Aviation safety investigations & reports

Runway incursion involving Sling 2, VH-ZSD Moorabbin Airport, Victoria, on 23 July 2020

Investigation number:
AO-2020-037
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final report

Download Final Report
[Download  PDF: 1.51MB]
 

What happened

On the afternoon of 23 July 2020, five aircraft were operating in the runway 17 Left (L) circuit at Moorabbin Airport, Victoria. A Piper PA-28 aircraft, VH-TAX (TAX), was lined up in the displaced threshold area of runway 17L. A Sling 2 aircraft, VH-ZSD (ZSD), then on the base leg of the circuit approaching the occupied runway, passed above TAX and conducted a touch and go landing. The runway incursion by ZSD removed the required runway separation between the aircraft.

What the ATSB found

The ATSB found that the student pilot of ZSD sighted TAX but decided to conduct the touch and go landing due to an incorrect belief that the controller had provided a landing clearance. The ATSB identified that the student pilot’s training had not been effective in conveying that a go‑around must be initiated if the runway was occupied.

The investigation also found that the air traffic controller did not identify the developing conflict as ZSD approached runway 17L. Additionally, the controller did not recall the aircraft passing above TAX and conducting a touch and go landing, and remained unaware of the incident until after it was reported over an hour later.

What has been done as a result

Royal Victorian Aero Club, the flight training school operating ZSD, has made changes to its student training program including educational, procedural and recurring activities. The school updated instructor and student educational materials, procedural guidance and examination content.

Safety message

Runway incursions and other runway separation issues are one of the most significant risks to safe aviation operations and a key global safety priority. Airport operators and air navigation service providers are strongly encouraged to identify and mitigate risk areas, especially at locations with inexperienced pilots or unusual airport configurations, such as displaced thresholds. The Airservices‑published safety bulletin Preventing the risk of a runway incursion and the runway safety article Tips for flying at Moorabbin provide relevant guidance.

Pilots are strongly encouraged to identify potential conflicts or runway incursions that may develop during circuits early and to attend carefully to air traffic control communications. It is important that flight training schools reinforce training regarding occupied runways and go‑arounds to students. Air traffic controllers are encouraged to monitor all aircraft and provide clear and unambiguous instructions to their flight crew to avoid runway incursions and related occurrences.

 

Download Final Report
[Download  PDF: 1.51MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety actions

Sources and submissions

Appendices

General details
Date: 23 July 2020   Investigation status: Completed  
Time: 13:40 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Moorabbin Airport   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Runway incursion  
Release date: 29 June 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft model Sling 2  
Aircraft registration VH-ZSD  
Serial number 257  
Operator Royal Victoria Aero Club  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Departure point Moorabbin, Victoria  
Destination Moorabbin, Victoria  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-28-161  
Aircraft registration VH-TAX  
Serial number 2842252  
Operator J&J Aviation  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Departure point Moorabbin, Victoria  
Destination Moorabbin, Victoria  
Last update 29 June 2021