A QantasLink Dash 8 turboprop carrying 38 passengers taxied onto the runway at Gladstone Airport in front of a light aircraft on approach to land.
The ATSB said “increased workload and time pressures” experienced by the crew on the morning of the incident in March 2020 likely influenced the errors that were made, which included failing to turn on the traffic collision avoidance system.
The approaching ATEC Faeta 321 spotted the danger and conducted a go-around, before attempting to contact the QantasLink crew.
As result of the incident, QantasLink told Australian Aviation it has introduced a requirement for pilots to contact air traffic control prior to entering the runway at non-controlled airports like Gladstone.
On 17 March 2020 at about 6am, the flight crew of a QantasLink Bombardier Dash 8-402 commenced pre-flight preparations for a 6:45am flight to Brisbane. During those preparations the crew twice started the aircraft’s APU (auxiliary power unit), which failed on both occasions when selecting APU bleed air ‘ON’ to provide air-conditioning to the cabin.
The captain also had to review paperwork and brief cabin crew on arrangements for a ‘person in custody’ and their police escort to travel on the flight.
After applying the Minimum Equipment List (MEL) to the APU, the flight crew undertook the remainder of their pre-flight checks, but missed setting the traffic collision avoidance system (TCAS)/transponder to ‘ON ALT’ and selecting the Gladstone common terminal advisory frequency (CTAF) radio frequency.
The first officer identified the CTAF omission during the departure briefing, however incorrectly set the frequency to 126.7 MHz instead of 118.8 MHz, which was the correct frequency for the Gladstone CTAF.
“The ATSB’s investigation found that the flight crew of the Dash 8 had inadvertently selected the incorrect radio frequency for the airport’s CTAF and incorrect mode on the traffic collision avoidance system/transponder during the before start checks reducing the flight’s crew situational awareness and mental model of traffic,” said the ATSB’s director of transport safety, Stuart Macleod.
“The frequency selection error was further compounded by the flight crew not recognising the absence of the aerodrome frequency response unit reply when making radio calls on the incorrect frequency and the assumption they would be alerted to the presence of any transponder-equipped aircraft that were operating in the area.”
At about 6:45am, the Dash 8 was taxied onto the runway in front of the approaching light aircraft. In response, the instructor on board the light aircraft commenced a go-around and attempted, unsuccessfully, to contact the Dash 8 crew on the Gladstone CTAF.
Shortly afterwards, the captain identified that the TCAS/transponder was not appropriately set and selected it to ‘ON ALT’. The TCAS subsequently presented the flight crew with a traffic advisory indicating climbing traffic, which was the light aircraft that the flight crew subsequently sighted climbing in an easterly direction overhead the airport.
The ATSB said that the incident illustrates the human factors implications associated with the combination of increased workload and time pressures.
The full report stated, “During pre-flight preparations, the captain and first officer encountered a number of unanticipated events and distractions, including two APU failures, boarding of a person in custody, and application of a minimum equipment list to the APU system. The additional actions, due to these events, increased their workload.”
Macleod concluded, “Situations like this can result in degraded information processing, increased errors, the tunnelling of attention, and an increased reliance on familiar strategies or actions and probably resulted in the flight crew’s omission of the two ‘before start’ checklist items and the selection of the incorrect frequency.
“Flight crews can guard against similar situations by applying effective threat and error management strategies that recognise when such threats may arise and set in place suitable actions that minimise error potential.
“These actions include strict adherence to standard operating procedures and increased cross-checking of system inputs and mode changes.”
QantasLink told Australian Aviation in a statement, “Since this occurred, we have introduced a requirement for pilots to contact Air Traffic Control prior to entering the runway at non-controlled airports like Gladstone.
“We have also reinforced to our pilots the importance of following standard operating procedures when managing multiple unexpected events, as occurred in this incident. Our pilots are trained and expected to follow safety procedures regardless of the flight schedule.”
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