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AT76, Canberra Australia, 2019

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Summary
On 25 September 2019, an ATR 72-600 about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.
Event Details
When September 2019
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft ATR ATR-72-600
Operator Virgin Australia
Domicile Australia
Type of Flight Public Transport (Passenger)
Origin Canberra International Airport
Intended Destination Sydney Airport
Take off Commenced Yes
Flight Airborne No
Flight Phase Take Off
TOF
Location - Airport
Airport Canberra International Airport
General
Tag(s) Inadequate Aircraft Operator Procedures,
Airport Layout
HF
Tag(s) Ineffective Monitoring,
Procedural non compliance
RI
Tag(s) Accepted ATC Clearance not followed,
Incursion pre Take off,
Intersecting Runways,
Wrong Active Runway
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation,
Air Traffic Management
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 25 September 2019, an ATR 72-600 (VH-VPJ) being operated by Virgin Australia Airlines on a scheduled domestic passenger flight from Canberra to Sydney taxied out in normal night visibility on a clearance to line up and subsequently take off from runway 35 but instead entered and began takeoff from runway 30. ATC noticed the error and instructed the aircraft to stop which it did from a low speed with no consequences. The aircraft was subsequently repositioned for takeoff from runway 30 and departed without further event. The available distance on runway 30 was calculated to be insufficient for the aircraft to take off in.

The Terminal showing its proximity to the runway intersection where the incursion occurred. [Reproduced from the Official Report]

Investigation

An Investigation into the accident was carried out by the Australian Transport Safety Bureau (ATSB). Relevant aircraft flight data was available in support of the Investigation as was relevant recorded ATC data.

It was noted that the Captain, who was acting as PF for the sector, had a total of 6,500 hours flying experience of which 2,375 hours were on type. The First Officer had a total of 6,700 hours flying experience of which 6,100 hours were on type.

What Happened

After pushback, the aircraft was cleared to taxi to intersection ‘G’ as explicitly requested. The taxi time was only around a minute and, as they approached the holding point which was common to both runway 35 and runway 30 (see the illustration below), the First Officer reported “ready” to TWR and the aircraft was cleared to line up on runway 35. Shortly after that, takeoff clearance was given and since neither pilot realised that they had actually lined up on runway 30, the power levers were advanced to the takeoff position and the aircraft began to move. However, at about the same time as the crew reported having realised that they were on the wrong runway, the TWR controller, although not having had originally noticed that the aircraft had lined up on the wrong runway, then saw it beginning to take off and immediately instructed it to stop, to which the First Officer responded with “stopping”. After repositioning, the aircraft subsequently took off from runway 35 without further event.

Access to both runways 35 and 30 from taxiway ‘G’ with the aircraft track shown in green. [Reproduced from the Official Report]

Discussion

It was noted by the Investigation that:

  • There had been no other reported incidents involving an aircraft inadvertently taxiing onto the wrong runway from the taxiway ‘G’ access within the previous five years.
  • All markings, lighting and signage in relation to the distinction between access to runway 30 and 35 from taxiway ‘G’ were in accordance with regulatory requirements.
  • Both runways were in use at the time of the incursion but only runway 35 had centreline lighting.
  • Runway 35 was 45 metres wide whereas runway 30 was only 30 metres wide.
  • Due to the relative complexity of the layout, the ‘G’ intersection with runways 30 and 35 was designated and shown on the Jeppesen charts used by Virgin Australia as a Hotspot.
  • When the illuminated stop bar on taxiway ‘G’ was extinguished in accordance with the line up clearance being given, the lead on lines to both runways were simultaneously illuminated.
  • Both pilots had regularly operated out of Canberra “over a number of years” and were familiar with day and night operations. However, neither “could recall previously using intersection ‘G’ for departure at night, but had used it for departure at least once during the day”.
  • The TODA for a departure from intersection ‘G’ was 1,870 metres for runway 35 and 1,030 metres for runway 30. At the prevailing aircraft weight and in the environmental conditions, about 1700 metres was required for the takeoff and the ASDA for both runways was about 1,650 metres.

