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B738, Perth Western Australia, 2010

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Summary
On 24 February 2010, a Garuda Boeing 737-800 misunderstood the runway exit instruction issued during their landing roll at Perth and turned onto an intersecting active runway. An expeditious exit from this runway followed and no actual conflict resulted. The phraseology used by air traffic control was open to incorrect interpretation by the flight crew and led to their premature turn off the landing runway despite a prior briefing on exit options.
Event Details
When February 2010
Actual or Potential
Event Type
AGC, HF, RI
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 737-800
Operator Garuda Indonesia
Domicile Indonesia
Type of Flight Public Transport (Passenger)
Origin Denpasar/Ngurah Rai International Airport
Actual Destination Perth International Airport
Flight Phase Taxi
TXI
Location - Airport
Airport Perth International Airport
AGC
Tag(s) Phraseology
HF
Tag(s) Inappropriate ATC Communication
Ineffective Monitoring
RI
Tag(s) Accepted ATC Clearance not followed
Incursion after Landing
Intersecting Runways
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 24 February 2010, a Boeing 737-800 being operated by Garuda on a scheduled passenger flight from Denpasar, Indonesia to Perth failed to follow the runway exit instruction given by ATC after a daylight landing in normal visibility on runway 03 at destination and instead turned right directly onto intersecting active runway 06. ATC then instructed an expeditious exit of this runway to the right via taxiway S and no actual conflict occurred.

Investigation

An Investigation was carried out by the ATSB. It was established that no runway exit instructions had been given to the aircraft prior to touchdown and that an instruction to “take taxiway November, second on your right now’ had been issued as the aircraft decelerated on the landing roll prior to taxiway ‘P’.

Perth Aerodrome layout. Source: Final report

It was noted that the flight crew briefing for the approach and landing had identified taxiways P and N as the first and second exits from the landing runway.

The Final Report AO-2010-011 of the Investigation was published on 29 June 2010

Further Reading