Virgin Australia B738 at Perth on Jun 12th 2023, aligned with runway edge lights for takeoff

Last Update: November 20, 2025 / 18:28:05 GMT/Zulu time

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Photo of Virgin Australia VH-IWQ, Boeing 737-800 — Virgin Australia VH-IWQ, Boeing 737-800 (Photo modified based on photo from DaHuzyBru / Wikimedia Commons / License: CC by-sa 4.0)

Incident Facts

Date of incident
Jun 12, 2023

Classification
Report

Airline
Virgin Australia

Flight number
VA-552

Departure
Perth, Australia

Destination
Sydney, Australia

Aircraft Registration
VH-IWQ

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Virgin Australia Boeing 737-800, registration VH-IWQ performing flight VA-552 from Perth,WA to Sydney,NS (Australia) with an unknown number of passengers and 6 crew, had taxied to the holding point at taxiway V and was cleared to line up runway 06 for departure from Perth, but went past the runway center line and lined up with the left hand edge lights of the runway. After being cleared for takeoff and commencing takeoff the crew noticed a raised runway edge light ahead and steered the aircraft onto the runway center line. Believing they had not hit anything the crew continued the flight for a safe landing at Sydney.

On Nov 11th 2025 the ATSB released their final report into this and two other such occurrences concluding the probable causes of the incidents were:

Contributing factors

- On runway 06 at Perth Airport, features of the runway environment included extra pavement, degraded markings, and reduced lighting. As a result, the pilots in 3 separate occurrences misidentified this runway's edge lighting for centreline lighting and commenced take-off from this position.

- During the turn onto the runway in incident 1 (VH-IWQ), the flight crew were focussed on completing pre-take off tasks within the flight deck, and communicating with the air traffic controller about their take-off clearance. These actions diverted their attention away from monitoring their position on the runway.

Other factors that increased risk

- After the misaligned take-offs, the 3 pilots responded differently. This increased the risk of damage, to aircraft or runway lighting, remaining undetected.

The ATSB analysed:

On runway 06, there was extra pavement on either side of the runway where each aircraft lined up for take-off. As there were no markings or lighting to delineate this area, there were no visual cues to assist the pilots to identify the extra pavement was adjacent to the runway. Consequently, this area likely appeared to be an extension of the usable runway. This was consistent with the pilot’s observation in incident 2 where they reported seeing ‘plenty’ of runway to their right when lined up on the right runway edge.

Although the runway had all the required markings in accordance with regulations, they were reported by 2 of the pilots as being difficult to see at night and were ‘scuffed’, thereby reducing the contrast and visibility of the markings. It was also noted that, while not required, reflective paint was not used for the markings to improve conspicuity at night.

While there were taxiway centreline markings, there were no lead-on lights from the taxiway to the runway centreline. Although there were lead-off lights, these were unidirectional and designed to only be visible when exiting the runway. Therefore, at night, the pilots had limited cues to assist them while navigating from the taxiway to ensure they would turn the aircraft into the centre of the runway.

Runway 06 did not have centreline lighting. However, the first 2 edge lights on either side were white and inset within the runway, which were the same characteristics for centreline lighting. Given that all the pilots indicated they would use runway 03/21 more frequently for take-off, which was fitted with centreline lights, this potentially influenced them misidentifying the edge lights as centreline lights.

The pilots of the 2 incidents operating the Cessna 441 also commented that although the aircraft lighting was switched on, the environment appeared dark. One of these pilots also reported that there was limited ambient lighting at the intersection of taxiway V to runway 06. The combination of the reduced visual cues and runway features that can be misidentified may have also given the impression that the aircraft were aligned with the runway centreline and increased the risk of a misaligned take-off. These characteristics were evident in many previous similar investigations.

Consistent with the ATSB’s research, the extra pavement area, the absence of lead-on lights and runway centreline lights, and some degraded markings, were all factors that influence misaligned take-offs at night, where visual information may be markedly reduced. A combination of these factors in each incident supported the pilots’ belief that the aircraft were correctly aligned with the centreline when they were positioned on the runway edge lighting. Confirmation bias is the tendency for people to seek information and cues that confirm the tentatively held hypothesis or belief (Wickens et al 2022). As they believed they were correctly aligned with the runway centreline, the pilots in each occurrence commenced the take-off roll.

Flight crew focus of attention

In incident 1 (VH-IWQ), the flight crew divided their attention between pre-take off tasks being completed in the flight deck and monitoring the environment. Additionally, the flight crew also received their take-off clearance during the turn onto the runway, requiring the FO to communicate with air traffic control. While these are normal and a required part of the departure, they can divert the flight crew’s attention away from the external environment at a critical time, such as while lining up. Barshi and others (2009) state 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.

Pilots’ response to the misaligned take-off

The pilots’ responses to each misaligned take-off incident were different. During the take-off roll, the flight crew in the June 2023 incident identified that they had lined up on the runway 06 edge lighting and manoeuvred the aircraft toward the centreline and continued the take-off. However, believing they had not struck the runway lights, the misalignment of the take-off was not reported to the operator or to airport personnel until the flight had arrived in Sydney, around 4 hours later. Although the subsequent aircraft and runway inspections did not identify any damage, there was the risk that unrecognised debris could have affected the safety of other aircraft using the same runway or the flight continuing with unknown damage.

The pilot in the August 2023 incident detected an impact during take-off, though did not initially notice the aircraft was aligned with the runway edge lighting. As they had detected a problem, the pilot returned to the airport to ensure there was no damage to the aircraft and provided the opportunity for a runway inspection to occur to check for damage. The pilot’s decision was important as damage to the aircraft (which was carrying passengers) and debris on the runway can affect flight safety.

The pilot in the April 2024 occurrence did not identify they had lined up the aircraft on the runway edge lighting and subsequently completed multiple flights. As a result of the misaligned take-off, the aircraft had sustained damage to the right propeller and several runway lights were damaged, which was not detected until later that day. Damage from a foreign body impact to a propeller blade could lead to gouges, dents and deformation, or cracks and blade failure if left undetected (Federal Aviation Administration 2005), although in this instance there was no reported effect on flight from the sustained damage.

Overall, misaligned take-offs can increase the risk of damage to aircraft and lighting given that raised runway lighting, unlike recessed runway lighting, is more likely to sustain an impact. Given the risk, it is important to promptly communicate the incident, for example to air traffic control or airport personnel, to provide the opportunity for inspections to be conducted. The outcome of these inspections allows pilots to make more informed decisions on whether to continue the flight, return or divert to a closer location.

The ATSB reported Perth Airport took following safety actions:

After the first 2 misaligned take-off incidents, Perth Airport submitted a notice to Airservices Australia requesting an update to the Aeronautical Information Publication about the misaligned take-off risk on runway 06. Subsequently, this update was included in an Aeronautical Information Publication supplement H78/23 effective November 2023 containing an update to the ground and movement charts for Perth Airport. The new aerodrome chart highlighted there was a ‘misaligned take-off hot spot’12 at the intersection of taxiway V and runway 06. The supplement detailed that runway 06 had wider shoulders due to previously being used as a turn pad, had no centreline lights, and that, when lining-up on the runway from taxiway V, pilots should ensure that the aircraft was aligned with the runway centreline. In March 2024, Airservices Australia updated the En Route Supplement Australia to reflect this change.

Perth Airport conducted airport works in late March to early April 2024 to repaint all markings on the runway and taxiway. As part of this work, they also painted chevron markings on the extra pavement next to runway 06 to prevent future misalignment.