Key points:

• Shortly after take-off at about 500 ft AGL engine power reduced to below idle
• Power loss probably due to undetected water contamination in fuel
• Chemical hopper was used as a ferry fuel tank without approved or documented engineering process

A Piper PA-36 aerial application aircraft forced landed in a paddock shortly after take-off after experiencing an engine power loss that was probably the result of water-contaminated fuel, an ATSB investigation has found.

The Piper PA-36-300 Pawnee Brave aircraft, which had been fitted with a PT6A turbine engine, had just departed Latrobe Regional Airport, Victoria on 12 August 2019 on the first leg of a ferry flight on delivery to a new owner in New Zealand.

The day before the accident flight the pilot had detected water in the fuel in the chemical hopper – which, consistent with common industry practice, was being used as a ferry fuel tank. The pilot drained and refuelled the hopper before conducting a second fuel drain check. Then on the day of the accident flight, the pilot’s pre-flight inspection included a fuel drain check, checking the fuel by sight and smell, with no water detected.

The aircraft subsequently departed Latrobe Airport’s runway 21, turning to the north and staying below overcast cloud at around 500 feet AGL. As take-off flap was raised and departure course was set, engine power unexpectedly reduced to below idle.

With the aircraft unable to maintain height, the pilot elected to conduct a forced landing in a paddock. During approach, the pilot detected power lines and elected to fly below them but the aircraft struck and cut a smaller unseen power line running beneath the main power lines. The pilot then intentionally conducted a hard landing to avoid hitting a fence in the middle of the paddock while airborne.

During landing, the right wing struck a fence post resulting in the separation of the outboard wing section, while the undercarriage was removed after striking several tree stumps. The pilot sustained minor injuries in the impact.

ATSB Director Transport Safety Stuart Macleod said the loss of engine power was probably due to water‑contaminated fuel.

“A significant quantity of water was found in the aircraft’s fuel system, including the airframe fuel bowl, fuel pump and the fuel control unit, while an off-white jelly substance in the fuel section of the fuel control unit may have also hindered fuel flow to the engine,” Mr Macleod said.

While the pilot had conducted a fuel drain check pre-flight, the ATSB notes that using an opaque fuel sampling container and relying on sight and smell to determine fuel quality can be unreliable.

“Checking for water in fuel using an opaque sampling container to sight and smell the fuel is not in accordance with Civil Aviation Safety Authority and US Federal Aviation Administration guidance for pre-flight testing, and does not assure that there is no suspended water droplets, which is a particular risk for turbine fuel,” Mr Macleod said.

“Instead, there are a number of methods to positively check for the presence of water, such as using water-detecting paper or paste.” 

The ATSB’s investigation also found that that the use of the chemical hopper as a ferry fuel tank was contrary to the aircraft manufacturer’s recommendation, and that no approved technical data was available for the modification.

“Using approved and documented engineering processes to make changes to safety-critical aircraft systems ensures the modification complies with applicable airworthiness standards or an equivalent level of safety,” Mr Macleod noted.  

The accident also illustrated the importance of being mentally prepared for an emergency, particularly an engine failure or a power loss in a single-engine aircraft, Mr Macleod explained.

“In this case, the pilot had secured the four-point harness over their flying suit prior to take-off, and had conducted a pre-take-off brief and so was prepared to take immediate action in the event of an engine power loss.”

Read the final report: Engine power loss involving Piper Aircraft Inc. PA-36, VH-TVU, near Latrobe Valley Airport, Victoria, on 12 August 2019

Key points:

• Coal train wagon derailed due to through-axle failure of an axle
• Derailed wheelset travelled 2.6 km before train came to a stop
• Operator conducted non-destructive testing of affected axles

Rail infrastructure including 4,350 sleepers were damaged when the wheelset of a wagon of a fully loaded coal train derailed near Moss Vale due to fatigue cracking, a new transport safety investigation report says.   

The coal train TM94, consisting of three locomotives and 45 wagons, had departed Tahmoor Colliery for Port Kembla in the early hours of 28 June 2019. As the train approached the Suttor Road level crossing the 14^th wagon’s L1 axle bearing journal separated from the rest of the axle, resulting in the wagon’s R2 wheel derailing. As there was no loss of brake pressure the train continued, with the train crew initially unaware that a derailment had occurred.

