Guidance updated after airliner overruns wet Newman runway

Key points:

• Aircraft was conducting a higher than normal speed approach due to winds and turbulence;
• Runway was wet with active rain, reducing braking effectiveness;
• Aircraft came to a stop beyond the runway threshold, but inside the runway end safety area.

Operator and regulator guidance has been updated after a Fokker 100 airliner overran a wet runway at Newman Airport last year, an Australian Transport Safety Bureau investigation notes.

The ATSB investigation into the 9 January 2020 incident found the combination of the higher than normal approach speed required due to the prevailing winds and poor braking effectiveness on a wet runway resulted in the aircraft overrunning runway 05 at Newman Airport, in Western Australia’s Pilbara region.

The aircraft, with five crew and 88 passengers on board, was conducting a regular public transport service from Perth. It was operated by Network Aviation, a subsidiary of the Qantas Group.

The weather forecast for Newman Airport on the morning of the incident included heavy rain, moderate to severe turbulence below 5,000 feet, and a 25 knot crosswind. The airport had received about 88 mm of rainfall since 0900 the previous day.

“Despite assessing the weather as a threat, during their approach briefing the flight crew did not identify the potential effect of the rainfall on the stopping distance,” ATSB Director Transport Safety Stuart Macleod said.

Instead, their discussions were focussed on the cloud base and the visibility required to conduct the approach, the expectation of windshear, turbulence and the strong crosswind.

The flight crew followed guidance for the expected turbulence, selecting a flaps 25 approach, and maintained a faster than normal approach speed.

The aircraft touched down at or before the touchdown zone at an airspeed of 154 knots.

“The aircraft did not slow after crossing the runway threshold, or during the flare, and a higher groundspeed than airspeed was recorded, indicating a possible unforecast tailwind component,” Mr Macleod noted.

During the landing roll, the aircraft then did not decelerate as expected. Recorded flight data showed this low deceleration, along with directional oscillations, was consistent with aquaplaning.

The captain, sensing the aircraft aquaplane, applied the aquaplaning response technique to maintain directional control and subsequently commanded maximum reverse thrust. The aircraft came to a stop 70 metres beyond the runway threshold, but inside the runway end safety area.

There were no injuries to crew or passengers, while an inspection of the aircraft found that some components of the landing gear sustained minor damage from loose gravel.

“Given the magnitude of this overrun it is highly likely that had the landing speed been reduced, or the braking effectiveness had been normal, or there had been less crosswind, the overrun would not have occurred,” Mr Macleod said.

The ATSB found at the time of the incident neither the operator nor the regulator had guidance to allow flight crews to recognise the conditions at the time as a hazard to the operation.

“While Network Aviation policy did not approve operations on contaminated runways, there was limited documented guidance on how to determine if the runway was contaminated, and moderate or heavy rain were not identified as possible runway contaminants,” Mr Macleod explained.

The ATSB also found that prior to the occurrence, the runway had been examined and found to be requiring maintenance to ensure an adequate level of surface friction, however no maintenance was performed.

Following the overrun, the operator circulated additional guidance and procedures to flight crew for identifying runway water contamination and to ensure appropriate speed control on approach and landing.

The Civil Aviation Safety Authority has also since published guidance, reflecting research from the US Federal Aviation Authority, that found landing on ungrooved runways in moderate rain has the potential to significantly affect braking performance.

“Moderate to heavy rainfall is one of many factors that can influence the stopping distance of an aircraft,” Mr Macleod said.

“Water on an ungrooved runway can significantly reduce the ability of an aircraft to slow down.”

Operators and pilots are encouraged to review the latest guidance and tools available in relation to maintaining safety on runways and the factors that cause runway overruns, Mr Macleod continued.

“In wet weather, additional conservatism is encouraged when calculating the required landing distances.”

​Read the final report: Runway overrun involving Fokker F100, VH-NHY, Newman Airport, Western Australia, on 9 January 2020

ATSB preliminary report from on-going investigation into fatal accident involving a Cessna 150 light aircraft during aerobatic flight training released.

