ATSB report into runway incursion at Perth Airport

[Chronic Snoozer]

This was released on 1 October 2020.

Investigation AO-2018-032 (https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-032/)

[Sunfish]

Reading this report suggests to me, not an expert, that Qantas and Australia was about to experience a 300+ deaths collision. The Captain of one realised the problem, the SMCs radio call got to the other and the clearance was 15 metres. Talk about holes in swiss cheese lining up!

[metrodashbrazconkie]

Millions spent on stop bars around the country and these blokes manage to charge through them. Makes me wonder why they didn’t stop to change frequencies.

[Keg]

The intersection of 06/ A/ J2/ J1 was always a bit of a mess. J2 had a high speed taxiway ‘vibe’ about it when it wasn’t. When exiting J2 on the 767 by the time you came off the runway and transitioned to the taxiway you had one aeroplane’s length to stop before 06. When taking off on 06 I was always very cagey about aeroplanes coming off 03 onto J2 and kept a bloody close eye on them.

Add the late changeover in duties that afflicts all QF 737s (all 737s or just those in Australia?), new F/O, lack of familiarity with PER by both crew, an incorrect mental model for the Captain, and voila.

[Capt Fathom]

You’d think Red STOP lights hard to ignore.
But vehicle drivers ignore them everyday! Just goes against the grain for most.

Having flown 737s since 2007, the captain had operated into Perth Airport many times, including three to four times in the last 4–5 months.
:confused:

[Transition Layer]

Millions spent on stop bars around the country and these blokes manage to charge through them. Makes me wonder why they didn’t stop to change frequencies.
Careful with the gender bias there buddy!

Sunfish, whilst a collision would have resulted in damage and injuries, at those speeds I don’t think your scenario would have played out with hundreds of deaths. Still a massive f*ck up though!

[Lead Balloon]

Must be about due for the usual Qantas propaganda to the effect that there was never any risk to safety...

[Lookleft]

Add the late changeover in duties that afflicts all QF 737s (all 737s or just those in Australia?),

Interesting that isn't addressed in the report. Its not just QF 737s that only have the tiller on the LHS and at a critical point, particularly after a relatively high speed exit off the runway, the Captain has to take control of the aircraft. Another point not mentioned is functional blindness. The PIC didn't "see" rwy 06 because he wasn't expecting to see it, he also didn't "see" the aircraft lined up on 06. If you want a good example of functional blindness then just remember the bloke in the gorilla suit walking through the basketball passing competition. Most airline pilots would be familiar with this.

There is a lot more going on with this incident than is obvious to anyone not familiar with jet operations. The briefing; probably overly detailed and the Captain has already made up his mind how they are getting from the runway to the terminal. J2 is like the Haymarket roundabout in Melbourne and it should have been altered to be a 90 degree exit off the runway well before this. Look at the photo of the view to the terminal off J2, your eyeline goes to the terminal. Brand new FO is always going to be less situationally aware as they are still slightly behind the aircraft. Captains deal with that situation in different ways. Some will assume that because they have been cleared to line then they are fully up to speed, others will take it into account and slow the operation down. Despite all the briefings, all the HF training all the ICAO recommendations you cannot know what mental model the other pilot is operating to until it starts to manifest itself. There is only 19 seconds from entering J2 to crossing the stop bars, in that time there is a fair bit of activity going on in the flight deck including a change of rolls. Not a lot of time for the FO to comprehend that the Captain's idea of what is going to happen is different to his/hers.

I'm not critical of the report but I am not surprised that this occurred. The best safety action was Perth Airport getting rid of J2.

[morno]

I’m curious, are FO’s allowed to taxi in QF if there’s a tiller provided? If not, why not?

I’m aware that 737’s don’t have tillers on the FO’s side (or do some?).

[galdian]

F/O tiller was an optional extra - for a price of course - so not a lot around, company I flew with ordered first 8 NG's with tiller until someone in power asked "why are we paying for something we don't need?"
There were no SOP's for F/O operation so up to Captain how comfortable he was to allow the F/O to taxy - or not.

[sleeper]

F/O tiller was an optional extra - for a price of course - so not a lot around, company I flew with ordered first 8 NG's with tiller until someone in power asked "why are we paying for something we don't need?"
There were no SOP's for F/O operation so up to Captain how comfortable he was to allow the F/O to taxy - or not.

I get the money angle. However, the being comfortable with FO taxiing baffles me.
I spent 26 years in KLM, europe, and all aircraft had righthand side tillers. All FO's taxied the aircraft , some as young as 22, on their sector. None had any troubles with it. I was a captain for 20 years and everyone of my FO's performed very adequately in taxiing.

[Beer Baron]

I’m curious, are FO’s allowed to taxi in QF if there’s a tiller provided? If not, why not?

I’m aware that 737’s don’t have tillers on the FO’s side (or do some?).
Yes QF F/O’s on all the other fleets taxi the aircraft. All the way to the NIGS at least.

