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Mildura 2023 near miss final report out

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Old 16th May 2024, 09:09
  #21 (permalink)  
 
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Maybe there could be a 'human being' on the ground at Mildura, Griffo, making first-hand observations of the traffic and weather conditions and putting those observations to good use from an air safety perspective by telling everyone about them. Nah...would never work. What was I thinking?

But ACMA does need to be engaged. There's something weird going on near YMIA that's interfering with 'airband' comms, and it's been happening for a long time. I'm not sure there's the 'collective smarts' left in the Commonwealth bureaucracy such that ATSB and ACMA could sort it out, though.
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Old 16th May 2024, 09:22
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Originally Posted by AmarokGTI
All excellent.

Although it’s actually “Class Q” airspace by the way some of that operators crew boss people around CTAFs these days.

They key problem here though was their assumption the Piper was at a different airport and no assertiveness to check.

I recall descending into Kadina (126.7) and hearing a call that we weren’t sure was “Kadina” or “Ceduna”. Call me crazy but we just asked them to clarify.
Yeah - there's a 'flavour' in recent ATSB reports. Emphasis on the dumb 'light aircraft' pilot's mistake and a downplaying and excusing of what the 'professionals' in Row 0 did.

Reminds me of the ATSB report on the near miss at Port Augusta a while ago. Based on my experience and observation, the incident was 'mostly' caused by the inbound RPT reporting 'joining downwind' a number of nautical miles and minutes before that actually happened, resulting in the 'dumb' ag aircraft pilot assuming that when he arrived in the circuit the RPT aircraft he could see on the ground was the aircraft which reported 'downwind' minutes earlier.

Inexpert suggestion: When you report "doing" something - using a word ending in "ing" - only do that when you are actually "ing".

And please (please) stop using "taxis" and "turns" and "climbs" etc. I can report that Lead Balloon "plays" bass badly, but that doesn't mean I'm doing that NOW.

Last edited by Lead Balloon; 16th May 2024 at 09:50.
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Old 17th May 2024, 06:11
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Originally Posted by Ex FSO GRIFFO
[

Any of the Mildura ex FSO's on this channel? What were your ground VHF 'blackspots' in those former 'good ole days'..??

I used to pass thru a few times and don't remember any probs.

Cheeerrrsss....
Mea Culpa .... did some time there, and despite the DOT/CAA/ASA ruling that Mildura FSOs could not be positioned so that they could see the runway, I don't remember there being too many dramas. It was quiet workable and enjoyable. But then again, maybe time has dimmed my memory....just a dumb GA Pilot and FSO....
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Old 18th May 2024, 03:38
  #24 (permalink)  
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Not a nice incident all at. Had worse but there's not a real lot of difference between pretty close and really close.

Back in the day most of us were pretty particular to make sure that we had a sound mental picture of what was what in the local airspace (doesn't sort out the non radio folk but one can only do what the kit and conservative thought processes permit). If that meant a few redundant calls, so be it.

The report observes "Near collision highlights how line of sight limitations make non-mandatory radio calls essential". Perhaps I'm getting past it but non-mandatory and essential in the same sentence doesn't seem quite kosher ?

I don't think this is a case of not enough talking. I think it's a case of not enough listening and thinking about the implications of what was said and actually known, exacerbated by comms and visibility limitations due to the physical layout of the runways and buildings. Tick.
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Old 18th May 2024, 04:37
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I don't think this is a case of not enough talking. I think it's a case of not enough listening and thinking about the implications of what was said and actually known, exacerbated by comms and visibility limitations due to the physical layout of the runways and buildings. Tick.
That's it in a nutshell. The QLink aircraft was departing, so the Captain had ample time to listen to the CTAF for more than 10 minutes prior while doing preparation for departure. In that way you get that picture of what is moving around and where on the airfield before you start engines and make things busy. I would chasten Q Captains even more so as they have ample ground staff to ensure that the PIC is not distracted by anything other than their normal duties, they basically have a lot of time to just sit in the cockpit and listen to what is happening. Traffic does not just suddenly appear on the threshold and announce departure like some computer simulation, even at Mildura most of the apron is visible from the RPT area, you could see someone starting, moving for run-ups, taxiing to the hold line etc etc... By the time I start engines I have already a mental picture of what is moving around me and whats on the radio for the last 10 minutes at least. This would all have been a non event if the Captain just said to the FO 'hmm I heard a lighty taxiing around earlier, get on the radio and find out if he's still around'.

