Aviation safety issues and actions

Takeoff procedures

Issue number: AO-2009-007-SI-01
Who it affects: Operator and operator’s flight crew
Issue owner: QantasLink
Operation affected: Aviation: Air transport
Background: Investigation Report AO-2009-007
Date: 28 January 2011

Safety issue description

The operator did not have procedures to assist the crew to ensure that the aircraft was lined up on the runway centreline in preparation for takeoff.

Proactive Action

Action organisation: Qantaslink
Action number: AO-2009-007-NSA-024
Date: 02 April 2010
Action status: Closed

The aircraft operator conducted its own investigation of the incident and as a result advised the ATSB that:

The operator’s Safety Systems Manager recommended:

  • that, due to the potential consequences of the event, all involved aircrew undergo retraining in the specific safety management subjects of Reporting Requirements, TEM, human factors, and CRM; and
  • that the Flight Crew additionally undergo simulator and line training.

Operational procedures were amended, as follows:

  • incorporated a centre-line confirmation procedure by the First Officer prior to commencing the take-off roll;
  • expanded the policy contained in the company manuals for runway verification prior to take-off;
  • additional text was added to the Airport and Runway Data Manuals emphasising crew awareness of operational readiness platforms, and circumstances where no centreline lighting exists; and
  • a training module was incorporated into a simulator cyclic session to focus the attention of crews on the importance of ensuring that the aircraft is on the centreline prior to take-off.

ATSB response:

The ATSB is satisfied that the action taken by the operator adequately addresses the safety issue.

Current issue status: Adequately addressed
Last update 13 February 2014