Sunstate DH8D at Gladstone on Mar 17th 2020, taxied onto runway despite aircraft on final approach

Last Update: February 23, 2021 / 14:53:29 GMT/Zulu time

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Incident Facts

Date of incident
Mar 17, 2020

Classification
Report

Airline
Sunstate Airlines

Flight number
QF-2331

Departure
Gladstone, Australia

Destination
Brisbane, Australia

Aircraft Registration
VH-LQJ

Aircraft Type
De Havilland Dash 8 (400)

ICAO Type Designator
DH8D

A Sunstate Airlines de Havilland Dash 8-400 on behalf of Qantas, registration VH-LQJ performing flight QF-2331 from Gladstone,QL to Brisbane,QL (Australia) with 34 passengers and 4 crew, was taxiing for departure. During pre-flight preparation the checklists had been processed, however a point to activate the correct transponder mode/TCAS had been missed. Inadvertently the crew also used the wrong CTAF frequency on their VHF COM 2 when they broadcast their intentions to backtrack runway 28. A private aircraft flown by a student and instructor was on final approach to runway 10 having broadcast their intention for a touch and go on the correct CTAF frequency, which consequently was not heard by the Dash 8 crew. When the instructor saw the Dash 8 taxi onto the runway they initiated a go around. In the meantime the Dash crew contacted Brisbane Center on VHF COM 1 to provide a taxi report, Brisbane center provided a squawk, upon selecting that squawk into the transponder the crew discovered the transponder had not been correctly activated and selected the proper mode. At that point they discovered a plane was overhead them on the go around. Captain and first officer sighted the private aircraft afterwards. The crew now checked and corrected the frequency on VHF COM 2. The private aircraft indicated they were maneouvering for an approach to runway 28 giving room to the Dash 8 to depart. The Dash 8 subsequently departed and reached Brisbane without further incident.

On Feb 23rd 2021 the ATSB released their final report concluding the probable causes of the incident rated a runway incursion were:

- The flight crew of VH-LQJ were not aware that light aircraft 24-8279 was on approach and taxied onto the runway in front of it. Consequently, the pilot of 24-8279 had to conduct a go-around.

- The visual scan by the flight crew of VH-LQJ before entering the runway did not identify the approaching 24-8279, probably because of their degraded situational awareness.

- Increased workload and distractions while preparing VH-LQJ for departure led to the crew not setting the correct radio frequency and the appropriate mode on the traffic collision avoidance system/transponder. Without these essential aids to situational awareness, neither pilot developed an accurate mental model of the traffic.

The ATSB analysed:

This was the first flight of the day for LQJ and the crew had about 45 minutes to complete all pre-flight preparations prior to the scheduled departure time of 0645. During this period, the captain and FO encountered several unanticipated events and distractions, including the APU failure and person in custody paperwork, that required additional actions to be performed within the allocated timeframe. These interruptions and additional actions within a defined time period added workload and time pressures.

The combination of increased workload and time pressures is known to result in degraded information processing, increased errors, the tunnelling of attention, and an increased reliance on familiar strategies or actions (Staal, 2004). This response to workload and time pressures likely resulted in the flight crew’s omission of the two ‘before start’ checklist items and the selection of the incorrect frequency in VHF COM 2.

The frequency selection error was further compounded by the flight crew not recognising an absence of AFRU reply when making radio calls on the incorrect frequency. As a result, the captain and FO were not aware that they were monitoring and broadcasting on the incorrect CTAF.

The flight crew’s inadvertent omission of the TCAS/transponder selection resulted in the captain and FO incorrectly believing the TCAS would alert them to the presence of any transponder equipped aircraft that were operating in the vicinity of Gladstone Airport.

As a result of the frequency selection and TCAS/transponder errors, the flight crew’s situational awareness was significantly degraded resulting in the captain and FO forming the shared belief that no other traffic was operating in the vicinity of Gladstone Airport. This shared incorrect mental model likely impacted the efficacy of the visual scan conducted by the flight crew as they neared the A5 intersection. Consequently, neither flight crew member identified the approaching aircraft and LQJ was taxied onto the runway in front of Faeta 8279. The instructor on board Faeta 8279 conducted a go-around to avoid an incident on the occupied runway.
Aircraft Registration Data
Registration mark
VH-LQJ
Country of Registration
Australia
Date of Registration
mgg mecnAqqb Subscribe to unlock
Airworthyness Category
Eliqkindhhdg kecqi Subscribe to unlock
TCDS Ident. No.
QlkAg Subscribe to unlock
Manufacturer
BOMBARDIER INC
Aircraft Model / Type
DHC-8-402
ICAO Aircraft Type
DH8D
Year of Manufacture
mpA Subscribe to unlock
Serial Number
Emib Subscribe to unlock
Maximum Take off Mass (MTOM) [kg]
Gpfeb Subscribe to unlock
Engine Count
D Subscribe to unlock
Engine
JqhppqAcmjjccAbbifbfjlklppfihmjfdppAdghhebi Subscribe to unlock
Main Owner
eegmbAqbnhicmclnddgcgiicneemlAjeqkgkqeAjcfnm pddpA hecmAflceqfmblgAlfAqdh hpq Subscribe to unlock
Main Operator
GcddpdAqAAbhjnpnfdglngjdAqqbpqql Afhe nnfimAgmjc bAbppnq mqfAbqicff iifcfmqm cgphmbhjfilAnc Am Subscribe to unlock
Incident Facts

Date of incident
Mar 17, 2020

Classification
Report

Airline
Sunstate Airlines

Flight number
QF-2331

Departure
Gladstone, Australia

Destination
Brisbane, Australia

Aircraft Registration
VH-LQJ

Aircraft Type
De Havilland Dash 8 (400)

ICAO Type Designator
DH8D

This article is published under license from Avherald.com. © of text by Avherald.com.
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