The Q aircraft had the majority of the opportunity to avoid this, they had the better of everything, from better radios, TCAS, to two sets of ears and eyes and probably a quieter flight deck. Why you would angle at the light aircraft being in the wrong I don't know.
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Old 18th May 2024, 06:18
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You can't see the southern GA from bays 1 and 2. The crew were focused on com 1 and Melb Centre, who needed to discuss a bunch because the flightplan couldn't be found- all while ESL made their first taxi call. Pretty normal human factors issue not to hear something on com 2 when focused on com 1.

ESL's radio call was badly broken when lining up and they said runway 35, which made it exactly sound like they were at Wentworth. I don't know one pilot who chases up every broken radio call on a CTAF, especially at Mildura where it shares the frequency with numerous airports including nearby gliding. Hindsight is a wonderful thing to say you would have. And yes, you can hear broken Wentworth traffic on the ground at Mildura.

The question is, if locals knew VHF shielding was an issue for a long time, what did Mildura Airport do to mitigate this? It wasn't in ERSA to warn unfamiliar pilots. And despite not being able to see aircraft on the cross strip they didn't add a rolling call requirement until there were 2 near misses. Not that this really makes a difference when you can't hear each other from the thresholds of 09 and 36.

Also, TCAS on the ground doesnt pick up other TCAS ground returns. Check it out next time you taxi around. So that argument is silly.

The pilot of ESL didnt do anything wrong either, just the small mistake of saying '35' which threw the Link pilots. But this sort of incident is going to happen at very busy CTAFs with cross strip ops with the added bonus of not being able to see or hear each other from 09 and 36. Tick tock at this airport I fear.

Nearly happened a couple of months later when a lightie and Dash nearly took off at the exact time - again both didn't hear or see each other. It was only because another pilot taxiing on the apron saw what was happening and told the lightie to stop that an incident was avoided.

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Old 18th May 2024, 06:55
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Originally Posted by VH-FTS
The pilot of ESL didnt do anything wrong either, just the small mistake of saying '35' which threw the Link pilots.
Hang on. ENL twice stuffed up the runway number, did not give the location at the end of his Entering and Backtracking call and
Originally Posted by ATSB
The pilot of the PA-28 received and understood the calls from the Dash 8, however believed that the aircraft was still backtracking on runway 09 as they had not heard, but were expecting, the Dash 8 to give a rolling call.
Assuming it would all be OK.

Last edited by Capn Bloggs; 18th May 2024 at 07:10.
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Old 18th May 2024, 09:56
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How many times did the pilot of ENL have to say "Mildura" and "ENL" in the same broadcast, Cap'n, to make you happy? I count three in the ATSB Report.

And how many times did the pilot of ENL say "Wentworth"? I count zero in the ATSB Report.

QLINK 402 also "assumed it would be all OK", apparently on the basis of an assumption that it was possible to hear an aircraft taxiing on the ground 13nms away, which aircraft never transmitted the word "Wentworth". You seem to set a pretty high bar for us lowest common denominators, Cap'n, but not as high for those paid to sit in row 0A.

Mr JT noted this deliciously paradoxical statement in the Report, which statement in my view points up one of many chronic problems in ATSB:
Near collision highlights how line of sight limitations make non-mandatory radio calls essential.
This wasn't a case of too few radio calls, at least not from ENL. And, in any event, the law already says that a call is "mandatory" in G "when the pilot in command considers it reasonably necessary to broadcast to avoid the risk of a collision with another aircraft". There's no number of calls or number of event limitation on that obligation.