As the front of the train passed through the Suttor Road crossing at 12:42 am, a rail enthusiast who was filming the train saw sparks and heard a loud noise coming from the wheelset and contacted the Network Control Centre South at Junee. At 12:44 am, the Junee area controller requested the train crew to stop and check the train. The train came to a stop minutes later, about 2.6 kilometres past the point of derailment, by which point approximately 4,350 concrete sleepers and the concrete pad at the Suttor Road crossing had been damaged.

A transport safety investigation into the incident conducted on behalf of the ATSB by the New South Wales Office of Transport Safety Investigations (OTSI) found that the derailment was due to a through-axle fracture at the start of a radius transition, about 250 mm from the end of the axle.

The report notes that although no clear initiation point for the fatigue crack was visible, a discoloured area, extending 16 mm into the cross section, was the likely the initiation point and that cracking was likely present at the time of two separate wheelset maintenance activities in January and November 2016 and would have been detected had non-destructive testing been carried out on the wheelset.

There was no evidence to suggest that the actions of the train crew contributed to the derailment.

“This investigation highlights the need for rolling stock operators and maintainers to ensure that axle maintenance and inspection procedures include non-destructive testing of known defect areas are as part of their regular maintenance program,” said OTSI CEO and Chief Investigator Mick Quinn.

“Records of these inspections also need to be kept within their asset management system for the life of the asset.”  

To ensure that no axles pose an immediate risk of failure, the operator has completed a program in-situ of non-destructive testing of axles, including ultrasonic testing of all 7E5S axles.

The operator has also issued a Rolling Stock Notice to their wheel set overhaul contractors reinforcing the requirement to inspect and test the fillet radius for all axles where bearing removal is mandated.

Read the final report: Derailment of loaded Pacific National coal service TM94, near Moss Vale, New South Wales, on 28 June 2019

Key points:

• Duty controller granted track access to maintenance electrician during shunting
• Required protection flags were not placed on the train
• Elements of the operator’s safety management system had little scope to recover once human or procedural error occurred

A maintenance electrician was inadvertently briefly beneath a moving train wagon during a shunting operation at the Skitube Alpine Railway’s Bullocks Flat Terminal, a new ATSB investigation report details.

The electrician was uninjured during the 3 July 2019 incident, which occurred during a scheduled de-coupling of a four carriage Skitube train set into two two-carriage sets at the Bullocks Flat Terminal, New South Wales. Just before the carriage started moving the electrician heard the brakes release and moved against the wall under the platform, clear of the train, the report details.

The transport safety investigation into the incident, which was classified as a ‘near miss’, was carried out by the Office of Transport Safety Investigations (OTSI), which conducts rail incident investigations in New South Wales on behalf of the ATSB, found that the duty controller had granted access to the electrician during shunting activity on the track. 

“It is likely that the duty controller did not connect that the shunting operation and the electrician accessing the track was occurring at the same time, due to other activities occurring in the control room, including the visit of an off-duty controller,” noted acting OTSI Chief Investigator, Mick Quinn.

“In addition, the electrician did not apply the required protection flags to the train set to indicate that work was being conducted on the train.”

The investigation also found that Skitube’s safety management system was reliant on procedures being followed to manage safety risks and that there was little scope for the system to recover once there had been a human or procedural error.

“In this instance, the operator’s safety management system did consider the likelihood of the duty controller making an error and provided two secondary layers of control, the control room logbook and the temporary access track form, however these did not provide any greater awareness of a pending conflict for the controller,” Mr Quinn continued.

“Also, the placement of protection flags does not ensure energy to a train is isolated and that the train cannot be moved while it is being worked on.” 

The investigation highlights the importance of workers ensuring they are protected and that they follow safety procedures before entering the danger zone or when interacting with trains, Mr Quinn said.

“Safety management systems also need to identify when conflicting activities take place that increase the risk to workers, and organisations should assess their risk controls to ensure their safety systems are error-tolerant and have a second line of defence to protect workers,” he said.

Since the near miss, Skitube updated its temporary track access procedures. That included its red flag procedure – including lowering the pantograph, applying the brakes, removing keys and locking the driver’s cab, and placing a “Do Not Operate” tag on all driver’s cabs when a person is required to be in close proximity to a stationary train – which was formalised and documented as a discrete procedure.

Read the final report: Near miss with maintenance worker on Skitube Alpine Railway, Bullocks Flat, New South Wales, on 3 July 2019

Key points:

• Pilot of a PA-28 light aircraft did not sight an ATR airliner, which the controller had instructed them to follow
• PA-28 turned in front of the ATR, resulting in a near collision
• Pilots on both aircraft made incorrect assumptions about both each other’s movements
• Controller did not seek confirmation from the PA-28 pilot that they understood the instruction to follow the ATR

A near collision where a Piper PA-28 training aircraft turned in front of an ATR72 regional airliner, reducing separation between the two aircraft to about 110 metres horizontally and 75 feet vertically, illustrates the dangers of making assumptions and having incomplete situational awareness, an ATSB investigation highlights.

