Runway incursion

Runway incursion involving a Boeing 737-377, VH-CZO, Brisbane Aerodrome, Queensland, on 29 January 1997

Summary

Sequence of Events

The aircraft had commenced its take-off run on runway 19 when the driver of an FAC car on the eastern side of the runway radioed the Surface Movement controller (SMC) with a request to cross the runway at taxiway Mike. The SMC who did not hear the transmission properly, assumed that the car was already on the western side of the active runway and approved what he thought was a clearance to enter the taxiway.

The driver of the car did not realise that the clearance did not contain the words "clearance to cross the runway" and subsequently did not question the SMC. He also did not stop the car at the holding point to check for air traffic. He did not see the approaching jet until the car had entered the runway. He attempted to accelerate the car out of the way. The aircraft became airborne about 200 m short of the car and overflew at about 80 ft.

Analysis

The SMC did not follow standard ATS procedures. He did not ask for a repeat of the transmission from the FAC car driver and did not check the physical location of the vehicle before issuing a clearance. The clearance he issued did not comply with local operating instructions. The controller was moderately busy at the time.

The driver of the car did not follow ground safety instructions. He did not receive a correctly phrased clearance, nor did he stop at the holding point to check for any aircraft landing or taking off.

A collision between the aircraft and the car was avoided by good fortune only. The aircraft became airborne before reaching the taxiway.

Occurrence summary

Investigation number 199700267
Occurrence date 29/01/1997
Location Brisbane Aerodrome
State Queensland
Report release date 20/03/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZO
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane QLD
Destination Townsville QLD
Damage Nil

Runway incursion involving an Airbus A300-B4-203, VH-TAC, Brisbane Aerodrome, Queensland, on 28 September 1995

Summary

A utility vehicle was instructed by the surface movement controller to hold at taxiway A4 holding point which is clear of runway 01. At the same time an A300 was landing on runway 01 and was expected to exit the runway via taxiway A4S, a high-speed exit. However, the aircraft continued past this exit, and as it became obvious that it would now exit at taxiway A4 where the vehicle was stopped, the vehicle driver was instructed to vacate the taxiway. The driver reacted by driving across the runway, passing beneath the wing of the aircraft as it entered the taxiway. The driver misunderstood the instruction and was under the impression that he was cleared to cross the runway. The company has undertaken to re-brief all drivers with reference to clearance requirements.

Occurrence summary

Investigation number 199503192
Occurrence date 28/09/1995
Location Brisbane Aerodrome
State Queensland
Report release date 12/03/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident

Aircraft details

Manufacturer Airbus
Model A300-B4-203
Registration VH-TAC
Sector Jet
Operation type Air Transport High Capacity
Destination Brisbane, QLD
Damage Nil

Loss of separation involving a Boeing 717, VH-NXL and a vehicle, at Perth Airport, Western Australia, on 26 July 2014

Final report

On 26 July 2014, the crew of a QantasLink Boeing 717 aircraft, registered VH-NXL (NXL), conducted a scheduled passenger flight from Karratha to Perth, Western Australia, where runways 21 and 24 were in use. At about 1200, the first officer of NXL contacted the aerodrome controller (ADC) who acknowledged the call. At about 1201, an airport safety officer contacted the ADC and advised that their vehicle was holding short of runway 24 for a runway inspection. The ADC cleared the vehicle to enter runway 24 and hold short of runway 21, then indicated on the console runway strip that runway 24 was occupied.

At that time, NXL was on final approach about 7.5 NM from runway 24 and the flight crew did not hear the vehicle being cleared onto the runway. The safety officer drove along the centreline of runway 24 towards the intersection with runway 21.

At about 1203, the ADC cleared an aircraft for take-off from runway 21. After observing that aircraft pass through the intersection of runway 24, the ADC picked up the flight progress strip for NXL, scanned the runway but did not see the vehicle on it, and moved the strip into the console runway bay. The ADC then cleared NXL to land on runway 24. At that time, NXL was on final at about 1,000 ft and 1.5 NM from the runway threshold. The safety vehicle was on runway 24 heading south-west. The safety officer heard NXL being cleared to land but not the assigned runway.