The ATSB has released a preliminary report from its on-going investigation into a fatal accident involving a Cessna 150 light aircraft during aerobatic flight training near Peachester, South East Queensland, on 23 June 2021.

The report, which details factual information from the investigation’s early evidence collection phase, notes the Cessna A150M Aerobat had departed Sunshine Coast Airport with an instructor and student aerobatic pilot on board with the intention of conducting spin recovery training. The aircraft arrived overhead the locality of Peachester, the area intended to conduct aerobatics, about 20 minutes later.

Air traffic control radar data from the last 90 seconds of the aircraft’s flight shows the aircraft turned left and decelerated while maintaining an altitude of 6,000 feet, before beginning to descend rapidly. Shortly after it impacted a dense stand of trees.

The aircraft was destroyed, and the two occupants were fatally injured.

ATSB transport safety investigators’ examination of the wreckage and accident site determined the aircraft was intact prior to the collision.

Calculations of tree impact points along a 50 metre wreckage trail indicated the final flight path was a descent of about 13°. The throttle setting was at idle, and propeller rotational damage signatures were minimal, indicating a low power setting.

“The disruption to the aircraft and foliage, coupled with the length of the wreckage trail, indicated that the aircraft had significant forward speed at impact,” ATSB Director Transport Safety Dr Mike Walker said.

No evidence was found of pre-impact defects with the flight controls or aircraft structure, and external examination revealed no obvious defects with the engine.

Dr Walker noted the preliminary report does not include any safety findings or analysis, which will be detailed in the investigation’s final report.

“As the investigation continues, the ATSB will interview parties involved with the aircraft’s operation, further analyse the radar data, examine the pilots’ qualifications, experience and medical histories, and review aircraft records,” he said.

“Spin training requirements and practices will also be assessed.”

A final report will be published at the conclusion of the investigation.

“However, should a critical safety issue be identified at any time during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken,” Dr Walker concluded.

Read the preliminary report: Collision with terrain involving Cessna A150M, VH-CYO, 5 km west-south-west of Peachester, Queensland, on 23 June 2021

ATSB seeks information from Robinson Helicopter owners and operators on ground handling incidents

The Australian Transport Safety Bureau (ATSB) is asking for pilots, operators, and engineers with knowledge of aft tail cone bulkhead or tail rotor gearbox input cartridge damage involving Robinson R22, R44 and R66 helicopters to make contact.

The call for information comes as the ATSB releases an investigation update from its ongoing investigation of a fatal Robinson R44 helicopter accident in Broome, Western Australia on 4 July 2020.

During the accident flight, the R44’s tail rotor gearbox, tail rotor and tail assembly separated from the helicopter soon after take-off. The helicopter subsequently collided with the ground, fatally injuring the pilot and rear-right passenger, while the other two passengers sustained serious injuries.

The ATSB has since undertaken extensive and ongoing metallurgical examination and analysis of the airframe and tail rotor components, including examining other R44 helicopter tail rotor gearboxes, components and bulkhead castings.

“Due to the disruptive nature of the accident, this examination and analysis may not reveal a specific point of failure in the helicopter,” said ATSB Director Transport Safety Dr Mike Walker.

“Indeed, in similar accidents overseas, despite extensive materials analysis, contributing factors have not been identified.”

Dr Walker said the ATSB has to date worked closely with the manufacturer, the US National Transportation Safety Board and the UK Air Accidents Investigations Branch to better understand this and similar accidents involving the R44 helicopter, and was now seeking the assistance of industry.

“To help us better understand the nature of this accident, we are seeking Robinson R22, R44 and R66 helicopter pilots, operators and maintenance engineers who may have knowledge of aft tail cone bulkhead or tail rotor gearbox input cartridge damage to make contact with us as soon as practical,” he said.

Regulations under the Transport Safety Investigation Act 2003 require the ATSB to be notified of damage sustained from when an aircraft is being prepared for flight until it has landed and passengers and crew have disembarked, but not for damage sustained during ground handling.

“There may have been events during ground handling resulting in damage to Robinson helicopters that were not required to be reported to the ATSB,” said Dr Walker.

“As a result, industry may be aware of information that could significantly aid the ATSB’s investigation.”