The Australian Airline Pilot Academy-operated PA-28, with a single student pilot on board, was conducting a navigation exercise to Albury from Wagga Wagga, NSW as part of the commercial pilot licence syllabus. On approach to Albury, air traffic control cleared the pilot to enter Albury (Class D*) airspace from the north. At the same time, a Virgin Australia Airlines ATR72 with two pilots, two cabin crew and 66 passengers on-board, was approaching Albury from the north-east, conducting a straight-in approach.

After the PA-28 had joined the downwind circuit leg for a touch-and-go landing on Albury’s runway 25, air traffic control informed the PA-28 pilot that ‘…you’re number two following an ATR on about a four‑mile final, report traffic in sight’.

The pilot acknowledged the instruction with the aircraft’s callsign, but did not read back any part of the instruction.

The controller later advised the ATSB that, due to their attention being focussed on a third aircraft, they were not monitoring the PA-28 as the aircraft continued on downwind and turned on to the base leg of the circuit. At that point the PA-28 pilot had not sighted the ATR nor advised the controller that they did not have it sighted.

Passing through approximately 600 feet above ground level, the ATR crew received a TCAS (traffic collision avoidance system) TA (traffic advisory) alert. They quickly identified the PA-28 below them and immediately commenced a missed approach.

The controller later reported not observing the near collision, and only shifted their attention back to the two aircraft when the ATR crew reported the missed approach. The controller advised that, as the ATR was already conducting a missed approach, they did not issue a safety alert.

The PA-28 pilot, meanwhile, advised the ATSB that when the ATR was first sighted it was so close that they lowered the nose of their aircraft to increase separation. The pilot recalled carrying out normal visual checks to ensure the base and final legs were clear, but did not look along the long final flightpath, assuming that the ATR, which had been cleared to land before the PA-28 joined downwind, was either on short final or had landed.

“As the PA-28 was operating under visual flight rules, separation between the two aircraft was the pilots’ responsibility, and the pilots on both aircraft made incorrect assumptions about both each other’s movements, rather than taking positive action to confirm that adequate separation would be maintained,” said ATSB Director Transport Safety Stuart Macleod.

“In addition, the air traffic controller had recognised the potential conflict and implemented a plan to sequence the aircraft’s arrival, however, the controller did not seek confirmation from the PA-28 pilot that they understood the instruction to follow the ATR.”

As well as finding that the PA-28 pilot did not sight the ATR, and did not advise the controller that they did not have the aircraft in sight before turning in front of the ATR, the ATSB’s investigation found the ATR flight crew were aware there was traffic in the area but did not assess the position of the PA-28 until the TCAS traffic advisory alert activated, Mr Macleod noted.

In addition, the investigation found that the controller did not identify the developing near collision as they were not effectively monitoring the aircraft in the circuit area due to their attention being focussed on another aircraft.

“The circumstances of this near collision incident illustrates the danger of assumption and incomplete situational awareness,” Mr Macleod said.

A number of safety actions have stemmed from the occurrence and the ATSB’s investigation, Mr Macleod noted.

“Virgin Australia and Airservices Australia have commenced discussions to convene a cross industry stakeholder meeting to include operators, the Civil Aviation Safety Authority, the ATSB and the broader industry to discuss the ongoing risk to operations at non‑controlled and Class D airports, such as Albury.”

Separately, AAPA conducted an internal investigation and implemented a number of additional risk controls, including the introduction of regular face-to-face seminars between controllers at Albury Tower and new students to explain operations in Class D airspace before students complete their first solo flight to Albury.

Read the final report: Near collision between Piper PA-28, VH-XDI and ATR72, VH-FVR, Albury Airport, New South Wales, on 19 October 2019

* Apart from runway operations, there is no separation standard required between VFR and IFR aircraft operating in Class D airspace, but flight crew are required to follow the instructions provided by controllers. An instruction given by a controller is to prevent collisions, however, separation between aircraft is the responsibility of flight crew. While not applying separation standards, controllers use separation methods to ensure aircraft do not conflict. Additionally, traffic information should be passed in situations where the controller considers pilots may be uncertain of the intentions of a second aircraft.