As NXL touched down on runway 24, the first officer saw the flashing lights of a vehicle ahead on the runway, immediately stated ‘go-around, car on the runway’ and the captain commenced a go-around. The safety vehicle was then stationary on the centreline of runway 24 about 1180 m from the threshold and facing away from the approaching aircraft. The safety officer did not see the aircraft until it passed about 150 ft over the safety vehicle.

With experience comes the ability to fuse conscious control with largely automated actions. The penalty for this can be absent-mindedness or a lack of attention to a specific task.

Aviation Short Investigations Bulletin - Issue 39

Occurrence summary

Investigation number AO-2014-133
Occurrence date 26/07/2014
Location Perth Airport
State Western Australia
Report release date 26/02/2015
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 717-200
Registration VH-NXL
Serial number 55093
Aircraft operator National Jet Systems
Sector Jet
Operation type Air Transport High Capacity
Departure point Karratha, WA
Destination Perth, WA
Damage Nil

Runway incursion involving Bombardier DHC-8-402, VH-QOP, Gladstone Airport, Queensland, on 17 April 2014

Summary

On 17 April 2014 at about 1705 Eastern Standard Time, the crew of a Bombardier DHC-8, registered VH-QOP, were taxiing at Gladstone Airport, Queensland, for a scheduled passenger service to Sydney, New South Wales. There were heavy showers in the vicinity of the airport at the time.

The crew reported taxiing for runway 10, which was soon followed by a report from the crew of an ATR-72 that they were 5 NM from Gladstone, on final approach to runway 10. Noting the position of the ATR-72, the crew of VH-QOP elected to taxi in a westerly direction along taxiway A (parallel to the runway), planning to enter the runway via taxiway A1 after the ATR-72 had landed. The crew were not particularly familiar with Gladstone Airport, and even less familiar with taxiway A and A1. The crew commented that, subject to traffic conditions, it was more common to enter the runway using other taxiways leading directly from the terminal area.

As they taxied, the crew contemplated switching to runway 28 for departure because weather surrounding the airport appeared to be less intense to the west. The crew discussed departure options and reviewed aircraft performance information as they taxied. At the same time, they remained mindful of the ATR-72 on final approach to runway 10.

The crew of VH-QOP made a right turn from taxiway A onto taxiway A1 as the ATR-72 was on late final approach. As they entered taxiway A1, the crew inadvertently continued over the holding point line before coming to a stop. The main wheels of the aircraft were just beyond the holding point line as the ATR-72 landed. Although the crew of VH-QOP stopped well short of the runway surface and were aware of the ATR-72 on final approach, the incident still falls within the definition of a runway incursion given the ‘incorrect presence’ of the aircraft within the runway flight strip as another aircraft was landing.

This incident highlights the importance of careful attention to airfield markings during ground manoeuvring, especially when crew workload is elevated, and when a crew is unfamiliar with the airport layout. This message applies equally to all airside vehicle operators.

Aviation Short Investigations Bulletin - Issue 35

Occurrence summary

Investigation number AO-2014-073
Occurrence date 17/04/2014
Location Gladstone Airport
State Queensland
Report release date 15/10/2014
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Bombardier Inc
Model DHC-8-402
Registration VH-QOP
Serial number 4238
Aircraft operator Sunstate Airlines
Sector Turboprop
Operation type Air Transport High Capacity
Departure point Gladstone, Qld
Destination Sydney, NSW
Damage Nil

Runway incursion involving a Cessna 172, VH-WGL and a De Havilland DHC-8, VH-QQD, at Toowoomba Airport, Queensland, on 28 March 2014

Summary

On 28 March 2014, at about 1628 Eastern Standard Time, the pilot of a Cessna 172, registered VH-WGL (WGL), broadcast on the common traffic advisory frequency (CTAF) that he was 10 NM to the north-east, inbound to Toowoomba, and intended to conduct a straight-in approach to runway 29. At about 1631, the pilot of WGL broadcast on a 5 NM final and about 1 minute later, he broadcast on a 3 NM final for a full stop landing on runway 29. At about 1633, he broadcast on short final for runway 29. The aerodrome frequency response unit (AFRU) provided a beep-back for each of those calls, but no other response was heard on the CTAF.