Any information provided to the ATSB that could assist the investigation would be protected as evidence under the Transport Safety Investigation Act 2003, Dr Walker noted.

“If damaged components are available, we may seek to recover these for examination,” he said.

The context of the occurrence and the results of ATSB’s analysis will be published in the final report at the conclusion of the investigation.

"At this point in the investigation it is important to stress that the ATSB has not determined that this helicopter sustained ground handling damage, nor that damage while ground handling contributed to this accident," Dr Walker stated.

Read the update here: In-flight break-up, Robinson R44 Raven I, VH-NBY, 3 km north of Broome Airport, Western Australia, on 4 July 2020

Rail Safety Week: Stand Back. Look Up. Stay Rail Safe

The Australian Transport Safety Bureau is joining the rail industry in recognising the key messages of the 16th annual Rail Safety Week, from 9-15 August.

An initiative of the TrackSAFE Foundation, this year Rail Safety Week seeks to remind community members, workers and operators that a single moment of distraction can change your life forever – so Stand Back, Look Up, and Stay Rail Safe.

The face of this year’s Rail Safety Week is Paralympian, and rail accident survivor, Vanessa Low. 

When Ms Low was 15, she fell from a busy platform into the path of an oncoming train. She lost both her legs in the accident, and was in a coma for two weeks. It took two years for her to walk again, with the aid of prosthetics.

“Ms Low’s story is a powerful reminder for everyone to stand back, look up and stay rail safe,” said ATSB Head of Engagement and Influence Paul Sadler.

A member of the public is killed or injured on the Australian rail network every two and half days, and there are around 2,000 near misses at level crossings or because of trespassing on the rail network.

“The majority of these incidents can be avoided by acting responsibly when near or on the rail network,” said Mr Sadler.

“As part of the ATSB’s promotion of Rail Safety Week, we will be highlighting the safety messages of some of our investigations that tie directly to this year’s theme.”

The ATSB is the nation’s independent ‘no-blame’ rail safety investigator.

ATSB investigations aim to determine what and why an accident happened, identify ongoing safety risks, and to influence safety actions to address those safety issues.

For more information on how you can Stay Rail Safe, visit the Rail Safety Week 2021 website(Opens in a new tab/window).

ATSB investigation highlights safety issues with emergency egress from the Cessna 206 with a cargo door

Key points:

• Extended flap significantly restricts emergency egress via the Cessna 206’s rear cargo door;
• ATSB recommends that Textron amend the Cessna 206 pilot operating handbook procedure for ditching and forced landing;
• ATSB also recommends regulatory authorities take safety action to address the certification basis for the design of the Cessna 206 cargo door.

The collision with water of a Cessna 206 near Fraser Island, Queensland highlights known issues with evacuating from the aircraft where extended flap obstructs the opening of its rear clamshell cargo doors.

The Australian Transport Safety Bureau (ATSB) investigation into the 29 January 2020 accident has identified two safety issues associated with the Cessna 206 with a cargo door that can lead to fatal consequences in the event of a ditching. As a consequence, the ATSB has issued safety recommendations to the manufacturer and regulatory authorities in Australia and the United States to address the issues.

“The Cessna 206 procedure for ditching and forced landing states that the flaps are to be extended to 40°,” said ATSB Director Transport Safety Stuart Macleod.

“While that permits the aircraft to land at a slower speed, it also significantly restricts emergency egress via the cargo door. However, there is no warning about that aspect in the pilot’s operating handbook emergency procedures for a ditching or forced landing.”

The ATSB also found that the Cessna 206 with the cargo door does not meet the aircraft certification basis for the design of cabin exits, due to the complexity associated with opening the cargo door if it is blocked by the flaps.

“This significantly hampers emergency egress and has previously resulted in fatalities.”

To address these issues the ATSB has issued safety recommendations to Textron Aviation (Cessna’s parent company) and the US Federal Aviation Administration and Australia’s Civil Aviation Safety Authority.