Key points:

• Cessna 152 entered a steep dive after student pilot released control wheel during pitch trim demonstration
• Instructor sustained minor injuries and aircraft sustained structural damage during recovery
• Instructors need to account for the potential for students to carry out unexpected actions

A Cessna 152 abruptly pitched down and entered a steep dive when a student pilot released the aircraft’s control wheel during a demonstration of the effects of control and the use of trim, an ATSB investigation details.

The Basair Aviation College-operated Cessna 152 had departed Brisbane’s Archerfield Airport on 28 May 2019 with a student pilot on their first flight and an instructor on board to demonstrate manoeuvres from the effects of control flight training syllabus.

With the student flying, the aircraft was approaching overhead Lagoon Island south-east of Brisbane at about 2,000 feet above ground level when the instructor moved the pitch trim to about two-thirds travel nose down while the student maintained attitude with nose-up pressure on the control wheel.

“When returning the elevator trim to neutral, the student became confused about the correct procedure and suddenly released the control wheel and the aircraft rapidly pitched nose-down, rolled left, and entered into a dive,” said ATSB Director Transport Safety Dr Mike Walker.

“The instructor took control of the aircraft and arrested the descent 25 seconds later, at about 400 feet. Flight radar data showed the aircraft experienced an average descent rate of over 3,000 feet/minute.”

The instructor, who sustained minor injuries, then terminated the lesson and returned to Archerfield. 

A post-flight examination of the aircraft identified significant structural damage with bending and buckling of the right horizontal stabiliser structure, likely due to excessive asymmetric flight loads from the dive recovery.

“The instructor’s use of a large amount of nose-down elevator trim for the lesson increased the effect when the student released backpressure on the elevator, leading to a sudden nose-down pitch change and subsequent entry into a dive,” Dr Walker said.

The investigation report notes that the flying school’s instructor guide did not specify a limit of trim input for such exercises.

“The ATSB also determined that the instructor’s hands were not in a ready position to take control in the event of any mishandling by the student pilot,” Dr Walker said.

“The recovery by the instructor was likely further delayed after sustaining a head injury during the in-flight upset, and initially being unsure about what had happened and how to then recover the aircraft.”

Following the incident the flying school operator revised its training procedures to include detailed instructor demonstrations prior to student practice of effects of control manoeuvres, and to ensure the use of a consistent moderate amount of trim following the incident.

“The first stages of flight training can be both exciting and daunting and this incident serves to remind student pilots to raise with their instructor any uncertainties they have over procedures,” Dr Walker stated.

“Conversely, instructors need to account for the potential for students to carry out unexpected actions. This means that lessons should be conducted under the lowest risk conditions that still impart the lesson intent.”

Read the final report: Loss of control involving Cessna 152, VH-JIW, 34 km east-south-east of Archerfield Airport, Queensland, on 28 May 2019

Key points:

• The helicopter’s rotor RPM began to decay and the pilot initially did not apply full throttle
• The pilot attempted a forced landing, but was unable to arrest the rate of descent, resulting in a hard landing and injuries
• Low rotor RPM may develop in various flight conditions, but it is the low airspeed-low height condition that is most likely to result in an accident

The Australian Transport Safety Bureau (ATSB) reminds all helicopter pilots to be prepared and respond immediately to low rotor RPM warnings, following the investigation into the collision with terrain of a Robinson R44 helicopter south of Ayers Rock Airport, Northern Territory, on 17 January 2018.

Shortly after departing the Yulara Town helipad for a 15-minute scenic flight with the pilot and three passengers onboard, the helicopter’s rotor RPM began to decay and the low rotor RPM warning activated. Following this warning, the pilot initially did not apply full throttle (for at least 5 seconds), and lower the collective lever sufficiently to stop the helicopter climbing.

The helicopter continued flight for about another 90 seconds, climbing to about 200 feet at a low airspeed. This resulted in the rotor RPM decaying further to a level from which the pilot could not recover. The pilot attempted a forced landing, but was unable to arrest the rate of descent, resulting in a hard landing. The pilot and two passengers were seriously injured, with the third passenger sustaining minor injuries. The helicopter was substantially damaged.

Transport Safety Investigators found that the take-off was conducted at a high density altitude at near maximum weight. Therefore, a high engine manifold pressure (MAP) would be expected for the take-off. However, passenger video evidence indicated the rotor RPM decay started at a relatively low MAP, and that the MAP increased slowly as the RPM steadily decayed.