About 20 seconds later, the first officer of a de Havilland DHC-8, registered VH-QQD (QQD), broadcast on the CTAF that QQD was taxying to runway 29, for a flight to Brisbane. He then contacted Brisbane Centre air traffic control and made a taxi call on that frequency as the aircraft approached the holding point. As WGL flared to land, the pilot heard both taxi calls from QQD on the CTAF and Brisbane frequency and observed QQD taxi towards the runway. Approaching the holding point, the captain of QQD reported that he looked to the left and confirmed all clear, and the first officer looked to the right, did not sight any aircraft and confirmed clear to the right. The captain taxied QQD onto the runway and the first officer reported sighting the Cessna on the runway as QQD crossed the holding point.

At about 1634, WGL touched down about 5 m beyond the runway threshold, and the pilot observed QQD continue to taxi and turn onto the runway and he braked heavily. The crew of QQD had not heard any of the broadcasts from WGL.

This incident highlights the importance of maintaining a listening watch and communication in alerting pilots to other aircraft.

Aviation Short Investigations Bulletin - Issue 32

Occurrence summary

Investigation number AO-2014-061
Occurrence date 28/03/2014
Location Toowoomba Airport
State Queensland
Report release date 14/07/2014
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-8-102
Registration VH-QQD
Serial number 245
Aircraft operator Skytrans
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Toowoomba. Qld
Destination Brisbane, Qld
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172S
Registration VH-WGL
Serial number 172S9271
Sector Piston
Operation type Private
Departure point Redcliffe, Qld
Destination Toowoomba, Qld
Damage Nil

Runway incursion between a Fairchild SA227, VH-UZP and a Bell 47, VH-UTF, at Ballina Airport, New South Wales, on 9 October 2013

Summary

On 7 October 2013, the pilot of a Fairchild SA227 aircraft, registered VH‑UZP (UZP), was preparing for a freight charter flight from Ballina/Byron Gateway Airport (Ballina) to Coffs Harbour, New South Wales.

At the same time, the flight instructor and pilot of a Bell 47G helicopter, registered VH‑UTF (UTF), were conducting circuit training at Ballina. After landing, the pilot broadcast on the common traffic advisory frequency (CTAF) that UTF was entering runway 06 to conduct left hand circuits. Shortly after, UTF departed and recommenced circuit training.

The pilot of UTF broadcast turning onto a left base for runway 06. Soon after, UTF landed about two-thirds of the way along the runway and came to a stop, facing east.  The instructor briefed the pilot prior to commencing a further circuit. 

The pilot of UZP broadcast a taxi call and commenced taxiing to runway 06. After hearing no further broadcasts from the pilot of UTF, the pilot of UZP broadcast on the CTAF that he was entering and backtracking runway 06. The pilot again received no response. He taxied UZP onto the runway and lined up on runway 06. The pilot broadcast a lining up and rolling call and commenced the take-off run. Just prior to rotation, he sighted UTF stopped on the runway, towards the departure end. He elected to continue the take-off and increased the climb angle to provide separation with UTF.

The instructor of UTF then attempted to contact UZP, with nil response received. He then realised that the radio volume had been turned down. UTF then vacated the runway.

Broadcasting and monitoring the CTAF and maintaining a good lookout are useful strategies to improve safety at non-towered aerodromes.

Aviation Short Investigation Bulletin - Issue 25

Occurrence summary

Investigation number AO-2013-177
Occurrence date 09/10/2013
Location Ballina/Byron Gateway Airport
State New South Wales
Report release date 20/01/2014
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Bell Helicopter Co
Model 47
Registration VH-UTF
Serial number 25026
Sector Helicopter
Operation type Flying Training
Departure point Ballina, NSW
Destination Ballina, NSW
Damage Nil

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227
Registration VH-UZP
Serial number AC-498
Sector Turboprop
Operation type Charter
Departure point Ballina, NSW
Destination Coffs Harbour, NSW
Damage Nil

Runway incursion between a Cessna 206, VH-LHX and a Cessna 210, VH-HGZ, Gove Airport, Northern Territory, on 13 August 2013

Summary

On 13 August 2013, the pilot of a Cessna 210 aircraft, registered VH-HGZ (HGZ), was conducting a charter flight from Groote Eylandt to Gove Airport, Northern Territory. Prior to commencing the descent, the pilot broadcast an inbound call on the Gove common traffic advisory frequency (CTAF). Soon after, the pilot reported broadcasting a call advising he was at 10 NM, inbound, with the intention of joining the base leg of the circuit for runway 31.