The pilot of ENL made numerous broadcasts because the pilot evidently considered them "reasonably necessary ... to avoid the risk of collision" in the circumstances. They were either just not heard or just not comprehended or just misunderstood. Sure, 35 rather than 36 was a mistake, but "Mildura" was used repeatedly. "Wentworth" - never.

And the exquisite irony: ENL did make a "rolling" broadcast, because ... ? But QLINK 402 didn't make a rolling call, because ...?

The "rolling" broadcast made by ENL was actually "mandatory" - if you read what the rules require and assume the PIC thought the broadcast was "reasonably necessary to ... avoid the risk of a collision with another aircraft". I think that assumption is reasonable because the PIC in fact made the broadcast in circumstances in which there was, in fact, the risk of a collision with another aircraft. It's just that the other aircraft - QLINK 402 - made what I consider to be an unreasonable assumption about the location of the aircraft whose broadcasts had been heard (and let's go crazy and introduce some settled wisdom about these kinds of situations - which assumption was convenient to QLINK 402 operations in the circumstances).

The number of "mandated" calls won't change the propensity for people to make mistakes in those calls or for them to be misunderstood or their implications not to be comprehended. Then there's the minor problems of calls that 'don't make it through' for whatever reason - propagation problems and finger trouble...

Finally, where in the Report is the analysis of who had 'right of way' in the circumstances at this aerodrome in Class G? You know: That silly stuff in Part 91 that people get tested on? For example, which runway was most into wind? Doesn't the report say: "moderate north-north easterly wind at 10 kt". Did I read two "norths" there? Was runway 36 at Mildura most into wind in the circumstances? It may well be that QLINK 402 could safely and lawfully use 09. But that doesn't necessarily give it right of way or excuse it from ignoring the possibility of aircraft using the most in to wind runway at an aerodrome in G. There are "laws" about this stuff that have nothing to do with radios and who broadcasts what. Mildura, Ballina, Caboolture or wherever in G: same rules.

If we're going to keep mixing RPT with other operations at aerodromes in Class G, the reintroduction of a set of mandatory radio calls at specific points in the vicinity and in circuit and on the ground etc won't change the rules about who has right of way there and won't change the propensity for people to make mistakes in making and interpreting those calls.

I know it grinds the Capn's and others' gears, and I understand why. But this is Australia's third world aviation system. We might have a better chance for change if we identify and call out the actual cause/s of these kinds incidents.
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Old 18th May 2024, 10:21
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Originally Posted by Lead Balloon
If we're going to keep mixing RPT with other operations at aerodromes in Class G, the reintroduction of a set of mandatory radio calls at specific points in the vicinity and in circuit and on the ground etc won't change the rules about who has right of way there and won't change the propensity for people to make mistakes in making and interpreting those calls.
Without opening very old wounds again ...your statement that increasing radio calls won't necessarily decrease the risk, as we are all human and we all make mistakes ,,, especially when under the pump, or when that mongrel chain of human factors, geography and technology is being tensioned towards breaking point,,, directs us toward the obvious solution ...a "third set of eyes and ears" .... whether that be a CAGRO or Controller. That is, of course, unless we accept this particular risk, in this particular location....and in other similar locations. Cost and Benefit.
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Old 18th May 2024, 12:47
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The Dash isn't approved to use runway 18/36, so the most into wind argument two posts above is irrelevant. There isn't a law or advice either that says the most into wind runway when there's a cross strip has priority. Right of way is also irrelevant when you don't know another aircraft is there.

You also keep forgetting the part that the Link crew didn't hear the lining up broadcast from ENL because of local VHF shielding. All they heard was garble and the word 35. It was understandable to think it was from Wentworth at the time, you're applying hindsight bias to think a normal pilot would do otherwise.

But to the main problem. Sounds like blind cross strip operations in Class G should be banned. How long ago was the Caboolture accident, cross strip fatal crash?

CASA didn't seem to care when 2 people died. Will it take 50 plus people dying for change to finally come?

