Aviation safety investigations & reports

Runway incursion involving a SAAB 340B, VH-ZRH Carnarvon Airport, Western Australia, on 31 August 2020

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


Download Final Report
[Download  PDF: 646KB]

What happened

On 31 August 2020, a Regional Express (REX) SAAB 340B, registered VH-ZRH, and a Shine Aviation Piper PA-31, registered VH-ITF, were both being prepared for their respective passenger transport flights at Carnarvon, Western Australia.

At about 1704 local time, VH-ZRH entered runway 22 just after VH-ITF had commenced its take-off roll on the same runway. The pilot of VH-ITF immediately advised the crew of VH-ZRH that they were rolling and then rejected the take-off. VH-ZRH stopped just inside the runway strip.

What the ATSB found

The ATSB found that, although the crews of both aircraft were aware that they were mutual traffic, their expectations led to an incorrect understanding of the other’s position and/or intentions. This situation led to them not recognising the potential conflict and therefore not directly communicating with each other.

The lookout conducted by the flight crew of VH-ZRH prior to entering the runway was not effective and likely to have been influenced by the crew’s expectation that VH-ITF had already departed.

What has been done as a result

REX advised that the incident was discussed amongst its checking and training organisation for future training events. The operator also published related policy items in an operations notice to highlight the requirements for operating in non-controlled environments. REX also reviewed its human factors and non-technical skills training specifically in relation to communication.

Shine Aviation planned for the incident to be used as a learning tool in order to promote discussion of behaviours and best practice with respect to communications in CTAF environments.

Safety message

This incident highlights the potential effects that expectations can have on how a flight crew perceives information. It is important that flight crew remain vigilant while maintaining situational awareness to counter any expectation bias. Pilots should not hesitate to contact another aircraft if there is any uncertainty as to their position and/or intentions.

The ATSB’s SafetyWatch highlights the broad safety concerns that come out of the bureau’s investigation findings and from occurrence data reported by industry. One of those safety concerns is that insufficient communication between pilots operating in the same area is the most common cause of safety incidents near non-controlled aerodromes. The ATSB booklet A pilot’s guide to staying safe in the vicinity of non-controlled aerodromes outlines many of the common problems that occur at non-controlled aerodromes.

The Civil Aviation Safety Authority has also produced important safety advice for Radio procedures in non-controlled airspace.

Download Final Report
[Download  PDF: 646KB]

The investigation


The ATSB is investigating the runway incursion involving a Piper PA-31, registered VH-ITF, and a Saab 340B, registered VH-ZRH, at Carnarvon Airport, Western Australia, on 31 August 2020.

The Saab 340B entered the active runway after the Piper PA-31 had commenced its take-off roll. The PA-31 rejected the take-off.

The evidence collection phase of the investigation will include interviewing the flight crew from both aircraft and witnesses, a review of any available recorded flight data, and the weather at the time of the occurrence.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

General details
Date: 31 August 2020   Investigation status: Completed  
Time: 1704 WST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Carnarvon Airport   Investigation phase: Final report: Dissemination  
State: Western Australia   Occurrence type: Runway incursion  
Release date: 15 December 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-31  
Aircraft registration VH-ITF  
Serial number 31-7812014  
Type of operation Charter  
Sector Piston  
Damage to aircraft Nil  
Departure point Carnarvon, Western Australia  
Destination Geraldton, Western Australia  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Saab Aircraft Co.  
Aircraft model 340  
Aircraft registration VH-ZRH  
Serial number 340B-392  
Type of operation Air Transport Low Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Carnarvon, Western Australia  
Destination Perth, Western Australia  
Last update 15 December 2021