Aviation safety investigations & reports

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

Investigation number:
AO-2018-032
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 1.68MB]
 

What happened

On 28 April 2018, a Qantas Boeing 737 (VH-XZM) landed on runway 03 at Perth, Western Australia. The aircraft exited 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 without an air traffic control clearance.

At that time, a second Qantas Boeing 737 (VH-VZL) had commenced take-off from runway 06. An automated warning 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 situationally aware of their position and stopped just before crossing the edge of runway 06. VH-VZL’s wingtip passed about 15 m from VH-XZM’s nose at low speed.

What the ATSB found

The captain of VH-XZM developed an incorrect mental model of the exit taxiways off runway 03, believing the aircraft would not have to cross runway 06 after exiting onto either of the potential taxiways (J2 or D). 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.

Taxiway J2 was the preferred runway exit for jet aircraft landing on runway 03. However, the location and design of the taxiway significantly increased the risk of a runway incursion onto runway 06/24. In particular, it had a relatively shallow intersection angle with the runway and a relatively wide turn radius, leading to higher taxi speeds, and a short distance to the holding point for runway 06/24.

Although the junction around taxiway J2 was identified as a ‘hot spot’, there was no detailed information about the reasons why it was a hot spot on aerodrome charts, and Qantas did not specifically require pilots to brief hot spots during departure and approach briefings.

What's been done as a result

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

In addition, Airservices Australia 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.

Qantas published a safety information notice to all pilots containing information about the background of runway incursions, details of two recent runway incursion occurrences and safety educational information related to influencing factors, stop bar techniques and strategies to avoid a runway incursion. Qantas 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.

Safety message

Runway incursions are one of the most significant risks to safe aviation operations and a key global safety priority. 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.

Pilots are strongly encouraged to identify runway hot spots during departure and approach briefings, and discuss the actions they will take to reduce the risk of a runway incursion at such hot spots.

Air traffic controllers are strongly encouraged 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.

Download final report
[Download  PDF: 1.68MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to AO-2018-032-SI-01 - Go to AO-2018-032-SI-02 - Go to AO-2018-032-SI-03 -

Operator guidance for flight crew briefing of aerodrome hot spots

Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed.

Safety issue details
Issue number: AO-2018-032-SI-01
Who it affects: All of the operator’s flight crew
Status: Closed – Adequately addressed

Location and design of taxiway J2 at Perth Airport

The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient to effectively reduce the risk of a runway incursion.  

Safety issue details
Issue number: AO-2018-032-SI-02
Who it affects: All flight crew and operators of jet aircraft using runway 03 at Perth Airport
Status: Closed – Adequately addressed

Inhibition of safety alerts for combined air traffic control roles

Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation alert or runway incursion alert at their workstation.

Safety issue details
Issue number: AO-2018-032-SI-03
Who it affects: Tower controllers at Perth Airport
Status: Closed – Adequately addressed
General details
Date: 28 April 2018   Investigation status: Completed  
Time: 1442 WST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Perth Airport   Investigation phase: Final report: Dissemination  
State: Western Australia   Occurrence type: Runway incursion  
Release date: 01 October 2020   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer The Boeing Company  
Aircraft model 737-838  
Aircraft registration VH-XZM  
Serial number 44574  
Operator Qantas Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Sydney, New South Wales  
Destination Perth, Western Australia  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer The Boeing Company  
Aircraft model 737-838  
Aircraft registration VH-VZL  
Serial number 34194  
Operator Qantas Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Perth, Western Australia  
Destination Sydney, New South Wales  
Last update 01 October 2020