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Old 18th May 2024, 13:07
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There appears to be no mention anywhere in this discussion about the fact that the Mildura CTAF has an AFRU (beepback) facility whereas Wentworth does not. This would mean I would think that an aircraft taxiing on the ground at Mildura would activate the response whereas one taxiing on the ground at Wentworth would not. Another clue perhaps missed by the Qlink crew despite a wrong (slightly) runway identification by the lightie.
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Old 18th May 2024, 13:46
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Any of the Mildura ex FSO's on this channel? What were your ground VHF 'blackspots' in those former 'good ole days'..??
Did my field training there...but I hardly knew my ar*e from my elbow at that stage!
The Departmental VHF aerials would have been a lot higher than an aircraft's on the ground, and most talking in those AFIZ days was to/from the aircraft to the FSO. Especially if both were on the ground, once they called and you answered, provided the traffic etc, they tended not to talk to each other that much.
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Old 18th May 2024, 22:55
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I would chasten Q Captains even more so as they have ample ground staff to ensure that the PIC is not distracted by anything other than their normal duties, they basically have a lot of time to just sit in the cockpit and listen to what is happening
I’m sure most Q captains got a good giggle out of that.

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Old 18th May 2024, 23:18
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The Dash isn't approved to use runway 18/36, so the most into wind argument two posts above is irrelevant. There isn't a law or advice either that says the most into wind runway when there's a cross strip has priority. Right of way is also irrelevant when you don't know another aircraft is there.
You scored a trifecta there.

I know the Dash isn’t approved to use that runway. But lots of other aircraft are approved and obliged to use that runway if it is most in to wind, subject to some exceptions. The most in to wind runway was, according to my reading of the Report, 36 in the circumstances of this incident.

And there is a rule prohibiting an aircraft from commencing a take-off run on one runway if another aircraft is landing using a cross runway and that other aircraft hasn’t crossed or stopped short of the first runway. (Standby for what the Report of the Caboolture tragedy has to say about this.) Now ENL wasn’t landing, but if there was another aircraft landing on 36, the Dash would have been obliged to wait until the other aircraft had crossed or held short 09.

“Right of way is also irrelevant when you don’t know another aircraft is there”? Difficult to know where to start with that. Try using that on a police officer if you have a collision in a car. Not knowing when you should have known is not good enough. “[T]he pilot must keep a lookout for other aircraft that are being operated on the manoeuvring area, or in the vicinity, of the aerodrome to avoid a collision.” If there are things in the way preventing or restricting the ability to see those other aircraft, maybe there’s an obligation on the pilot to do something to mitigate the consequent risks?

ERSA entry: “Caution: training airfield. Multiple RWY may be in use with significant TFC within circuit at any time.”

ERSA entry: “ACFT on RWY may not be visible to one another.”

Common knowledge: VHF shielding problems on the ground at Mildura.

Now I’m just a lowest common denominator nobody. But if I were taxiing to take off at 09 Mildura when there’s a north, north easterly blowing, I can’t see what’s happening on most of the first half of RWY 36 and TWYs A and B and I’m not sure if I’m hearing all broadcasts on the CTAF correctly, I would have a very strong uneasy feeling in my nether regions about potential traffic on 36 as would prompt me to take further actions to relieve me of that unease.

I’ll put all this in short and finally, by asking: If there had been a collision between the Dash and ENL, who thinks it would be reasonable to attribute the cause to ENL’s mistaken broadcast of “35” rather than “36”, alone? I earnestly hope not too many people put their hand up.
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Old 19th May 2024, 00:02
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Nearly happened a couple of months later when a lightie and Dash nearly took off at the exact time - again both didn't hear or see each other. It was only because another pilot taxiing on the apron saw what was happening and told the lightie to stop that an incident was avoided.
You are just completing my argument that the Dash is the common denominator in this, or was it ENL again involved? I've seen QLink on multiple occasions make absolute minimal radio broadcasts, departing runway 09 after an entering call you could be rolling 5 minutes after entering the runway if the cabin is slow, or something dings while you backtrack, it really is essential to tell the CTAF at least you are lined up or rolling just to fill in the gaps. In this case it was 3 minutes from the entering call to the airborne call for QLK 402, with no rolling or line up call. I've always practiced a line up or rolling call, and a pause for response before adding power, never had a near miss on take-off, have had several occasions after making such call that I've held and clarified another aircrafts intentions, once or twice vacated after due to traffic conditions not suitable for that departure and letting a landing aircraft right of way.

