Virgin Australia AT72 at Canberra on Sep 25th 2019, runway incursion

Last Update: December 11, 2020 / 07:11:01 GMT/Zulu time

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Photo of Virgin Australia VH-VPJ, ATR ATR-72-200 — Virgin Australia VH-VPJ, ATR ATR-72-200 (Photo credit: mitchul / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Sep 25, 2019

Classification
Incident

Cause
Runway incursion

Airline
Virgin Australia

Flight number
VA-669

Departure
Canberra, Australia

Destination
Sydney, Australia

Aircraft Registration
VH-VPJ

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A Virgin Australia Avions de Transport Regional ATR-72-212A, registration VH-VPJ performing flight VA-669 from Canberra,AC to Sydney,NS (Australia), was taxiing for departure from runway 35 and had been cleared to taxi to holding point Golf for departure from runway 35. Subsequently ATC cleared the aircraft for takeoff from runway 35, the aircraft however lined up runway 30 and was instructed to stop.

The ATSB reported tower subsequently provided taxi instructions to holding point November for departure from 35, the aircraft departed without further incident. A short investigation was opened into the occurrence rated an incident.

On Dec 11th 2020 the ATSB released their final report concluding the probable causes of the incident were:

Contributing factors

- At night, the flight crew inadvertently lined-up and commenced the take-off 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 take-off was rejected.

- The runway intersection selected reduced the taxi time, resulting in the flight crew announcing they were 'ready' before completing the 'before take-off' 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 take-off 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 take-off 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).

Other findings

- The immediate response of air traffic control and the flight crew with rejecting the take-off, reduced the risk of a runway overrun.

The ATSB summarized the sequence of events:

As part of their pre-flight planning, the flight crew elected to depart from intersection ‘Golf’ (G) for runway 35 (refer to section titled Canberra Airport information). The flight crew reported they based this decision on the aircraft’s performance, taking into account the weight and environmental conditions at the time, and the proximity of intersection G to their parking bay.

At about 1855, after the flight crew completed their pre-flight briefing, they requested a pushback clearance from air traffic control (ATC), which was approved. Several minutes later, the flight crew requested a taxi clearance to the holding point at intersection G, which was also approved. At around the same time, the flight crew of two other aircraft also requested clearances for pushback and taxi.

At about 1858, the captain commenced taxiing the aircraft. While taxiing to intersection G, the flight crew completed their departure review, which included checking the departure runway and intersection, take-off performance speeds and the flap setting. Before departure, there was no mention of the departure’s complexity or its designation as a hotspot. Just prior to reaching the holding point, the first officer (FO) advised ATC that they were ‘ready’ [to take-off] and then commenced the Before take-off procedure (refer to section titled Take-off performance).
At about 1859, ATC instructed the flight crew to line-up on runway 35 and about a minute later, they were cleared for take-off, with both instructions read back correctly by the FO. After the stop bar was deactivated by ATC, the aircraft crossed the holding point and the captain commenced turning through the intersection, inadvertently aligning with the centreline of runway 30.

During the turn, the FO was completing the final Before take-off checks and therefore, only looked up after the aircraft was lined-up on the runway. The captain recalled focusing on taxiing the aircraft to follow the lead-on lights (refer to section titled Airport lighting) and trying not to go too far into the intersection. Both flight crew recalled ‘the picture didn’t look right’ when they were lined-up on what they thought was the departure runway (runway 35). They also reported the runway (runway 30) appeared shorter than expected and that there was no centreline lighting. Neither of the flight crew could recall if they cross-checked the aircraft’s heading or position by available means as per the operator’s Before take-off procedure when they were in the lined-up position.

The ATSB analysed:

Line-up on incorrect runway

Shortly after the flight crew were cleared for take-off on runway 35 at night by ATC, the captain inadvertently taxied the aircraft onto runway 30. After lining-up on runway 30, the engine power increased and brake pressure decreased, which was consistent with commencing the take-off roll. The recorded flight data was consistent with the airport closed-circuit television footage of the aircraft’s movements on the taxiway and runway 30.

While the flight crew did not recall commencing the take-off roll, they did notice there were differences in the runway environment to what they were expecting and discussed it with each other. Specifically, there was no centreline lighting and the runway appeared shorter than expected. The abrupt rejection of the take-off at about the same time ATC issued the ‘stop’ instruction was consistent with the flight crews’ reported awareness of a problem with the runway environment.

Time pressure before take-off

The flight crew elected to depart from intersection G for runway 35 primarily due to its proximity to their parking bay and this departure was within the performance limits. Although there were no delays on the night of the incident and the flight was reported to be running early, it was possible that the flight crew were also attempting to depart ahead of the other two aircraft, particularly given the captain’s rescheduled flight to Brisbane. However, neither flight crew recalled these factors influenced their decision to use intersection G for departure.

By selecting intersection G, the flight crew only allowed themselves around 90 seconds to complete their preparatory tasks before arrival at the holding point. These tasks included the departure review and Before take-off procedure. If they had selected another taxiway entry to runway 35, they would have had several additional minutes before arrival at the respective holding point in which to complete their checks.

This self-imposed time pressure led to the First Officer (FO) calling ‘ready’ as the aircraft taxied to the holding point for intersection G and prior to completing the Before take-off procedure. This procedure should have been completed before entering the runway, with the exception of the last item in the procedure to confirm that they were lined-up on the runway’s centreline. This resulted in the FO’s attention being diverted to the procedure when entering the runway environment.