“The ATSB is recommending that Textron amend the procedure for ditching and forced landing in the pilot operating handbook for the Cessna 206 to ensure pilots are aware that extending the flaps beyond 10° will significantly restrict emergency egress via the cargo door,” said Mr Macleod.

“Separately, the ATSB also recommends that the Federal Aviation Administration and Civil Aviation Safety Authority take safety action to address the certification basis for the design of the cargo door in the Cessna 206.”

The accident aircraft, a Cessna U206G operated by Air Fraser Island, was being used to conduct emergency procedures training at a beach landing area on Fraser Island with two pilots (a training pilot and trainee pilot who had just commenced flying with the operator) on board. During a simulated failure of the left main wheel during landing, a section of the nose landing gear attachment failed just after landing, resulting in the rudder becoming jammed in the full‑left position.

The aircraft veered to the left, toward the sea, and the training pilot elected to conduct a go-around. With the rudder jammed in the full‑left position, the pilot had to apply full opposite aileron to maintain control.

Subsequently, fuel starvation, due to either the uncoordinated ‘crossed controls’ flight (using opposite aileron to counter the jammed rudder) or damage associated with the nose gear failure, led to the engine losing power at a height too low for recovery, and the aircraft impacted the water.

After hitting the water, the aircraft remained upright, and the cabin quickly began to fill with water.

With the trainee unable to open the pilot door, the training pilot moved to the back of the aircraft and attempted to open the forward door of the ‘clamshell’ rear double cargo doors. In order to escape the training pilot had to force the door open by kicking it, as it was partially blocked by the partially-extended flap (set at 20°).

The pilot managed to leave the cabin through the cargo door, while the trainee exited through the pilot door window. Both swam to shore.

The aircraft, without the engine, washed up on the beach the morning after the accident.

“Cessna 206 pilots should be aware that lowering the flaps will block the cargo door exit and significantly increase the difficulty of opening the door,” said Mr Macleod.

“In the event that a ditching is required, pilots should consider not extending the flaps.

“Additionally, all passenger pre-flight briefings should also include a practical demonstration of how to open a partially-obstructed cargo door.”

Mr Macleod noted that research by the Transport Safety Board of Canada found that in the 20 years leading up to 2009, 70 per cent of fatalities where an aircraft collided with water were caused by drowning.

“That statistic reflects the inherently disorienting nature of underwater exit from an often-inverted aircraft,” he said.

Read the final report: Collision with water involving Textron Aviation Inc. (Cessna) 206, VH-AEE, near Happy Valley, Fraser Island, Queensland, on 29 January 2020

Planned and proposed safety actions outlined in ATSB interim report from Wallan XPT derailment investigation 

A number of safety actions are planned and proposed as a result of the derailment of an XPT passenger train near Wallan, Victoria on 20 February 2020, an Australian Transport Safety Bureau (ATSB) interim report from the on-going investigation into the accident details.

Melbourne-bound XPT passenger train ST23, operated by NSW TrainLink (NSW Trains), derailed after entering a passing loop at a speed probably between 114 and 127 km/h, the interim report notes, when the speed limit for entering the loop was 15 km/h. With the train unable to negotiate the turnout at that speed, the lead power car (locomotive) rolled onto its side and all five passenger cars derailed. Only the rear (unoccupied) power car did not derail.

The train driver and an Accompanying Qualified Worker (AQW) in the lead power car did not survive the accident, while of the 155 passengers aboard, eight passengers sustained serious injuries and 53 minor injuries. The five passenger-services crew located in the train’s passenger cars also sustained minor injuries.

“Today, in releasing an interim report, the ATSB is detailing factual information as to the circumstances of this tragic accident as we understand them, and outlining planned safety actions as proposed by ARTC – the rail infrastructure manager – and NSW Trains, the rail operator, ” said ATSB Chief Commissioner Greg Hood.

“It is important not to draw conclusions from the factual information detailed in this report as there remains a significant body of further analysis work prior to concluding this investigation. Instead, the interim report serves to detail the investigation’s progress to date and to update stakeholders and the travelling public as to our areas of on-going investigation,” he said.

“Findings, safety factors and contributing factors will be detailed in the final report, which is anticipated to be completed in the first quarter of 2022.”