In defense of the Dash, ENL probably could have asked the dash for their intentions before rolling, but he could also have assumed that the dash would have responded to his 'rolling' call if there was conflict. The ensuing conversation after the event alludes the later train of thought.

Also the report does not state what ENL did prior to taxiing, it's normal at Mildura that light aircraft first taxi to a position near the wind sock for run-ups. From the look of the ground track and the timing it looks like ENL was doing run-ups at the time the dash entered the runway, so viewable if you looked around.

The Dash isn't approved to use runway 18/36, so the most into wind argument two posts above is irrelevant. There isn't a law or advice either that says the most into wind runway when there's a cross strip has priority. Right of way is also irrelevant when you don't know another aircraft is there.
If your aircraft is incapable of using the most into wind runway then you have to give way to those that are, sorry but that's how it works. A crossing strip is obviously considered occupied if there is a risk of collision at the intersecting point, so if one aircraft is using the crossing strip it is considered using the main strip as well until its use of the crossing is complete or it's past the point a collision is possible (outside the strip width of the main and moving away). As pilots we know the risks during take-off/ landing and that any aircraft may use substantially more runway then they need for a variety of reasons, so that is why we don't practice 'hold short' operations or such OCTA as we are all aware that numerous factors could cause the holding aircraft to over run and pass the intersection, so it would be considered dangerous or a collision risk to do otherwise.

Size or type of operation does not matter, a 747 choosing to depart 09 with a tailwind or even strong crosswind favoring operations on 36 would still have to give way to a Jabiru on 36 and arrange it's departure accordingly.

Last edited by 43Inches; 19th May 2024 at 00:45.
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Old 19th May 2024, 00:38
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Originally Posted by itsnotthatbloodyhard
I’m sure most Q captains got a good giggle out of that.
Was in reference to the opposition such as Rex where the flight crew help clean cabins or assist ground staff in a lot of duties on a turn.

PS in QLinks defense since this has all happened they have markedly changed their radio procedures for the better. So there is more focus in this area and it will be less likely in the future.
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Old 19th May 2024, 04:44
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If your aircraft is incapable of using the most into wind runway then you have to give way to those that are, sorry but that's how it works.
Can you guys show me a reference to the CASRs, MOS or advisor circular that says this. I'm not talking about tailwinds ops.

The Link crew didn't just decide they'd go first. They had no idea the other aircraft was there because they couldn't see or hear it. You can talk about beyond human levels of situational awareness you all claim to have, but put most pilots in their situation and the same thing would have happened. You're not expecting an extremely broken radio call to be coming from another aircraft only 1km away. But if the poor CTAF coverage advice had been available to pilots they'd probably be more vigilant in chasing up broken transmissions.

The danger is a non towered airport where you can't see or now hear each other from the threshold of 09 and 36. That's some pretty mega layers of defence lost no matter how good a pilot is.
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Old 19th May 2024, 04:52
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Now I’m just a lowest common denominator nobody. But if I were taxiing to take off at 09 Mildura when there’s a north, north easterly blowing, I can’t see what’s happening on most of the first half of RWY 36 and TWYs A and B and I’m not sure if I’m hearing all broadcasts on the CTAF correctly, I would have a very strong uneasy feeling in my nether regions about potential traffic on 36 as would prompt me to take further actions to relieve me of that unease.
Enlighten us what you would have done. Taxied up and down the runway to double check? Made extra radio calls before rolling despite the shielding potentially stopping it, and reply, from getting through anyway? Get the ARO to do an inspection?

