A Virgin Australia ATR 72 was forced to abort a take-off attempt after lining up and accelerating on a “considerably shorter” runway than instructed at night.
The ATSB revealed the incident took place at Canberra Airport in September 2019 and the departure was only stopped after both air traffic control and the flight crew realised the mistake simultaneously.
Significantly, while take-off power had not been applied, flight data indicated the ATR 72’s power levers had been advanced to commence take-off.
The ATSB’s acting director of transport safety, Kerri Hughes, said, “The complexity of some airport runway and taxiway layouts can be exacerbated by reduced visibility conditions, such as at night or in poor weather, which can easily increase flight crew confusion.
“This investigation highlights the need for flight crews to familiarise themselves with complex runway layouts, particularly any unique designs, and ensure effective flight crew co-ordination is employed to minimise the risk of a runway incursion.”
The flight crew of the 25 September 2019 flight to Sydney had elected to depart Canberra Airport’s runway 35 from intersection G (‘Golf’), based on aircraft performance considerations, environmental conditions and the short distance between their parking bay and the runway holding point.
While taxiing to the holding point at intersection Golf, the flight crew completed their departure review. Just before reaching the holding point, the flight crew advised air traffic control (ATC) they were ready for take-off. After clearing the aircraft for take-off, ATC deactivated the stop bar and the lead-on lights were illuminated.
The aircraft then crossed the holding point and started turning through the intersection and inadvertently lined-up with the centreline of runway 30, which is considerably shorter in length than runway 35.
ATC saw the aircraft moving on runway 30 and immediately instructed the flight crew to stop. At about the same time, the flight crew rejected the take-off.
A review of airport closed-circuit television and recorded flight data showed the aircraft lined-up on runway 30, paused and then briefly accelerated and braked suddenly. The aircraft then exited the runway and departed from intersection ‘N’ (November) for runway 35 as per ATC instructions, without further incident.
The full report focused on the exact seconds before the planned take-off.
“The flight crew reported that take-off power had not been applied, nor the take-off roll commenced, and no braking was required,” it reads. “However, recorded flight data showed an immediate increase in torque for both engines from 4-6 per cent during taxi to 17.7 per cent, as well as a decrease in brake pressure to 16 pounds per square inch (psi) after the turn onto runway 30. About four seconds later, the engine torque reached 28.1 per cent, indicating the power levers had been advanced to commence the take-off. At about this time, ATC instructed the flight crew to stop, after which, the data showed a decrease in the power lever positions to flight idle and an increase in brake pressure to 1,686 psi.”
The ATSB’s Hughes added that using intersection Golf for runway 35 meant the flight crew only had about 90 seconds to complete the preparatory tasks for departure. This resulted in the flight crew advising ATC they were ready for take-off prior to completing the before take-off procedure.
“The first officer reported being focused on the before take-off checks as they approached the holding point, while the captain was focused on the runway lead-on lights,” Hughes said.
“The challenge and response nature of the before take-off procedure would have required some of the captain’s focus. This likely resulted in the captain taxiing the aircraft through the intersection with divided attention, while the first officer’s attention was focused inside the cockpit.”
Hughes explained that intersection Golf leads to the intersection of the Canberra Airport’s two runways, 12/30 and 17/35, and is listed in airport documentation as a known runway incursion hotspot due to this complex layout. There are few airports in Australia where a taxiway leads to the intersection of two runways.
Further, when the stop bar at intersection Golf was deactivated, the lead-on lights to both runway 30 and 35 were illuminated, increasing the risk of confusion.
The investigation also found that Virgin Australia’s ATR 72 before take-off procedure did not specify when the crew were to advise ATC they were ‘ready’ for take-off. Further, runway verification checks using external cues were not included in procedures for all their aircraft.
“The ATSB notes that, while Virgin Australia no longer operate the ATR 72 aircraft, they have developed a new runway verification procedure for inclusion in their Flight Crew Operating Manual for their Boeing 737 fleet,” it said.
A Virgin Australia spokesman said safety remains the airline’s top priority.
“While we no longer operate ATR services nor use the departure intersection involved in this incident, we’re proactively implementing additional runway verification procedures across our mainline operation,” said a spokesperson for the business. “Updates to standard operating procedures will be rolled out to our Boeing 737 pilots early next year.”
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