The interim report notes that the rail signalling system for the standard-gauge track through Wallan had been damaged on 3 February 2020. As a result, ARTC was managing trains through the Wallan area using Train Authority procedural systems.

On the day of the derailment, the points at either end of the crossing loop at Wallan had been manually reconfigured to divert rail traffic through the loop, which ARTC had detailed through a supplemental train notice issued on 19 February.

That train notice specified a 15 km/h speed limit for entry into the loop, and a limit of 35 km/h when exiting the loop.

However, analysis of data from the train’s Hasler electro-mechanical data recorder shows that the train was approaching the loop at near the line speed of 130 km/h before a brake application was made a short distance from the turnout to the loop.

“The ATSB has made eight interim observations of the factual information detailed in the interim report,” Mr Hood noted.

“These observations are based upon evidence gathered as part of the investigation, and have been used in the report to highlight and clarify certain items of factual information,” he said.

“Among the observations are those pertaining to ARTC’s implementation of altered train working arrangements and risk management, as well as NSW Trains’ distribution of safety information to rail workers.”

Since the accident, ARTC has advised it is developing amendments to its code of practice for traffic management, and is modifying its risk assessment practices, while NSW Trains is making changes to its procedures for accessing and distributing safety critical information to train crews.

Mr Hood noted that the investigation is being led by Victoria’s Chief Investigator, Transport Safety (CITS), which investigates rail accidents in Victoria on behalf of the ATSB under a collaboration agreement using the powers of the Commonwealth Transport Safety Investigation Act (TSI Act) 2003. The investigation is also being supported by the ATSB and NSW’s Office of Transport Safety Investigations (OTSI).

“As the investigation continues, there will be further consideration of a number of factors including the management of train operations and associated risk management, and the distribution of safety critical operational information to train operators and crew,” said Chief Investigator, Transport Safety Chris McKeown.

Other areas of ongoing investigation include further human factors analysis and rail vehicle survivability and crashworthiness standards.

“The investigation team will also finalise their analysis of the derailment sequence and their assessments of the condition of the rolling stock and track conditions,” Mr McKeown said.

“They will also review passenger services crew training and preparedness for a derailment, and passenger safety information.”

Read the interim report: Derailment of passenger train ST23, Wallan, Victoria, on 20 February 2020

Safety Advisory Notice for Robinson R44 operators and maintainers 

The ATSB has released a Safety Advisory Notice to Robinson R44 operators and maintainers highlighting the importance of inspecting the helicopter’s clutch shaft yoke.

The Safety Advisory Notice arises from the ATSB’s ongoing investigation into a loss of control and collision with terrain accident involving an R44 that was conducting aerial spraying operations near Clare, South Australia on 22 December 2020, which has identified that fatigue cracking in the clutch shaft forward yoke resulted in the total loss of drive to the main rotor system.

“The ATSB’s preliminary metallurgical examination of the drive train components identified that the clutch shaft forward yoke had fractured,” said ATSB Director Transport Safety Stuart Macleod.

“Corrosion product and fretting damage were identified in the vicinity of the bolt hole adjacent to the fatigue fracture surfaces.“

The yoke is required to be inspected at every 100-hour, or annual, inspection, however, the ATSB’s Safety Advisory Notice states that a general visual inspection of the assembled clutch shaft yoke during the 100‑hour or annual inspection may not easily identify defects such as corrosion, fretting and/or cracking.

“The ATSB advises operators of R44 helicopters to note the preliminary finding of this accident and to look for the presence of corrosion, fretting or cracking, which may not be visually obvious, during inspections of the clutch shaft yoke,” said Mr Macleod.

“Any identified defects should be notified to both the ATSB and the Civil Aviation Safety Authority.”

While the specific circumstances that led to the fatigue crack on the accident helicopter are still under investigation, the ATSB has issued the safety advisory notice to advise R44 operators of the potential safety concern.

Pending the publication of an investigation’s final report, the ATSB may issue Safety Advisory Notices to raise awareness of safety critical concerns determined during the course of an investigation without waiting for the conclusion of the investigation.

