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On 12 October 2016, at about 1330 Eastern Standard Time, a Pilatus BN2A-20, registered VH‑IOA (IOA), departed from Kubin on a charter flight to Horn Island, Queensland. At about the same time, a Bombardier DHC-8-202, registered VH-ZZJ (ZZJ), conducting surveillance operations, was preparing for departure from Horn Island.

The flight crew on board ZZJ taxied their aircraft for a departure from Horn Island runway 08. While backtracking runway 08, ZZJ’s flight crew observed an aircraft appear on their traffic collision avoidance system display, which was identified as IOA. The pilot of IOA reported to ZZJ that they were approaching a 3 NM final for runway 14 and ZZJ would have time to depart from runway 08 if they were quick. The pilot of IOA reported that at about 300 ft on final approach, they broadcast ‘hold short’ to ZZJ, which was accelerating down the runway. However, the captain of ZZJ reported they heard the pilot of IOA say ‘land and hold short of runway 08’ and therefore continued their take-off. As IOA approached 100–150 ft, ZZJ had not crossed the runway intersection and the pilot flying IOA conducted a left climbing turn away from the runways. The captain of ZZJ looked out their left window when they were in the initial climb overhead the threshold of runway 26 and saw IOA turning through east at about the same level. 

This serious incident highlights that pilots and operators need to consider how best to employ and integrate the sources of information available to them in order to develop an accurate mental model of a potential traffic threat.


Aviation Short Investigations Bulletin - Issue 57

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General details
Date: 12 October 2016 Investigation status: Completed 
Time: 13:45 EST  
Location   (show map):Horn Island Airport Investigation type: Occurrence Investigation 
State: Queensland Occurrence type: Near collision 
Release date: 09 February 2017 Occurrence class: Operational 
Report status: Final Occurrence category: Serious Incident 
 Highest injury level: None 
Aircraft 1 details
Aircraft manufacturer: Pilatus Britten-Norman Ltd 
Aircraft model: BN2A-20 
Aircraft registration: VH-IOA 
Serial number: 842 
Type of operation: Charter 
Sector: Piston 
Damage to aircraft: Nil 
Departure point:Kubin, Qld
Destination:Horn Island, Qld
Aircraft 2 details
Aircraft manufacturer: Bombardier Inc 
Aircraft model: DHC-8-202 
Aircraft registration: VH-ZZJ 
Serial number: 551 
Type of operation: Aerial Work 
Sector: Turboprop 
Damage to aircraft: Nil 
Departure point:Horn Island, Qld
Destination:Cairns, Qld
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Last update 14 November 2018