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On 9 December 2016, a QantasLink Bombardier DHC-8-402, registered VH-LQG (LQG) departed runway 16 left at Sydney Airport. The aircraft was operating a scheduled passenger flight from Sydney to Tamworth, New South Wales.

When LQG departed, an Air New Zealand Boeing 777-219ER, registered ZK-OKF (OKF), operating a scheduled passenger flight from Auckland, New Zealand, was on descent to Sydney.

The projected routes of the aircraft conflicted and Sydney air traffic control planned to apply vertical separation between them by assigning LQG an intermediate altitude of 5,000 ft and OKF and intermediate altitude of 6,000 ft.  LQG did not maintain 5,000 ft, reaching an altitude of 5,600 ft, and separation was not maintained between the aircraft.

The ATSB determined that the flight crew were cognisant of the requirement to maintain 5000 ft and had configured the autopilot accordingly. An unexpected autopilot mode changed occurred, before the assigned altitude was reached, and the PF decided to hand fly the aircraft until the autopilot was again correctly configured. They then attempted to reconnect the autopilot but in doing so made a mistake and the autopilot did not reconnect. The flight crew both believed the autopilot was reconnected and did not realise the mistake until after the level excursion occurred.

The incident highlights the critical nature of effective crew resource management in multi crew operations.

Aviation Short Investigations Bulletin - Issue 58

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General details
Date: 09 December 2016 Investigation status: Completed 
Location   (show map):near Sydney Airport Investigation type: Occurrence Investigation 
State: New South Wales Occurrence type: Loss of separation 
Release date: 24 March 2017 Occurrence class: Airspace 
Report status: Final Occurrence category: Incident 
 Highest injury level: None 
Aircraft 1 details
Aircraft manufacturer: Bombardier Inc 
Aircraft model: DHC-8-402 
Aircraft registration: VH-LQG 
Serial number: 4376 
Type of operation: Air Transport High Capacity 
Sector: Turboprop 
Damage to aircraft: Nil 
Altitude: 5600 ft AMSL 
Departure point:Sydney NSW
Destination:Tamworth NSW
Aircraft 2 details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 777-219ER 
Aircraft registration: ZK-OKF 
Serial number: 777-219ER 
Operator: Air New Zealand 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Altitude: 6000 ft AMSL 
Departure point:Auckland NZ
Destination:Sydney NSW
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Last update 18 April 2017