Aviation safety investigations & reports

Runway incursion involving Beech Aircraft Corp. 58, VH NSK Bankstown Airport, New South Wales, on 26 October 2021

Investigation number:
AO-2021-046
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final report
[Download  PDF: 466KB]
 

What happened

On the 26 October 2021, a Beech Aircraft Corp. 58, registered VH-NSK, operated by Little Wings Limited, was prepared for a private flight from Bankstown Airport, New South Wales. The purpose of the flight was to test the stall warning system following maintenance. The pilot was the sole person on board.

The aircraft was cleared to enter and line up on runway 29 right (29R) however, the pilot crossed the runway and entered occupied runway 29 centre (29C) without a clearance. As the pilot was cleared to take-off, the controller identified the error and instructed the pilot to hold position on the runway. At the same time, the pilot detected an Embraer 190, which was conducting high power engine runs on the upwind end of runway 29C and did not commence the take‑off.

What the ATSB found

The ATSB found that the pilot typically departed Bankstown from the centre runway, under the instrument flight rules procedures. This likely created an expectation that they were using this runway, despite reading back the correct runway to the controller. This resulted in them crossing runway 29R and entering runway 29C without a clearance.

Additionally, while the air traffic controller watched the aircraft enter 29R, due to subsequent focused attention on two helicopters in the vicinity of the airport, they did not identify its continued movement on to the occupied runway 29C.

Safety message

This incident illustrates the importance of pilots focusing on the specific instructions given by air traffic controllers. In 2012, the United States Federal Aviation Administration Safety Team (FAASTeam) released notice NOT4214 Pilot safety tip – Expectation bias stating that ‘analysis of runway incursion data shows that expectation bias is one of the most common causal factors for pilot deviations’.

The notice went on to say that pilots ‘need to understand that expectation bias often affects the verbal transmission of information. When issued instructions by air traffic control, pilots should “focus on listening and repeat to yourself exactly what is said in your head — and then apply that information actively”.’

Runway incursions remain an ongoing safety concern globally. In October 2016, Airservices Australia released A pilot’s guide to Runway Safety. This guide focused on seven important areas in surface operations and identified safety measures to help reduce the errors that lead to runway incursions. In addition, Airservices Australia have released specific guidance for pilots flying at Bankstown Airport Tips for flying at Bankstown, along with tips for flying at other metropolitan airports: Moorabbin, Parafield, Jandakot and Archerfield.

 

Download Final report
[Download  PDF: 466KB]
 
 
 

The investigation

Summary

The ATSB has commenced a transport safety investigation into a runway incursion involving Beech Aircraft Corp. 58, registration VH-NSK at Bankstown Airport, NSW on 26 October 2021.

ATC cleared the aircraft to line up on runway 29R. The aircraft crossed runway 29R and entered runway 29C without a clearance. The crew observed a stationary aircraft, undergoing engine ground runs for maintenance, at the other end of the runway. The pilot held position and immediately contacted ATC.

The evidence collection phase of the investigation will include interviews with crew, reviewing air traffic control surveillance information and the gathering of any other relevant evidence.

A report will be published 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: 26 October 2021   Investigation status: Completed  
Time: 1149 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Bankstown Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Runway incursion  
Release date: 16 February 2022   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model Baron 58  
Aircraft registration VH-NSK  
Serial number TH-106  
Operator Little Wings Limited  
Type of operation Private  
Sector Piston  
Damage to aircraft Nil  
Departure point Bankstown Airport, New South Wales  
Destination Bankstown Airport, New South Wales  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Embraer-Empresa Brasileira De Aeronautica  
Aircraft model ERJ 190-300  
Sector Jet  
Last update 16 February 2022