Aviation safety investigations & reports

Near collision between Piper PA-28, VH-XDI and ATR72, VH-FVR, Albury Airport, New South Wales, on 19 October 2019

Investigation number:
AO-2019-066
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 19 October 2019, a Piper PA-28-161, registered VH-XDI (XDI), operated by the Australian Airline Pilot Academy (AAPA), was inbound to Albury, New South Wales (NSW) from Wagga Wagga, NSW, on a training flight. The pilot was the only person on board. An ATR72-212A, registered VH-FVR (FVR), operated by Virgin Australia Airlines, was also inbound to Albury on a scheduled passenger flight from Sydney, NSW. There were two flight crew, two cabin crew and 66 passengers on board.

During the approach, the pilot of XDI turned on to the base leg of the circuit in front of FVR. The crew of FVR received a traffic collision avoidance system (TCAS) traffic advisory (TA) and conducted a missed approach to increase separation. Separation between the two aircraft reduced to about 110 metres horizontally and 75 feet vertically.

What the ATSB found

The ATSB found that the pilot of the PA-28 did not sight the ATR aircraft, which the controller had instructed them to follow, and did not advise the controller they did not have the aircraft sighted before turning in front of the ATR aircraft, resulting in a near collision. The crew of the ATR were aware that there was traffic in the area but did not assess the position of the PA-28, in relation to their aircraft until activation of the TCAS TA.

The ATSB also identified that the air traffic controller did not confirm that the pilot of XDI correctly understood the planned method of sequencing the two aircraft by requiring readback of the instruction to sight and follow the ATR, nor did they seek confirmation that it had been sighted. The controller did not identify the developing near collision as they were not effectively monitoring the aircraft in the circuit area due to their attention being focussed on another aircraft.

What's been done as a result

Following this occurrence AAPA implemented additional controls for students operating to Albury Airport. The academy also took action to ensure their pilots receive additional education and training on procedures for airports in Class D airspace (controlled airspace that surrounds general aviation and regional airports equipped with a control tower such as Albury) and complete training on air traffic control clearance requirements and compliance.

Virgin Australia have reminded all their crews of the separation that is provided in Class D airspace. Additionally, Virgin Australia and Airservices Australia have begun discussions to convene a cross industry stakeholder meeting to include operators, Civil Aviation Safety Authority, ATSB and the broader industry to discuss the ongoing risk to operations at non-controlled and airports in Class D airspace.

Safety message

This serious incident illustrates the danger of assumption and incomplete situational awareness.

Although separation between the two aircraft was the pilots’ responsibility on this occasion, the controller had recognised the potential conflict and implemented a plan to sequence their arrival. However, confirmation was not sought from the pilot assigned to follow the ATR that they understood the plan. Additionally, all parties made incorrect assumptions about the aircraft movements rather than taking positive action to confirm that adequate separation would be maintained.

Download final report
[Download  PDF: 413KB]
 
 
 

The occurrence

General details
Date: 19 October 2019   Investigation status: Completed  
Time: 1124 EDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Albury   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Near collision  
Release date: 12 November 2020   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-28-161  
Aircraft registration VH-XDI  
Serial number 2842301  
Operator Australian Airline Pilots Academy  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Departure point Wagga, Wagga, New South Wales  
Destination Wagga, Wagga, New South Wales  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer ATR-GIE Avions de Transport Régional  
Aircraft model ATR72-212A  
Aircraft registration VH-FVR  
Serial number 1058  
Operator Virgin Australia  
Type of operation Air Transport High Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Sydney, New South Wales  
Destination Albury, New South Wales  
Last update 12 November 2020