ATR flight crew inadvertently lines up and commences take-off roll on incorrect runway

Wrong runway at Canberra Airport for a night time departure

Key points:

  • Flight crew inadvertently lined-up and commenced take-off roll on Canberra Airport’s runway 30, rather than the assigned runway 35
  • Flight crew advised they were ready for take-off before checks were complete

 

A Virgin Australia ATR72 inadvertently lined-up on the wrong runway at Canberra Airport for a night time departure, a new ATSB report details.

The flight crew of the 25 September 2019 flight to Sydney had elected to depart Canberra Airport’s runway 35 from intersection G (‘Golf’), based on aircraft performance considerations, environmental conditions and the short distance between their parking bay and the runway holding point.

While taxiing to the holding point at intersection Golf, the flight crew completed their departure review. Just before reaching the holding point, the flight crew advised ATC they were ready for take-off. After clearing the aircraft for take-off, ATC deactivated the stop bar and the lead-on lights were illuminated. The aircraft then crossed the holding point and started turning through the intersection and inadvertently lined-up with the centreline of runway 30, which is considerably shorter in length than runway 35.

ATC saw the aircraft moving on runway 30 and immediately instructed the flight crew to stop. At about the same time, the flight crew rejected the take-off.

A review of airport closed-circuit television and recorded flight data showed the aircraft lined-up on runway 30, paused and then briefly accelerated and braked suddenly. The aircraft then exited the runway and departed from intersection ‘N’ (November) for runway 35 as per ATC instructions, without further incident.   

Acting ATSB Director Transport Safety, Kerri Hughes said that using intersection Golf for runway 35 meant the flight crew only had about 90 seconds to complete the preparatory tasks for departure. This resulted in the flight crew advising ATC they were ready for take-off prior to completing the before take-off procedure.  

“The first officer reported being focused on the before take-off checks as they approached the holding point, while the captain was focussed on the runway lead-on lights,” Ms Hughes said.

“The challenge and response nature of the before take-off procedure would have required some of the captain’s focus. This likely resulted in the captain taxiing the aircraft through the intersection with divided attention, while the first officer’s attention was focussed inside the cockpit.”

Ms Hughes explained that intersection Golf leads to the intersection of the Canberra Airport's two runways, 12/30 and 17/35, and is listed in airport documentation as a known runway incursion hotspot due to this complex layout. There are few airports in Australia where a taxiway leads to the intersection of two runways.

Further, when the stop bar at intersection Golf was deactivated, the lead-on lights to both runway 30 and 35 were illuminated, increasing the risk of confusion.

“The complexity of some airport runway and taxiway layouts can be exacerbated by reduced visibility conditions, such as at night or in poor weather, which can easily increase flight crew confusion,” Ms Hughes said.

“This investigation highlights the need for flight crews to familiarise themselves with complex runway layouts, particularly any unique designs, and ensure effective flight crew co-ordination is employed to minimise the risk of a runway incursion.”

The investigation also found that Virgin Australia’s ATR72 before take-off procedure did not specify when the crew were to advise ATC they were ‘ready’ for take-off . Further, runway verification checks using external cues were not included in procedures for all their aircraft. 

“The ATSB notes that, while Virgin Australia no longer operate the ATR72 aircraft, they have developed a new runway verification procedure for inclusion in their Flight Crew Operating Manual for their Boeing 737 fleet.”  

Read the investigation report AO-2019-055: Runway incursion and take-off commenced on incorrect runway involving GIE Avions de Transport Régional ATR72, VH‑VPJ Canberra Airport, Australian Capital Territory, on 25 September 2019

Last update 11 December 2020

Final report

AO-2019-055: Runway incursion and take-off commenced on incorrect runway involving GIE Avions de Transport Régional ATR72, VH VPJ Canberra Airport, Australian Capital Territory, on 25 September 2019