ATR72 Canberra runway incursion

[markfelt]

www.atsb.gov.au/publications/investigation_reports/2019/aair/ao-2019-055/ (https://www.atsb.gov.au/publications/investigation_reports/2019/aair/ao-2019-055/)

[wheels_down]

They picked up on the error that’s the main thing, they didn’t roll or depart. One would hope this would be fairly obvious considering how little length was in front of them, could have been a different outcome late night. Countless cases of this occurring in other countries in which most don’t really pick up on the error until the tail is for some reason wiping out the runway lights past the end.


https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/1125x1641/8eb82b41_845c_4273_a83e_eab66f15c490_1df94533b2badc46e85a1fe d5a877622bca2c416.jpeg

[john_tullamarine]

One can't be too careful.

Although not at Canberra, but not all that far away, I did much the same late at night many years ago, didn't realise my error, took off and got a substantial fright.

One of the few times I let myself get out of the normal checking sequence which included a runway heading check ... I never let that happen again ...

[noclue]

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/750x1334/af1e0895_104b_42fc_91ae_3d92ce665410_052d9ff1276acbdaf05d09a 9c6be600b58c9e0a9.png
What was the vis like that night? Looks like they’ve simply followed the first taxi line they saw?.

[Derfred]

That is one hell of a confusing intersection.

I’ve never taken off from Golf in a jet, but I’ve vacated there after landing on 17 plenty of times.

I’d put it down as an accident waiting to happen.

[VH DSJ]

That is one hell of a confusing intersection.

I’ve never taken off from Golf in a jet, but I’ve vacated there after landing on 17 plenty of times.

I’d put it down as an accident waiting to happen.


And a similar accident has happened with fatalities in Lexington, USA back in 2006. This example is widely used in human factors training at various airlines in the USA.

https://en.wikipedia.org/wiki/Comair_Flight_5191

[On Track]

I did my ab initio training at YSCB. I never found the layout of the airport in the least bit confusing.

YMMB, on the other hand, is chaotic and, in my view, a catastrophe waiting to happen.

[Despot 78]

The weather was fine. I was cleared to line up and wait at intersection N 35 as the ATR behind me was cleared for take off from G. I couldn’t see if he had started to roll, but heard the Tower controller telling him to “STOP STOP STOP”.

[Capt Fathom]

I never found the layout of the airport in the least bit confusing.
Well the intersection was flagged as a hotspot, so you may have been missing something!

[On Track]

Well the intersection was flagged as a hotspot, so you may have been missing something!

Actually I don't know that it was back in those days, and I had never heard of AIP, ERSA, DAP, etc at that stage of my training.

[Derfred]

I did my ab initio training at YSCB. I never found the layout of the airport in the least bit confusing.

Well, given your familiarity with the airport, I guess it wouldn’t be!

Not every pilot using the airport will have your familiarity.

[Pastor of Muppets]

Line marking for bays is also terrible.

[havick]

This is being blown out of proportion,.. They followed the wrong lead in lines (understandable looking at the airport diagram) never took off, admitted they made a mistake and ostensibly taxied off the runway and departed on the correct runway? Not a massive deal? I don’t get how this warrants a prune thread


^^^^This x 1000. Crew made a small cock up and fixed it before it became a problem.

[hoss]

I’m interested in the ‘stop stop stops’ statement. How far into the takeoff did they get? This recent incident is mega alarming to me and should not be played down. I could write 3 pages on why I believe this but I don’t have the time right now. In a nutshell there is clear policy and procedures to prevent this at VA. I would be looking closely at Standards and Training!

👍

[Ragnor]

This is being blown out of proportion,.. They followed the wrong lead in lines (understandable looking at the airport diagram) never took off, admitted they made a mistake and ostensibly taxied off the runway and departed on the correct runway? Not a massive deal? I don’t get how this warrants a prune thread

its a massive deal! They didn’t recognise they were on the wrong runway. Loss of situational awareness by the crew.
ATC stoped them, was the Stop Stop Stop issued before or after take off clearance?

[machtuk]

This is being blown out of proportion,.. They followed the wrong lead in lines (understandable looking at the airport diagram) never took off, admitted they made a mistake and ostensibly taxied off the runway and departed on the correct runway? Not a massive deal? I don’t get how this warrants a prune thread

There's an old saying...……….."rob a bank of $1 dollar or $million dollars you are still a bank robber"!
Whilst the outcome was minor the potential was huge! Safety cannot be trivialised.

