Operational non-compliance involving a Boeing 747-400, 9M-MPB, Sydney, New South Wales, on 6 February 1994

199400425

Summary

ASOR Summary

The aircraft was to depart via a Wollongong One Standard Instrument Departure (SID) after taking off from runway 16. After this instruction had been passed to the aircraft, the duty runway was changed to runway 07. This information was passed to the aircraft along with the instruction that the Wollongong One SID was to be flown. (The Wollongong One SID from runway 16 is different to the Wollongong One SID from runway 07.) In the event, the aircraft was observed on radar after take-off from runway 07 to commence to fly the Wollongong One SID applicable to runway 16. The aircraft was then instructed to track direct to Wollongong.

Safety Action

The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:

(a) review the presentation of standard departure instructions in order to ensure that they are clearly laid out to make them easily assimilated, and

(b) review the instructions for each runway so that they are contained on individual charts or, are clearly delineated on each chart.

Occurrence summary

Investigation number 199400425
Occurrence date 06/02/1994
Location Sydney
State New South Wales
Report release date 11/08/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-400
Registration 9M-MPB
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Melbourne VIC
Damage Nil