Read the Safety Advisory Notice: AO-2020-064-SAN-014 R44 helicopter drive train failure

Read the report: Loss of control and collision with terrain involving Robinson R44 II, VH-HOB, near Clare, South Australia, on 22 December 2020

Preliminary report released for Cessna 172 accident during powerline survey 

The ATSB has released a preliminary report from its on-going investigation into a fatal accident involving a Cessna 172 light aircraft conducting power line survey work near Sutton, north of Canberra, on 13 April 2021.

The report details that the aircraft, a Cessna R172K registered VH-DLA, had departed Canberra Airport with a pilot and observer on board to conduct power line survey work to the north of Sutton, New South Wales. While surveying power lines servicing properties to the east of Tallagandra Lane, witnesses in the area described seeing the aircraft flying low above the trees before commencing a left banking turn followed by a steep descent shortly before it collided with the ground.

“Witness reports indicated that a loss of control and entry into a spin preceded the ground impact,” said ATSB Director Transport Safety Stuart Macleod.

Examination of the wreckage showed that the aircraft impacted the ground in a near vertical, nose down attitude.

The pilot and observer sustained fatal injuries, and the aircraft was destroyed.

“To date, ATSB transport safety investigators have examined the aircraft wreckage, mapped the accident site with a drone, retrieved relevant aircraft components for further analysis, interviewed witnesses and the aircraft operator, downloaded flight-related electronic data, and collected weather information,” said Mr Macleod.

Mr Macleod noted the preliminary report does not include any safety findings or analysis, which will be detailed in the investigation’s final report.

“As the investigation progresses, the ATSB will continue to analyse the aircraft’s flight path and recorded data, and review pilot qualifications, maintenance records and the operator’s procedures for conducting flight survey aerial work,” he said.

A final report will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified during the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”

Read the preliminary report: Loss of control and collision with terrain involving Cessna R172K, VH-DLA, near Sutton, New South Wales, on 13 April 2021

Ongoing investigation reveals recorded flight paths of Airbus A320 and private Jabiru two-seat recreational aircraft intersected with vertical separation of about 600 feet.  

The ATSB is continuing its investigation into a separation occurrence in uncontrolled airspace near Ballina where recorded data showed that the tracks of an Airbus A320 and a private Jabiru two-seat recreational aircraft intersected with a vertical separation of about 600 feet.  

The Jetstar Airbus A320, with seven crew and 163 passengers on board, was on approach to land at Ballina Byron Gateway Airport, having operated a scheduled service from Melbourne, while the Jabiru J230D aircraft, with a pilot and a passenger on board, was conducting a private visual flight rules flight from Heck Field in Queensland to Evans Head.

Aircraft operating into Ballina and Evans Head, as well as nearby Lismore and Casino airports, are required to broadcast positional calls on a common traffic advisory frequency, or CTAF, while at Ballina Airport a certified air/ground radio operator (CA/GRO) relays positional information (but does not provide a separation service) to aircraft operating in and out of Ballina to aid pilots with decision making.

The ATSB’s preliminary report into the 28 November 2020 occurrence details that as their aircraft tracked towards Ballina the flight crew of the A320 received a traffic collision avoidance system (TCAS) proximate traffic alert for an unidentified aircraft at an unspecified altitude in the 11 o’clock position, which unbeknown to them, was probably the Jabiru aircraft.

The A320 crew attempted to sight the traffic, but were not successful. The proximate alert then escalated to a traffic advisory.

The flight crew maintained their visual scan and continued with the approach to Ballina.

Subesequent analysis of the A320’s quick access recorder and data recorded by the Jabiru pilot’s OzRunways electronic flight bag app indicated that at approximately 12 NM south west of Ballina Airport, the tracks of the A320 and the Jabiru intersected, with vertical separation between the two aircraft reducing to about 600 feet.

The flight crew of the A320 sighted the Jabiru just prior to passing below the aircraft, the preliminary report notes. The pilot of the Jabiru sighted the A320 shortly after passing above it. Both the pilot of the Jabiru and the A320 flight crew observed no lateral separation between the two aircraft. 