At about the same time, the pilot of a Cessna 206 aircraft, registered VH-LHX (LHX), broadcast a call on the CTAF advising that he was taxiing at Gove. Shortly after, the pilot broadcast another call stating that he was entering and backtracking runway 13.

The pilot of HGZ joined base for runway 31 and broadcast a call. The pilot stated that he was aware of LHX taxiing.

The pilot of LHX contacted the pilot of HGZ and confirmed that he was approaching runway 31. The pilot of LHX then immediately broadcast a call advising that he was on the runway and was lining up for runway 13, but no response was received. The pilot of LHX then broadcast his intention to hold at the turning node, which was located mid-way along the runway, but within the confines of the flight strip. The pilot of HGZ responded and advised that he had LHX sighted and was on final approach for runway 31. 

HGZ landed on runway 31 and vacated the runway. At the time, LHZ was positioned at the turning node, but the runway was still occupied. LHX subsequently departed from runway 13.

Aviation Short Investigation Bulletin - Issue 24

Occurrence summary

Investigation number AO-2013-162
Occurrence date 13/08/2013
Location Gove Airport
State Northern Territory
Report release date 10/12/2013
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210
Registration VH-HGZ
Serial number 21060430
Sector Piston
Operation type Charter
Departure point Groote Eylandt, NT
Destination Gove, NT
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 206
Registration VH-LHX
Serial number U20603555
Sector Piston
Operation type Charter
Departure point Gove, NT
Destination Baniyala, NT
Damage Nil

Runway incursion between a De Havilland DH-82, VH-BJE and a Piper PA-34, VH-SEN, Redcliffe (ALA), Queensland, on 8 September 2013

Summary

On 8 September 2013, the pilot and passenger of a De Havilland DH‑82A aircraft, registered VH‑BJE (BJE), were conducting a local scenic flight from the Redcliffe aeroplane landing area (ALA).

At about 1615 Eastern Standard Time, the pilot broadcast a taxi call on the common traffic advisory frequency (CTAF) and commenced taxiing via the eastern-most taxiway toward runway 07. The pilot then reported broadcasting a call advising that he was entering and backtracking runway 07. The aircraft was backtracked on the grass on the southern side of the sealed runway.

At the same time, the pilot of a Piper PA‑36 aircraft, registered VH‑SEN (SEN), broadcast a taxi call on the CTAF and taxied from the eastern taxiway behind BJE, then turned onto the sealed taxiway to runway 07. When SEN arrived at the intersection between the western taxiway and runway 07, the pilot reported that he broadcast his intention to line up after an aircraft on final had landed.

The pilot of BJE taxied off the flight strip, outside the gable markers, to allow the aircraft on final to land and vacate the runway. He then reported broadcasting a lining up and rolling call and lined up on the grass to the right of the sealed runway.

At about the same time, the pilot of SEN also broadcast a call advising he was entering, lining up and rolling on runway 07. The pilot of BJE heard the pilot of SEN broadcast the call. He looked back and observed SEN lined up on the sealed runway. He immediately broadcast a call requesting the pilot of SEN delay his take-off as BJE was within the confines of the flight strip. The pilot of SEN had also observed BJE about 100 m ahead on the grass, to the right, and reported that he rejected the take-off and made a call to BJE requesting his intentions. The pilot of BJE then commenced a turn towards the gable markers.

Shortly after, SEN recommenced the take-off. When SEN passed BJE, the pilot of BJE reported that his aircraft was still within the flight strip and estimated that the aircraft came within 10-15 m of each other.

Aviation Short Investigation Bulletin - Issue 24

Occurrence summary

Investigation number AO-2013-148
Occurrence date 08/09/2013
Location Redcliffe Aerodrome
State Queensland
Report release date 10/12/2013
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer de Havilland Aircraft
Model DH-82
Registration VH-BJE
Serial number A17-97
Sector Piston
Operation type Charter
Departure point Redcliffe, Qld
Destination Redcliffe, Qld
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-34
Registration VH-SEN
Serial number 34-7250053
Sector Piston
Operation type Charter
Departure point Redcliffe, Qld
Damage Nil

Runway incursion between Piper PA-31, VH-KLS and vehicle, at Port Hedland Airport, Western Australia, on 26 May 2013

Summary

On 26 May 2013 at 1512 Western Standard Time, the pilot of a Piper PA‑31, registered VH-KLS (KLS), taxied for departure from runway 32 at Port Hedland for a flight to Karratha, Western Australia. The pilot made the necessary common traffic advisory frequency (CTAF) broadcast.