Reduced awareness of the runway environment

On the night of the incident, the flight crew elected to depart from intersection G for runway 35. Although they operated routinely to Canberra Airport, they both reported they could not recall having departed from this intersection at night. After pushback and while taxiing towards intersection G, the flight crew briefed the departure, but did not specifically include the layout of the intersection in their brief.

As they approached intersection G, the FO reported focusing on the Before take-off procedure and was therefore not monitoring the external environment. The captain reported being focussed on the lead-on lights. However, the Before take-off procedure was a challenge and response procedure, and therefore would have required some of the captain’s attention. This likely resulted in the captain taxiing the aircraft through the intersection with divided attention while the FO’s attention was focussed inside the cockpit. Barshi and others (2009) reported that during busy periods, it is easy for attention to be absorbed in one task, which can divert attention from other important tasks, such as monitoring.
Neither flight crew could recall if they checked the aircraft’s heading after line-up. As they subsequently commenced the take-off roll, they had not identified they were lined-up on the incorrect runway. This indicated the flight crew had a reduced awareness of their position within runway environment.

Lead-on lights from intersection ‘Golf’

Taxiway G led to the intersection of runway 12/30 and runway 17/35. This intersection was identified as a hotspot, which could potentially be confusing to flight crew, particularly at night. When ATC issued the line-up clearance to the flight crew from this intersection, the stop bar was selected off by ATC and the lead-on lights for runway 35 illuminated. The lead-on lights for runway 30 were already illuminated with the taxiway lighting, which resulted in the lead-on lights for both runways illuminated at the same time. As the lead-on lights for runway 30 were the first set encountered when entering the intersection, these lights likely drew the captain’s attention, resulting in the aircraft being manoeuvred to follow them.

A risk when operating at an airport with a complex layout at night and/or low visibility conditions is runway confusion, where pilots enter, take-off, or land on the incorrect runway (Airservices Australia 2016). This can occur when features of the taxiway or runway, such as lighting are misidentified. While there were no other known incidents at Canberra Airport, the simultaneous activation of the lead-on lights at intersection G increased the risk of an aircraft being manoeuvred onto the incorrect runway.

ATR72 before take-off procedure

The flight crew called ‘ready’ prior to commencing the Before take-off procedure on the night of the incident, which they reported they had done frequently. However, the Virgin Australia Airlines ATR72 Standard Operating Procedure did not specify a particular time when the flight crew were to make this call to ATC. By comparison, calling ‘ready’ was specified as the final item in the operator’s Boeing 737 Before take-off procedure, meaning that there were no further tasks to be completed until the flight crew received their take-off clearance from ATC.

Degani and Weiner (1993) as well as Barshi and others (2016) research into checklist design concluded that checklists should be designed in such a way that their execution will not be integrated with other tasks. They suggested countermeasures could include carefully examining the content and timing of procedures and checklists, such as specifying the tasks that must be completed at specific points in each phase of flight. Specifically, the timing of the procedure and checklist should minimise the risk of interruptions, distractions, and concurrent tasks. Similarly, Virgin Australia Airlines and Airservices Australia provide general guidance to consider the timing of tasks, such as avoiding heads down activity while the aircraft is moving.

For the incident flight, the timing of the ‘ready’ call resulted in the aircraft crossing the holding point and entering the runway with the FO focussed on checklist items. Consequently, the FO was unable to monitor the environment as the aircraft entered the runway to line-up.

Therefore, the omission of a step in the ATR72 Before take-off procedure for the ‘ready’ call, increased the risk of flight crews actioning this procedure while entering the runway. In turn, diverting their attention to checklist items at a time when monitoring and verifying the runway environment was critical.

Runway verification cues procedure

Virgin Australia Airlines’ ATR72 Standard Operating Procedure and fleet-wide policy and procedures draw reference to the importance of verifying the aircraft is on the correct runway. However, the only cues listed in the ATR72 Before take-off procedure to achieve this related to internal cues such as the cockpit instruments, including the horizontal situation indicator. The only other reference to external runway verification cues was in specific reference to low visibility operations.

The external cues available to the flight crew at the intersection G holding point prior to runway entry included the airport chart and runway marker boards. The cues to indicate they were on runway 30, in addition to the aircraft instruments, were the absence of centreline lighting, the presence of the apron lighting and the proximity of the runway end lights.
Other operators, particularly those operating into airports with complex layouts, include a runway verification procedure. This procedure would require the flight crew to verbalise their identification and verification of the runway entry point prior to entry, and the departure runway prior to commencing take-off using available internal and external cues. Making use of all available external cues at an airport, including signs, lighting, and markings will improve awareness of the environment and reduce the risk of runway incursions (Federal Aviation Administration 2016).

To avoid a runway incursion or overrun event, operators and flight crew need to ensure the aircraft enters the correct runway from the correct holding point and is then lined-up on the correct runway for take-off. The inclusion of a published procedure could promote a habit of directing attention to both internal and external cues, to verify the aircraft’s position in the runway environment.

Detection of incorrect runway

When the flight crew lined-up and commenced the take-off roll on runway 30, ATC immediately issued a stop instruction. At around the same time, the flight crew rejected the take-off and commenced braking. The ATSB’s calculations based on the runway length and the aircraft’s performance data showed that there was insufficient distance available on runway 30 for the aircraft to take-off. Virgin Australia Airlines conducted simulator sessions that demonstrated a successful take-off was possible if there were no abnormal conditions.

Therefore, had neither the flight crew nor ATC detected the aircraft was lined-up on the incorrect runway, it was possible that the take-off would have been achieved. However, if an engine failure occurred near V1, or if the take-off was mishandled, there was a risk of a runway overrun due to the shorter runway length.