No evidence was found that would indicate that either pilot was experiencing a level of fatigue known to have an adverse effect on performance. The Investigation therefore focused primarily on the consequences of the very short time between the aircraft beginning to taxi and beginning to take off, the reasons for the crew’s desire to minimise this time and the effectiveness of the operator’s relevant SOPs:

  • The short taxi time meant that the prescribed checks were of necessity rushed and unlikely to have been fully completed. In particular, the ‘Before Takeoff’ checklist had not been completed as far as required before the First Officer called “ready” and received the line up clearance and once on the runway the final item requiring the crew to “verify the aircraft had lined up on the correct runway using internal cues within the cockpit such as those provided by the HSI” and all other relevant information was evidently ignored.
  • The apparent priority to make a rapid departure from a rarely used intersection despite being ahead of schedule may have been associated with action taken by the Brisbane-based Captain before the aircraft left Sydney for the flight to Canberra and back. He had been rostered to position back to Brisbane after operating the flight from Canberra on a flight which departed 1 hour and 40 minutes after the scheduled arrival time from Canberra but had called crewing to transfer his booking to an earlier flight which was scheduled to depart just 10 minutes after the scheduled arrival of his flight from Canberra. The request for the shortest taxi route possible from the terminal to the runway may also have been made in the knowledge that two other flights had also requested pushback at around the same time.
  • The operator’s ATR72 ‘Before Takeoff’ procedures did not specify at what point it was appropriate to make the call ‘ready’ (for takeoff) to ATC and the crew involved stated that they would often make this call prior to even commencing these procedures. It was noted that by comparison, the call ‘ready’ was placed at the end of these procedures for the operator’s Boeing 737 fleet. It was also found that the operator’s ATR72 before takeoff procedures did not include an explicit requirement for a crew to confirm and verbalise external cues to confirm that the position of an aircraft during taxi and line up was correct.

Six Contributing Factors, two of which were defined as ‘Safety Issues’, were identified as follows:

  • At night, the flight crew inadvertently lined-up and commenced the takeoff roll on runway 30, rather than the assigned runway 35. The flight crew and air traffic control noticed the error about the same time and the takeoff was rejected.
  • The runway intersection selected reduced the taxi time, resulting in the flight crew announcing they were 'ready' before completing the 'before takeoff' procedure.
  • While taxiing onto the runway, the captain was focused on following the runway lead-on lights while the first officer was completing the ‘before takeoff’ procedure and checklist. This likely resulted in them having a reduced awareness of the runway environment and aircraft orientation.
  • When the runway holding point stop bar at intersection Golf was turned off, the lead-on lights to both runway 30 and 35 were illuminated. This increased the risk of an aircraft being manoeuvred onto the incorrect runway, particularly at night and/or in low visibility conditions.
  • The Virgin Australia Airlines ‘Before Takeoff’ procedure did not include a step to report ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying was critical.

[Safety Issue]

  • Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.

[Safety Issue]

It was also formally recorded that the immediate response of air traffic control and the flight crew in rejecting the takeoff, reduced the risk of a runway overrun.

Safety Action stated by Virgin Australia Airlines to be intended as a result of this event in respect of their continuing (Boeing 737) flight operations - ATR 72 operations having since been discontinued - involves amending their Operating Policies and Procedures Manual to include reference to external cues, including runway signs and the localiser and changes to the 737 FCOM to add the following to required pre takeoff actions:

  • Both flight crew are required to verify the intended takeoff position with the TOLD [take-off and landing data] card.
  • Both flight crew are required to verify the runway and runway takeoff position are correct. The pilot flying references the runway signage and/or runway markings and the pilot monitoring verifies the position and verbalises that it has been ‘checked’.
  • Prior to commencing the takeoff roll, verify that the aircraft heading agrees with the runway heading.

On the basis of the findings of the Investigation, the ATSB formally documented a Safety Message as follows:

The design of airport runways and taxiways vary from relatively simple to more complex layouts. This can be exacerbated by reduced visual cues, such as night-time or poor weather, which can easily increase confusion. It is important for all flight crew to familiarise themselves with these layouts, particularly any unique designs, and ensure effective flight crew co-ordination is employed to minimise the risk of a runway incursion.
Operators should ensure the design of their operating procedures minimises the risk of human error. Clearly delineating procedural steps may reduce the likelihood of flight crews’ heads down activities at critical moments throughout the flight.

The Final Report was released on 11 December 2020. No Safety Recommendations were made.

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