[Chadzat]

I would be looking at why the hell you would want to be taking off from Golf at night in an ATR. Just because it is possible, doesnt mean its a good idea...... and Im not talking about the line markings being the issue.

[hoss]

kcboy is correct, there are ‘question marks’ all over this and the final report ‘may’ shed some light. The reason for the 140 degree lineup will be interesting.

Airmanship gone wrong, Human Factors.......Tic Toc

[morno]

I would be looking at why the hell you would want to be taking off from Golf at night in an ATR. Just because it is possible, doesnt mean its a good idea...... and Im not talking about the line markings being the issue.

Please elaborate. Is this another one of those “runway behind you is no good” things that is really only applicable to flying a 152 and not an ATR or any transport category aircraft for that matter?

[Ragnor]

“The flight crew later advised that, as they turned on to runway 30 they realised something was wrong, and soon after air traffic control advised them to stop.”

We will have to wait for the final report to come out here but no where does it say the take off was commenced and/or a rejected take off executed. As soon as ATC notice something wrong on the ground the standard phraseology is “stop stop stop” for anything like this - not for just a rejected take off. Again, I’m just guessing here but I would of thought had the crew started the take off, then the preliminary report would of mentioned that a rejected take off was executed. So for this reason I stand by my original thoughts - this is out of proportion, an error was made, (and a totally understandable one when I look at the airport diagram) recognised, and then rectified.

if you listen to the ATC recording there is no communication from the ATR to ATC advising them they were on the incorrect runway. In this instance Canberra tower were all over it and recognized what the crew should of.

[kcboy]

I do have sympathy for the crew here.

This is is what I think could of happened - very short taxi from the VA terminal, so the F/O could of been distracted doing the line up checks as they were taxiing on to the runway and not properly monitoring the turn. Captain followed the first lead in lines he saw (30). They could of been running the checklist as the captain or F/O realised the error, been in the middle of a quick confused discussion about it and Canberra tower are already all over it, telling them ‘stop stop stop’ (great job tower). Incident occurred at 7PM so crew could of come off a long day. Having asked around, there was no application of take off power.

I’m not downplaying the negative outcome that could of occurred from this, but I’m giving some sympathy to the crew. I’ve made many mistakes whilst flying all of which could of had questionable outcomes had they not been picked up by the person next to me or even myself, we’re just human. I’ve even heard of captains turning the wrong way on to a runway at uncontrolled airports realising instantly their blunder taxi to the end, backtrack for the correct runway, file a report and hear nothing about it! Unfortunately in this case they ostensibly made the same mistake realised the error, never were going to take off but had ATC screaming ‘STOP STOP STOP’ which sounds very frightening over a frequency and picks up traction with media.

end!

[VH DSJ]

I do have sympathy for the crew here.

I think you're missing the point. True, everyone makes mistakes but it's important that we all learn from them to prevent them from occurring again. An ATSB report follows the ICAO Annex 13 mandate where the objective of an investigation is to prevent accidents and incidents, and not to apportion blame or liability.

As a result of the Lexington accident I quoted above, our company implemented a procedure where the intended runway heading for departure is bugged during our pre-flight preparation. Then, when we line up for departure, the captain will say 'runway heading check' and the FO will look to see that the heading bug is pointing in the right direction and say 'check'. A very simple procedure that would have saved the lives lost in Lexington in 2006. I now fly for a different airline, and although it's not in our current SOPs, I still use this as a simple line up check to see if I'm on the correct runway for departure.

[BO0M]

Standard ATR checklist and procedure (I dare say world wide and including VA) is to bug runway heading and course during pre-flight. The checklist also calls for Lateral Flight Director bar as one of the last things to do prior to take-off. This a last check to ensure heading is bugged and your are on the correct runway. You can still muck it up if you're lazy and instead of checking the FD Bar correctly with the departure runway you just hit heading and centre it.

Don't know the crew but would suggest theres a few holes that lined up here (possibly)

1. Decision to go from that intersection at night was a poor idea (I operated CBR for years and never once did it for many reasons)
2. Maybe a laxed briefing
3. Checklist not ad-heard to
4. FMS not set up as per FCOM ( possibly still not putting departure runway in etc)
5. Airmanship aspect missed of checking which runway you're lined up on

I'm not having a go at the crew because knowing this operation theres a very high chance theres a lot of other factors at play the report wont suggest. Also lets face it, we are all human and do our best not to make errors on a daily basis but sometimes things just don't go our way and mistakes happen.