Virgin Australia B738 at Sydney on Oct 19th 2022, verbal slip in clearance

Last Update: June 6, 2023 / 08:40:09 GMT/Zulu time

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Incident Facts

Date of incident
Oct 19, 2022

Classification
Incident

Flight number
VA-942

Aircraft Registration
VH-YFT

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Virgin Australia Boeing 737-800, registration VH-YFT performing flight VA-942 from Brisbane,QL to Sydney,NS (Australia), reached the top of descent into Sydney at FL340 and was cleared for a descent and a BOREE 3 Alpha approach to runway 34L, although runways 16 were active at the time also indicated by ATIS. The flight crew read the clearance back as issued, however, entered the correct runway 16L into their flight management system. After being handed off to Sydney Approach the controller detected the error, corrected the approach clearance for runway 16L and informed the center controller about the erroneous clearance. The aircraft continued for a safe landing on runway 16L.

On Jun 6th 2023 the ATSB released their final report concluding the probable cause of the incident was:

The enroute controller verbally issued the clearance to the flight crew to land on runway 34L instead of 16L, which was not identified during readback. This slip was likely due to the similarity between the flight level (FL 340) and runway 34L.

Other findings

- The flight crew did not enquire further with ATC about the runway assignment of 34L until the approach controller provided runway 16L.

The ATSB reported that following the information about the erroneous clearance the enroute controller checked the recordings of whether other aircraft might have received a similiarly wrong clearance, however, only VA-942 had received a clearance to runway 34L while the others had received a proper 16L clearance.

The ATSB wrote in their announcement of the final report under the title: "737 issued incorrect runway arrival clearance after undetected verbal slip":

A mistakenly-issued standard instrument approach arrival clearance for the incorrect runway at Sydney Airport highlights the importance of pilots and air traffic controllers being alert to verbal slips and seeking verification when there is confusion.

The ATSB analysed:

The enroute controller reported that when the crew of VA942 initially made contact and the STAR was provided, runway 16L was selected from the available runways as intended. However, they were looking at the flight level (FL 340) on the ASD, when they issued the clearance for 34L. This skill-based error most likely occurred because of the interference of information between FL 340 and 34L. Verbal slips of this nature are more likely to occur when there is a high degree of similarity between the presentation of simultaneous, related information, while performing a familiar and repetitive action.

The read-back and hear-back procedure was the opportunity for both parties to detect the error before it propagated further. However, on this occasion the error went undetected. The radio recordings confirmed that the standard phraseology was used during the communication, and the flight crew correctly read-back the assigned runway 34L, and this was acknowledged by the enroute controller.

There was information available to the crew in the ATIS indicating that runway 34L was not in operation. This provided an opportunity to identify and question the conflicting clearance and ATIS information between themselves, but the evidence obtained by ATSB showed that they did not enquire further with ATC until they were in contact with the approach controller, who correctly assigned 16L.
Aircraft Registration Data
Registration mark
VH-YFT
Country of Registration
Australia
Date of Registration
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TCDS Ident. No.
Manufacturer
THE BOEING COMPANY
Aircraft Model / Type
737-8FE
ICAO Aircraft Type
B738
Year of Manufacture
Serial Number
Maximum Take off Mass (MTOM) [kg]
Engine Count
Engine
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Main Owner
Jndplhgcl inkpkAmbpqgn dnnihpkpiAc fdpfk cfejqbkcniecifmAlhnechfdfnedqchfhfkmgdh Subscribe to unlock
Main Operator
JcfgnpbhfepckpkgclcjlgAmhkql ml fqpiccpjfegmebhegmmld emAbdphdnkmefdqnbggbcdhlqm geid gh hqhA Subscribe to unlock
Incident Facts

Date of incident
Oct 19, 2022

Classification
Incident

Flight number
VA-942

Aircraft Registration
VH-YFT

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

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