​​​​​​​There's a crazy amount of hindsight bias in this thread.
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Old 19th May 2024, 05:05
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Originally Posted by FTS
You can talk about beyond human levels of situational awareness you all claim to have
Not all of us, FTS, just one of us.
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Old 19th May 2024, 05:06
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I explained above how I (and many others) avoid this exact situation by making rolling calls, which QLink has now adopted as a procedure. This was avoidable if the QLink crew had made a rolling call the other aircraft would have waited, they even said that when questioned. It was very much practice by QLink crews in the past NOT to say anything between entering the runway and departing the circuit mandatory calls, which leaves a gaping hole of time where a conflict can occur, which did in this instance and several other occasions at other non controlled airports. ENL assumed QLInk would make a rolling call before doing so, so they made the rolling call and went when they heard nothing. This is the hole in the cheese, the gap between entering to backtrack a runway, and the time you actually use the runway for departure, it makes absolute sense that an aircraft broadcast just prior to commencing take-off as this is the point it all becomes dangerous for any conflict.

Can you guys show me a reference to the CASRs, MOS or advisor circular that says this. I'm not talking about tailwinds ops.
Right-of-way rules for take-off and landing (91.340) During a take-off or landing you must not fly an aircraft in a way that creates a risk of collision with another aircraft, person, vessel, vehicle or structure.
The above rule is what gets you if you take off opposite direction to an aircraft, take-off with aircraft on a crossing runway, take-off in a faster aircraft behind a slower one and so on. It is the pilots prerogative to avoid a collision risk. Note also it mentions risk, but does not state the amount of risk, that is distances and so on, so that's where it gets debatable over what is considered a risk of collision. The Warrior passing 600m behind the Dash in this case was considered a collision risk or it would not have attracted so much attention.

Take-off or landing at non-controlled aerodromes – all aircraft (91.370)
The above handles the separation rules for take-off and landing, of note is the landing requirement for crossing runways that you can not continue to land until the preceding landing on a crossing has passed through the intersection or is already holding short (not will or about to, hold short). You could assume that take-off would be treated much the same, with common sense that you would not commence take-off until the same applied.

Operating on manoeuvring area, or in the vicinity, of a non-controlled aerodrome – landing and taking off into the wind (91.380) To the extent practicable, you must land and take-off into wind unless: › the aircraft’s flight manual allows you to land or take-off downwind or crosswind › you are satisfied that traffic conditions at the aerodrome will allow you to land or take off safely.
The last point there effectively states that you have to fit in with traffic operating into wind, not that the traffic fits in with you, ie give way. Seriously anyone who is in command of a regional turboprop should know this stuff backwards.
91.380 Operating on manoeuvring area, or in the vicinity, of non‑controlled aerodrome—landing and taking off into the wind

(1) The pilot in command of an aircraft for a flight contravenes this subregulation if:

(a) the aircraft is operated on the manoeuvring area of, or in the vicinity of, a non‑controlled aerodrome; and

(b) the pilot does not, to the extent practicable, land and take off into the wind.

(2) Subregulation (1) does not apply if:

(a) the aircraft flight manual instructions for the aircraft allow the aircraft to land or take off downwind or crosswind; and

(b) the pilot is satisfied that traffic conditions at the aerodrome enable such a landing or take‑off to be carried out safely.

(3) A person commits an offence if the person contravenes subregulation (1).

Penalty: 50 penalty units.

Note: A defendant bears an evidential burden in relation to the matters in subregulation (2): see subsection 13.3(3) of the Criminal Code.
Full legalese version.

There's a crazy amount of hindsight bias in this thread.
And no, because prior to this event happening I have and many others diffused this exact situation by being proactive on the radio and having robust procedures that prevent it, including line-up/rolling calls. I've even discussed with QLink crews prior to this their reasoning on why they don't make such calls and the dangers.

BTW this has happened to Rex, VARA, Link, and pretty much all regionals in the past. Which is probably why all of those make/made rolling calls. Other close calls have been the result of radio calls made as/after you enter runways instead of before and pure inadequate lookout. All of which are preventable occurrences.

I wonder if the Captain was fined 100 Penalty units for failing to avoid collision risk and failing to safely operate in regard to traffic.

Last edited by 43Inches; 19th May 2024 at 05:54.
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