Aviation safety investigations & reports

Runway incursion and take-off commenced on incorrect runway involving GIE Avions de Transport Régional ATR72, VH-VPJ, Canberra Airport, Australian Capital Territory, on 25 September 2019

Investigation number:
AO-2019-055
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On the evening of 25 September 2019, the flight crew of a GIE Avions de Transport Régional ATR72 aircraft, registered VH-VPJ and operated by Virgin Australia Airlines, received a clearance to line‑up on runway 35 from intersection ‘Golf’ at Canberra Airport, Australian Capital Territory. While taxiing to the runway, the flight crew inadvertently lined-up on runway 30. Almost immediately after commencing the take-off roll, and at about the same time air traffic control instructed them to ‘stop’, the flight crew rejected the take‑off. The aircraft was re‑positioned for a departure from runway 35. 

What the ATSB found

The ATSB found that the flight crew elected to depart from intersection ‘Golf’ for runway 35. Due to the close proximity of the aircraft’s parking bay to the ‘Golf’ runway holding point, the selection of this intersection reduced the distance, and therefore the amount of time available for the flight crew to complete their pre-departure checks. After passing through the holding point, the captain taxied the aircraft onto runway 30, following the lead-on lights for that runway, while the first officer’s attention was focussed on completing procedures and checklists. This likely resulted in the flight crew having reduced awareness of the runway environment and aircraft orientation.

The lead-on lights to runway 30 were active with the taxiway lighting and the lead-on lights to runway 35 were activated when the holding point stop bar at intersection ‘Golf’ was turned off by air traffic control. Therefore, both runway lead-on lights were active. This increased the risk of an aircraft being manoeuvred onto the incorrect runway, particularly at night and/or in low visibility conditions. In this case, the captain, who recalled being focused on the lead-on lights, followed the first set of lights that led to runway 30.

The ATSB also established that Virgin Australia Airlines’ ATR72 Before take-off procedure did not specify when ‘ready [for take-off]’ was to be communicated to air traffic control. This increased the risk of procedures and checklists being completed while the aircraft was taxiing onto the runway, at a time when monitoring was critical. Virgin Australia Airlines’ procedures applicable to all the aircraft in their fleet did not include a runway verification check using external cues, including runway markings, signs and/or lights.

What has been done as a result

After the incident, Virgin Australia Airlines discontinued the use of intersection ‘Golf’ for departure at Canberra Airport during the day and night. Subsequent action included a proposal to amend the ATR72 Before take-off procedure to ensure it was completed at a time when the flight crew’s attention was not diverted to other tasks. However, ATR72 operations ceased before this was implemented. In addition, Virgin Australia Airlines have developed a runway verification procedure to be included in their Flight Crew Operating Manual for the Boeing 737, their current fleet.

Safety message

The design of airport runways and taxiways vary from relatively simple to more complex layouts. This can be exacerbated by reduced visual cues, such as night-time or poor weather, which can easily increase confusion. It is important for all flight crew to familiarise themselves with these layouts, particularly any unique designs, and ensure effective flight crew co-ordination is employed to minimise the risk of a runway incursion.

Operators should ensure the design of their operating procedures minimises the risk of human error. Clearly delineating procedural steps may reduce the likelihood of flight crews’ heads down activities at critical moments throughout the flight.

Download final report
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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to AO-2019-055-SI-01 - Go to AO-2019-055-SI-02 -

Timing of 'before take-off' procedure

Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying was critical.

Safety issue details
Issue number: AO-2019-055-SI-01
Status: No longer relevant

Runway verification cues

Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.

Safety issue details
Issue number: AO-2019-055-SI-02
Status: Open – Safety action pending
General details
Date: 25 September 2019   Investigation status: Completed  
Time: 1900 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Canberra Airport   Investigation phase: Final report: Dissemination  
State: Australian Capital Territory   Occurrence type: Runway incursion  
Release date: 11 December 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer ATR-GIE Avions de Transport Régional  
Aircraft model ATR72-212A  
Aircraft registration VH-VPJ  
Serial number 1169  
Operator Virgin Australia Airlines  
Type of operation Air Transport High Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Canberra, Australian Capital Territory  
Destination Sydney, New South Wales  
Last update 11 December 2020