The ATSB’s investigation concluded that the helicopter's rotor RPM steadily decayed due to a likely limited opening of the engine throttle during take-off. Fine-tuning of the engine throttle is controlled automatically by the engine governor, but it can be manually overridden by the pilot. The reason for the limited opening of the throttle could not be determined.

“Low rotor RPM may develop in various flight conditions, but it is the low airspeed-low height condition that is most likely to result in an accident,” acting Director Transport Safety Kerri Hughes said.

“Helicopter pilots should ensure they are familiar with the power curve, the associated airspeeds for their particular helicopter, and be prepared to respond immediately to a low RPM warning.”

Further, the investigation established that the pilot had inadvertently adopted a practice of conducting rotors running turn-arounds (for passenger transfers) with the governor switched off. This was not in accordance with the manufacturer’s checklist requirement for the governor to remain on from start until shut-down, nor the operator’s procedure for the governor to be selected on for the engine run-up.

“Although the pilot reported that the governor was selected on and checked before lift-off, this practice increased the risk of an inoperative governor not being detected before take-off,” Ms Hughes said.

The operator, Professional Helicopter Services, used individual passenger weights for their loading calculations, which was considered best practice. However, it was found that the operator’s passenger scales were not calibrated and were under-reading the actual occupant weights.

“This resulted in the helicopter operating at a higher weight than planned, but less than the maximum weight,” Ms Hughes said.

“While the operating weight was within the published limits, the under-reading scales increased the risk of their helicopters not achieving their take-off performance.”

The ATSB has issued a safety recommendation to the Robinson Helicopter Company to review the R44 pilot's operating handbook low rotor RPM recovery procedure for consideration to include a reference to the minimum power airspeed (Vy) for pilot awareness. Robinson reported that this will be reviewed by engineering staff for possible revision to the pilot operating handbook.

Read the final report: Main rotor speed decay and forced landing involving Robinson R44, VH-HGX, 5 km south Ayers Rock Airport, Northern Territory, on 17 January 2018

Key points:

• Train driver commenced braking slightly earlier than would normally be the case due to the wet and windy weather conditions
• Train passed through crossing at 93 km/h and collided with level crossing gates, after being unable to stop at Ballarat Station
• Investigation is on-going

A VLocity passenger train was travelling at 93km/h when it struck and destroyed heritage-listed swing level crossing gates at Ballarat, Victoria on 30 May 2020, a preliminary report confirms.

The V/Line VLocity passenger train, with a train driver, conductor and two passengers on-board, was operating an evening service from Melbourne’s Southern Cross Station to Wendouree in Ballarat’s west when it was unable to come to a stop at Ballarat Station, the preliminary report from the on-going transport safety investigation details.

“Departing Ballan, the driver began to experience wheel slip events during powering and as the journey progressed, experienced instances of wheel slide during braking,” said Chris McKeown, Victoria’s Chief Investigator, Transport Safety (CITS).

These wheel slip events triggered the train’s Wheel Slip/Slide Protection (WSP) system, which activates when a train’s powered axles are rotating faster than its non-powered axles.

If a wheel slide occurs during braking, brake cylinder pressure is reduced to regain the right braking effort for the available wheel adhesion and sand is applied to the rail to improve wheel traction.

“On the approach to Ballarat, the driver reported having commenced braking slightly earlier than would normally be the case due to the wet and windy weather conditions,” Mr McKeown said.

The train’s event recorder detected braking being initiated with the train 4.9 km from Ballarat Station and the train travelling at approximately 160 km/h, followed by indications of wheel-slide and a series of brake applications and activation of the train’s sanding valve.

“An emergency brake application was applied 235 metres before the train’s intended stop at Ballarat Station,” Mr McKeown said.

“The train travelled through Ballarat Station at 100 km/h and passed a Departure signal at Stop as it headed towards the Lydiard Street North crossing.”

One second before the train passed through the crossing, the crossing’s road traffic lights changed from green to flashing amber. However, the gates were still across the track rather than protecting the crossing from road traffic when struck by the train.

CCTV footage showed that approximately 49 seconds before, a group of three pedestrians passed over the crossing.

The train subsequently passed through the Doveton Street level crossing and came to a stop approximately 600 metres west of its intended stopping point. A passenger who had been standing near an exit door as the train approached Ballarat Station sustained head, back, and leg injuries, and was taken off the train by emergency services and admitted to hospital.

“The on-going investigation will examine a range of factors including operation and maintenance of VLocity sanders, track condition, dynamic performance of the braking system, train operation and performance,” Mr McKeown noted.

