take-off on Melbourne runway 16. About 1 minute later, another Boeing 737 was cleared for take-off on the same runway. The Essendon Aerodrome Controller observed the first Boeing 737 departing runway 16 on their Tower Situation Awareness Display. As the controller was unaware of the change of runway at Melbourne, they believed the Boeing 737 was an uncoordinated missed approach.

Shortly after, the second Boeing 737 departure appeared on the display. The Essendon Aerodrome Controller queried the active runway with the Melbourne Planner Controller, and found out that the active runway had been changed at Melbourne Airport without the required coordination with Essendon. At 0708, the Essendon Aerodrome Controller instructed the pilot of WYR to operate over or to the east of the Essendon runway 26 threshold, ensuring a 3 NM
(5.6 km) separation with the runway 16 departures from Melbourne Airport.

A review of the surveillance data confirmed losses of separation between WYR and the two Boeing 737 aircraft. At their closest, the first was 2.4 NM (4.4 km) west of and 800 ft above WYR, the second 2.5 NM (4.6 km) west of and 800 ft above. Either a 3 NM (5.6 km) surveillance separation standard or a 1,000 ft vertical separation standard was required.

What the ATSB found

The ATSB found that, while there were requirements for coordination between Melbourne and Essendon Airports, there were no documented procedures, checklists, tools or memory prompts to assist controllers to coordinate runway and airspace changes. In this case, the Melbourne Tower Coordinator and Melbourne Approach East Controller each forgot to conduct the required coordination with the Essendon Aerodrome Controller. Neither controller could explain this lapse. 

What's been done as a result

As a result of this occurrence, Airservices Australia conducted a number of safety actions, including examining the national procedures for coordinating runway and associated airspace changes at locations with units in close proximity. At Melbourne, temporary local instructions introduced a runway change coordination checklist and a runway configuration coordination prompt. At Essendon, any update to the Melbourne automatic terminal information service is automatically displayed in the message queue, increasing controllers’ situation awareness and providing early opportunities to detect breakdowns in coordination between Melbourne and Essendon controllers.

Safety message

This occurrence highlights the benefits of effective memory prompts and checklists as an aid to memory and in ensuring that critical items are not overlooked or forgotten. 

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The occurrence

Safety analysis

Safety issues and actions

Sources and submissions

Safety Issue

Go to AO-2016-005-SI-01 -

Absence of air traffic control procedures and tools for runway changes at Melbourne Airport

Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.

Safety issue details
Issue number: AO-2016-005-SI-01
Who it affects: Air traffic controllers at Melbourne and Essendon Airports
Status: Adequately addressed
General details
Date: 26 January 2016   Investigation status: Completed  
Time: 0706 EDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Essendon Airport west 5 km    
State: Victoria   Occurrence type: Breakdown of co-ordination  
Release date: 09 March 2017   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Robinson Helicopter Co  
Aircraft model R44 II  
Aircraft registration VH-WYR  
Serial number 10085  
Type of operation Aerial Work  
Sector Helicopter  
Damage to aircraft Nil  
Departure point Essendon, Vic.  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer The Boeing Company  
Aircraft model 737-8FE  
Aircraft registration VH-YFN  
Serial number 41009  
Operator Virgin Australia  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Melbourne, Vic.  

Aircraft 3 details

Aircraft 3 details
Aircraft manufacturer The Boeing Company  
Aircraft model 737-838  
Aircraft registration VH-VZV  
Serial number 34189  
Operator Qantas Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Melbourne, Vic  
Last update 14 November 2018