At about 1517, an aviation rescue and fire fighting (ARFF) vehicle that had been operating on the eastern side of the airport entered taxiway Bravo to return to the fire station on the western side. The crew made a CTAF broadcast at 1518, stating that they intended to cross runway 32 on taxiway Alpha. Hearing no response to the broadcast and seeing no aircraft on the runway, the crew crossed runway 32.

The pilot of KLS taxied onto the threshold of runway 32 and commenced the take-off roll. The pilot reported making the required CTAF broadcasts. At 1520, as KLS became airborne, the pilot observed the fire vehicle crossing the runway about 500 m ahead. As the aircraft was airborne, the pilot assessed the safest action was to continue the take-off and the aircraft passed over the intersection between runway 32 and taxiway Alpha between 300 and 400 ft above ground level. By the time KLS crossed the intersection the fire vehicle was clear of the runway.

The crew of the fire vehicle had not heard any CTAF broadcasts from KLS nor did they see the aircraft when they scanned the runway prior to crossing, possibly due to heat haze. The pilot of KLS had not heard the CTAF broadcast made by the fire vehicle.

As a result of this occurrence, the ARFF service provider has advised the ATSB that they will undertake two safety actions. They will release a national operational safety note advising ARFF operators of the efficient use of aviation radio communications when driving on an airfield. Additionally, they will undertake a comprehensive review of aviation radio coverage at Port Hedland as part of radio commissioning works. Any identified radio coverage deficiencies will be monitored by the service provider until resolution.

 Aviation Short investigation Bulletin Issue 22

Occurrence summary

Investigation number AO-2013-091
Occurrence date 27/05/2013
Location Port Hedland Airport
State Western Australia
Report release date 17/09/2013
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31
Registration VH-KLS
Serial number 31-8112030
Operation type Aerial Work
Departure point Port Hedland, WA
Destination Karratha, WA
Damage Nil

Runway incursion between Cessna 206, VH-TOC and vehicle, Mount Isa Airport, Queensland, on 24 February 2013

Summary

On 24 February 2013, the pilot of a Cessna 206 aircraft, registered VH-TOC (TOC), was conducting a private flight from Lake Nash, Northern Territory, to Mount Isa, Queensland, when the aircraft’s avionics system failed. The pilot commenced the radio failure procedure by squawking the transponder code of 7600 and transmitting blind.

The pilot overflew the Mt Isa Airport to assess the wind conditions and rocked the aircraft’s wings to alert any ground personnel of the communication failure, he then joined the circuit.

At around the same time, the Mount Isa airport safety officer (ASO) was preparing to conduct a runway and lighting inspection. The ASO turned on the vehicle’s radio and lighting. The ASO then activated the pilot activated lighting (PAL) and aerodrome frequency response unit (AFRU) systems.

The ASO broadcast a call on the Mount Isa common traffic advisory frequency (CTAF), advising that the vehicle was entering the runway and conducted a lookout for aircraft. As no response was received or aircraft sighted, the inspection was commenced.

By this time, the pilot of TOC was on the base leg of the circuit for runway 34 and observed a vehicle near the runway 34 threshold. He assumed the vehicle and would exit the runway, leaving the runway clear for him to land. The pilot continued to transmit his intentions blind.

As the pilot commenced the flare, he noticed that the vehicle had not yet vacated the runway. As a result of the vehicle being on the runway, the pilot initiated a go-around.

The aircraft passed 200-300 ft above the vehicle. The ASO heard TOC pass overhead and vacated the runway. The pilot of TOC conducted a second circuit and landed without further incident.

Mount Isa Airport Pty. Ltd. had planned to place yellow and black chequered safety stickers on the side and rear of the vehicle. As a result of this occurrence, that action was immediately implemented.

The need to conduct a go-around may occur at any point in the approach and landing phase, however, the sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

Aviation Short Investigation Bulletin Issue 19

Occurrence summary

Investigation number AO-2013-037
Occurrence date 24/02/2013
Location Mount Isa Airport
State Queensland
Report release date 29/05/2013
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 206
Registration VH-TOC
Serial number U20603678
Operation type Private
Departure point Lake Nash, NT
Destination Mount Isa, Qld
Damage Nil