Subsequent to the accident, testing identified performance issues with the VLocity 3VL70 train’s sanding system and manufacturer Bombardier has subsequently undertaken fleet-wide testing of VLocity sanders and performed remedial action where required.

Mr McKeown noted that the investigation’s preliminary report does not contain findings, identify contributing factors or outline safety issues, which will be detailed in the final report.

The Chief Investigator, Transport Safety (CITS) conducts rail investigations in Victoria on behalf of the ATSB under the Transport Safety Investigation Act 2003.

Read the preliminary report: Collision of passenger train 8185 with level crossing gates, Lydiard Street North, Ballarat, Victoria, on 30 May 2020

Key points:

• 737 taxied toward active runway; second 737 rejected take-off
• Taxiway location and design significantly increased the risk of a runway incursion
• Runway incursions are a significant risk to safe aviation operations and a key global safety priority

The crew of a Boeing 737 had to reject their take-off roll when a second 737 did not stop at a holding point and passed through an illuminated stop bar after landing at Perth Airport, an ATSB investigation report details. 

On 28 April 2018, a Qantas Boeing 737, registered VH-XZM, landed on runway 03 at Perth, exiting the runway onto taxiway J2, which led to a holding point for crossing runway 06. The aircraft did not stop at the holding point and crossed an illuminated stop bar (a set of lights embedded across the taxiway surface) without an air traffic control clearance.

At that time, a second Qantas 737, VH-VZL, had commenced its take-off roll from runway 06. An automated warning within the Perth air traffic control tower alerted the aerodrome controller (ADC) of the stop bar violation and the controller issued an instruction for the departing 737 to ‘stop immediately’.

Soon after, the flight crew of VH‑XZM became aware of their position and stopped their aircraft just before crossing the edge of runway 06. VH-VZL’s wingtip passed about 15 metres from VH-XZM’s nose at low speed just before coming to a stop.

Among other findings, the ATSB found that the captain of VH-XZM was not expecting to cross runway 06, having developed an incorrect mental model of their location and thinking the aircraft was on taxiway J1 which led directly to the terminal area.

“Due to this incorrect mental model, and a combination of workload and distractions at key times, the flight crew did not detect the runway crossing issue until their aircraft had almost reached the edge of runway 06,” said ATSB Director Transport Safety Dr Mike Walker.

Taxiway J2 was the preferred runway exit for jet aircraft landing on runway 03, the ATSB’s investigation report notes.

“The location and design of the taxiway significantly increased the risk of a runway incursion onto runway 06/24,” Dr Walker said.

“The relatively shallow intersection angle with the runway and wide turn radius meant pilots were more likely to take the exit at a higher speed, and this combined with the short distance to the holding point gave pilots less time to see the illuminated stop bar lights at the runway holding point and stop.”

Although the junction around taxiway J2 was identified as a ‘hot spot’ on aerodrome charts, there was no detailed information about the reasons for it.

Also, Qantas did not specifically require pilots to brief hot spots during departure and approach briefings.

In response to the runway incursion, Airservices Australia made taxiway J2 unavailable for use, and Perth Airport subsequently removed taxiway J2 from aerodrome charts.

In addition, Airservices changed the settings of an alerting system to ensure tower controllers at Perth Airport performing multiple roles received appropriate aural and visual alerts at their workstation.

“Runway incursions are one of the most significant risks to safe aviation operations and a key global safety priority,” Dr Walker said.

“Airport operators and local runway safety teams are strongly encouraged to identify and mitigate the risk of hot spots, especially those that involve short distances between runways, complicated junctions, and the potential for higher taxi speeds.”

Since the incident, Qantas published a safety information notice to all pilots containing information about the background of runway incursions. The airline also updated its Flight Administration Manual to include a requirement for pilots to brief relevant airport hot spots and their contingency planning to mitigate against the possibility of collision or runway incursion.

“Pilots can help prevent incursions by identifying runway hot spots during departure and approach briefings, and discussing the actions they will take to reduce the risk of a runway incursion,” Dr Walker said. 

“The ATSB also strongly encourages air traffic controllers to provide safety alerts and/or clear instructions – such as ‘stop immediately’ – to the flight crews of all aircraft involved in runway incursions and related occurrences.”

Dr Walker noted that the aerodrome controller and flight crew of VH-VZL exhibited a high level of situational awareness to respond to the incursion.

Read the final report: Runway incursion involving Boeing 737, VH-XZM, resulting in a rejected take-off involving Boeing 737, VH-VZL, Perth Airport, Western Australia, on 28 April 2018