“The ATSB’s continuing investigation will include the examination of airspace density levels; airspace suitability; flight crew actions; CA/GRS procedural design and application; and future Ballina airspace plans,” said ATSB Director Transport Safety Stuart Macleod.

Mr Macleod noted today’s preliminary report does not include any safety findings or analysis, which will be detailed in the investigation’s final report

“However, should a critical safety issue be identified during the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken,” he said.

Read the preliminary report: Separation occurrence involving Airbus A320-232, VH-VGP and Jabiru J230D, 24-7456, near Ballina Byron Gateway Airport, New South Wales, on 28 November 2020

Inappropriate radio frequency and transponder mode selection degraded flight crew's situational awareness

Key points:

• Flight crew inadvertently selected incorrect radio frequency and TCAS/transponder mode
• Unanticipated events and distractions during before flight checks increased workload and time pressures.
• Visual scan did not identify an approaching aircraft due to degraded situational awareness

The flight crew of a Dash 8 turboprop airliner that taxied onto the runway in front of a light aircraft on approach to land at Gladstone Airport had not selected the appropriate radio frequency and transponder mode which significantly degraded their situational awareness, a new ATSB investigation report details.

On 17 March 2020 at about 6.00 am, the flight crew of the QantasLink Bombardier Dash 8-402 commenced pre-flight preparations for a 6.45 am flight to Brisbane. During those preparations the crew twice started the aircraft’s APU (auxiliary power unit), which failed on both occasions when selecting APU bleed air ‘ON’ to provide air-conditioning to the cabin. The captain also had to review paperwork and brief cabin crew on arrangements for a ‘person in custody’ and their police escort to travel on the flight.

After applying the Minimum Equipment List (MEL) to the APU, the flight crew undertook the remainder of their pre-flight checks, but missed setting the traffic collision avoidance system (TCAS)/transponder to ‘ON ALT’ and selecting the Gladstone common terminal advisory frequency (CTAF) radio frequency.

The first officer identified the CTAF omission during the departure briefing, however incorrectly set the frequency to 126.7 MHz instead of 118.8 MHz, which was the correct frequency for the Gladstone CTAF.

“The ATSB’s investigation found that the flight crew of the Dash 8 had inadvertently selected the incorrect radio frequency for the airport’s CTAF and incorrect mode on the traffic collision avoidance system/transponder during the before start checks reducing the flight’s crew situational awareness and mental model of traffic,” said ATSB Director Transport Safety Stuart Macleod.

“The frequency selection error was further compounded by the flight crew not recognising the absence of the aerodrome frequency response unit reply when making radio calls on the incorrect frequency and the assumption they would be alerted to the presence of any transponder-equipped aircraft that were operating in the area.”

At about 6.45 am, the Dash 8 was taxied onto the runway in front of the approaching light aircraft. In response, the instructor on board the light aircraft commenced a go-around and attempted, unsuccessfully, to contact the Dash 8 crew on the Gladstone CTAF.

Shortly afterwards, the captain identified that the TCAS/transponder was not appropriately set and selected it to ‘ON ALT’. The TCAS subsequently presented the flight crew with a traffic advisory indicating climbing traffic, which was the light aircraft that the flight crew subsequently sighted climbing in an easterly direction overhead the airport.

Mr Macleod said that the incident illustrates the human factors implications associated with the combination of increased workload and time pressures.

“Situations like this can result in degraded information processing, increased errors, the tunnelling of attention, and an increased reliance on familiar strategies or actions and probably resulted in the flight crew’s omission of the two ‘before start’ checklist items and the selection of the incorrect frequency,” he said.

“Flight crews can guard against similar situations by applying effective threat and error management strategies that recognise when such threats may arise and set in place suitable actions that minimise error potential.

“These actions include strict adherence to standard operating procedures and increased cross-checking of system inputs and mode changes.”

As result of the incident, QantasLink has reviewed its operating procedures at non-controlled airports and introduced new requirements to contact air traffic control before entering the runway.

Read the final report: Runway incursion and communication issues involving Bombardier Dash 8, VH-LQJ, Gladstone, Queensland, on 17 March 2020