Aviation safety investigations & reports

Runway incursion and communication issues involving Bombardier Dash 8, VH-LQJ, Gladstone, Queensland, on 17 March 2020

Investigation number:
AO-2020-019
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On the morning of 17 March 2020, a QantasLink Bombardier Dash-8-402, registered VH-LQJ (LQJ), was being taxied for a scheduled flight from Gladstone Airport, Queensland to Brisbane Airport, Queensland. There were two flight crew, two cabin crew and 34 passengers on board. At the same time, an ATEC Faeta 321, registered 24-8279 (Faeta 8279), with one instructor and student on board, was conducting circuit training at Gladstone Airport.  

At about 0645, as Faeta 8279 was on approach to conduct a touch-and-go on runway 10, LQJ entered and taxied along the runway in front of Faeta 8279. The instructor on board Faeta 8279 conducted a go-around to avoid an incident on the occupied runway.

What the ATSB found

The ATSB found that the flight crew of LQJ set the incorrect common traffic advisory frequency and did not select the appropriate traffic collision avoidance system/transponder mode during the before start checks. These errors were likely influenced by increased workload and time pressures experienced during before start preparations.

The errors went undetected during the taxi phase of flight. As a result, the flight crew’s situational awareness was significantly degraded and caused the captain and first officer to form the shared belief that no other traffic was operating in the vicinity of Gladstone Airport. This shared incorrect mental model likely impacted the efficacy of the visual scan conducted prior to entering the runway, with neither flight crew member sighting the approaching aircraft.  

What has been done as a result

Following this incident, QantasLink undertook a review of operating procedures at non-controlled airports. The procedural review included transponder activation and introduced a requirement to contact Air Traffic Control prior to entering the runway. QantasLink also provided internal communications to flight crew detailing the importance of standard operating procedures and threat management when dealing with distractions and workload.

Safety message

This incident illustrates the human factors implications associated with the combination of increased workload and time pressures. Flight crews can guard against similar outcomes by applying effective threat and error management strategies that recognise when such threats may arise and set in place suitable actions that minimise error potential. These actions include strict adherence to standard operating procedures and increased cross-checking of system inputs and mode changes.

Download Final report
[Download  PDF: 322KB]
 
 
 

The investigation

General details
Date: 17 March 2020   Investigation status: Completed  
Time: 0645 AEST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Gladstone Airport   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Runway incursion  
Release date: 23 February 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Bombardier Inc  
Aircraft model DHC-8-402  
Aircraft registration VH-LQJ  
Serial number 4414  
Operator Sunstate Airlines (Qld)  
Type of operation Air Transport High Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Gladstone, Queensland  
Destination Brisbane, Queensland  

Aircraft 2 details

Aircraft 2 details
Aircraft registration 24-8279  
Serial number F770912A  
Type of operation Private  
Sector Other  
Damage to aircraft Nil  
Departure point Gladstone Airport, Queensland  
Destination Gladstone Airport, Queensland  
Last update 23 February 2021