An ATSB final report details how features of the airport runway and taxiway contributed to three separate misaligned take-off incidents before first light from Perth Airport’s runway 06.
On 12 June 2023, a Virgin Australia Boeing 737-800 entered Perth’s runway 06 via taxiway V from the south, the investigation report details. As the aircraft turned onto the runway, the crew inadvertently went past the centreline and aligned with the left-hand runway edge lighting.
After this, in two occurrences on 10 August 2023 and 4 April 2024, a Cessna Conquest 441 charter aircraft also entered runway 06 via taxiway V, but from the north. It also turned beyond the centreline, aligning with the right-hand runway edge lighting.
No damage was reported in the first incident involving the 737. During the take-off roll, the crew identified they were misaligned, and manoeuvred to the centreline, continuing the take-off and flight to Sydney without further incident.
During the second incident, the Cessna 441 pilot detected an impact with the aircraft and returned to land in Perth. Subsequent inspection found no aircraft damage, but several damaged runway edge lights.
In the third incident, the Cessna 441 pilot – a different pilot to the prior occurrence but in the same aircraft – heard an unusual noise, but believed it originated from outside the cabin, so continued their take-off and flight to Southern Cross. A runway inspection later that morning found several damaged runway edge lights and, after returning to Perth, the pilot identified minor damage to the aircraft’s right engine propeller.
ATSB Director Transport Safety Kerri Hughes said in all three incidents there were common contributing factors that increased the risk of misaligned take-offs.
“All three occurred before first light, exacerbated by factors specific to runway 06/24, which unlike Perth’s main runway, does not have centreline lighting,” Ms Hughes noted.
“There was also an unlit and unmarked pavement area on each side of the runway, making it appear wider, and the lead-on lights from taxiway V continued across the taxiway to the other side, meaning there was limited guidance when taxiing to the runway centreline.”
After the first two occurrences, Perth Airport submitted a notice to Airservices Australia requesting an update to the Aeronautical Information Publication to highlight the misaligned take-off risk on runway 06. This update was made effective in November 2023.
The airport has also painted chevrons on the extra pavement on either side of runway 06 to delineate this area from the useable runway.
Ms Hughes noted one factor specific to the first incident involving the 737, was the flight crew reported their attention was diverted to completing pre-take-off tasks and their take-off clearance, while lining up on the runway.
Following that occurrence, Virgin Australia revised its before take-off procedure to reallocate tasks earlier in the taxi to reduce flight crew workload during line-up.
The airline also added caution notes to its Perth Airport supplementary port information about centreline misidentification on runway 06, and developed case studies involving this event, which were incorporated into non-technical skills training.
The operator involved in the latter two occurrences, Western Sky Aviation, distributed notices to its flight crew, including strategies to check runway alignment prior to take-off.
“The features of airport runways and taxiways can vary, and at times the combination of these features can increase the risk of runway misalignments,” Ms Hughes said.
“This can be exacerbated at night-time, when the amount of visual information available is markedly reduced. These reduced visual cues can affect pilots even when they are familiar with an airport.”
The ATSB’s final report also encourages pilots to report any circumstances where they believe they may have conducted a misaligned take-off, to limit the risk to their aircraft and others subsequently using the same runway.
“This would also allow aerodrome operators to identify any trends or emerging misaligned take-off hotspots, and consider mitigations,” Ms Hughes concluded.
Read the final report: Misaligned take-off occurrences on runway 06 at Perth Airport, Western Australia