Aviation occurrence briefs

Runway misidentification occurrences during approach involving two Diamond DA 40 aircraft, Coffs Harbour, NSW, on 14 October 2019

Number:
AB-2019-040
Status: Completed
Investigation completed

Brief

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On the afternoon of 14 October 2019, the solo student pilots of two Diamond DA 40 aircraft were approaching Coffs Harbour, New South Wales 20 minutes apart at the conclusion of a navigation exercise. The exercise was under visual flight rules and both aircraft were flying in visual meteorological conditions.

As the first DA 40 approached the airport from the north, the student pilot was cleared by air traffic control (ATC) to conduct a visual approach to runway 21. As the aircraft became closer to the airfield, ATC questioned the final heading of the aircraft and requested confirmation from the pilot that they had the runway environment in sight. This made the pilot aware that they were aligned on final approach to taxiway E3-E5 (Figures 1 and 2).

Approximately 20 minutes later, the second inbound DA 40 approached the airport from the same heading and was cleared by ATC to conduct a visual approach to runway 21. ATC also questioned the final heading of this aircraft which notified the pilot that they were also aligned on final approach to the taxiway.

Both pilots made the necessary corrections to successfully land on runway 21.

In the navigation exercise briefing, the students were made aware of the potential to misidentify the runway as it is not an uncommon occurrence at this aerodrome. They were thoroughly briefed and provided with methods to confirm the correct runway, particularly when approaching from the north. The possibility of misidentifying the runway is also annotated as a warning in Airservices publications, En Route Supplement Australia (ERSA) and Departure and Approach Procedures (DAP).

Figure 1: Aerodrome Chart – Coffs Harbour, NSW

Figure 1: Aerodrome Chart – Coffs Harbour, NSW. Source: Airservices Australia

Source: Airservices Australia

Figure 2: Aerial image of Coffs Harbour Airport, NSW

Figure 2: Aerial image of Coffs Harbour Airport, NSW. Source: Google Earth, annotated by the ATSB

Source: Google Earth, annotated by the ATSB

Safety action

As a result of this occurrence, the training organisation has advised the ATSB that they will provide further information in the navigation briefing for students to mitigate against the misidentification of taxiway E3-E5 for runway 21 at Coffs Harbour. They now also require supervising instructors to provide special pre-flight briefings for all solo flights into this location regarding positive identification of the runway.

Similar occurrences

In the previous five years, there have been seven additional similar occurrences reported to the ATSB involving the E3-E5 taxiway being mistaken for runway 21 during approach into Coffs Harbour.

Safety message

Pilots and operators should be aware of documented and well-known issues when identifying particular features critical to navigation and airfield operations. In this situation, identifying the runway environment would have benefited from using secondary features to confirm identification – runway heading, surrounding topographical features and visible runway infrastructure (runway approach lighting and runway markings).

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

 

General details
Date: 14 October 2019   Investigation status: Completed  
Location   (show map): Coffs Harbour    
State: New South Wales    
Release Date: 29 November 2019   Occurrence category: Incident  
Report status: Final    

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Diamond Aircraft Industries  
Aircraft model DA 40  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Destination Coffs Harbour, New South Wales  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Diamond Aircraft Industries  
Aircraft model DA 40  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Destination Coffs Harbour, New South Wales  
Last update 29 November 2019