No, none of our 737’s have a RHS tiller.

[machtuk]

Plenty of A/C pass each other less than 15M daily world wide! Humans fly planes, humans f**k up, it will happen again!

[morno]

Yes QF F/O’s on all the other fleets taxi the aircraft. All the way to the NIGS at least.

No, none of our 737’s have a RHS tiller.

Thanks Beer Baron

[717tech]

You’d think Red STOP lights hard to ignore.
But vehicle drivers ignore them everyday! Just goes against the grain for most.


:confused:
There was a lot of taxiway disruption while they were digging the tunnels for the new train line under the Runways. This included a horrendous amount of red lights scattered over the ground (can't remember what they were highlighting). But I remember approaching this intersection from alpha, heading towards the terminal, and the Stop Bars were lost in a sea of these red lights.

[Chronic Snoozer]

It's staggering that it takes 2 years and 5 months to put a report together into such an incident. Resourcing issue?

[Icarus2001]

So to be clear, how many years did this taxiway orientation exist?
How many thousands of aircraft and crews had NO PROBLEM?
But the answer is close the taxiway.

[morno]

So to be clear, how many years did this taxiway orientation exist?
How many thousands of aircraft and crews had NO PROBLEM?
But the answer is close the taxiway.

Maybe it was an obvious threat that existed, but no one ever thought to do anything about it. The best threat management is to eliminate the treat is it not?

[By George]

That taxiway was an accident waiting to happen due to bad design. Many contributing factors including the close proximity of the terminal creating the mental feeling there is not a runway between you and the parking spot. I always use to brief to hold the after landing scans until safely across. So why has nobody reported this? Maybe they have, but in my opinion it is because our whole safety culture is wrong. All this 'strict liability fifty points' nonsense, everybody just keeps their head below the parapet and just tries to keep out of trouble. There is not enough encouragement to participate in promoting safety anymore. A little like the Medical now, "tell the bastards nothing". Great system we have created.

[gordonfvckingramsay]

The taxiway was an accident waiting to happen and I imagine it would have been reported many times, but in typically Australian form, nothing was done until after a serious incident. However, isn't that our job? We are paid the big bucks to mitigate threats. This one was even identified, published and in most companies briefing hotspots is a requirement.

When the system presents a hole, we (flight crew) must fill it. I always think of that scene in Indiana Jones where his sidekick declares that there is nothing to fear and Indy replies with “Thats what scares me”. Just because you can see the terminal doesn’t mean you make a charge for it.

[Lookleft]

So to be clear, how many years did this taxiway orientation exist? How many thousands of aircraft and crews had NO PROBLEM? But the answer is close the taxiway.

If you read the report this may have answered your question:

Of the 44 incursions, 16 involved taxiway J2 on both runway 03/21 and runway 06/24. For that reason, the taxiway intersection of J2, J1 and A with runway 06/24 was marked as a runway incursion hot spot on aerodrome charts.

And that was between 2015 and 2018 so clearly there was a problem with that taxiway. The incident highlighted the potential for a collision at that intersection, now that J2 has been removed that potential no longer exists.

[Icarus2001]

Quote:
So to be clear, how many years did this taxiway orientation exist? How many thousands of aircraft and crews had NO PROBLEM? But the answer is close the taxiway.


If you read the report this may have answered your question:

I don't think the report answered either of my questions. Can you show me where it says how many thousands of crews had no problem?

[C441]

Can you show me where it says how many thousands of crews had no problem?
A better metric would be how many crews managed to hold short of runway 06 when it was active and they were instructed to.

Despite that though, 43 crews other than this one had a significant enough potential conflict on this particular runway/taxiway intersection to warrant some action. That would seem to deem physical response being necessary rather than just a visual or verbal mitigator which seems to have failed 44 previous times.

[morno]

I don't think the report answered either of my questions. Can you show me where it says how many thousands of crews had no problem?

You obviously don’t understand threat identification and mitigation. Just because thousands of crews had no problem, the fact that 44 didn’t shows there was an obvious threat that wasn’t being managed by other means every time, so the safest mitigation was to close it.

[Awol57]

Given the position of the holding point on J2 was a long way back from the gable markers to allow aircraft to also pass on taxiway A, it would be interesting to see how many of the 43 got close to even the gable markers versus just crossing the holding point without a clearance. No idea how you could determine that from historical data but I suspect if we had that information the answer may not have been to simply remove the J2 option.

[georgetw]

Could go back to 1965 where all aircraft STOPPED, looked both ways and awaited clearance.

[megan]

Can you show me where it says how many thousands of crews had no problemAfter any accident/incident/close call you can point to thousands, if not millions, of prior successful operations, but following a failure you learn from the lesson imparted and endeavor to do something about it. 747 that had the slats retract at rotation not so long ago, never a problem prior, would you expect the authorities to do something about it, or dismiss it, as it's never happened before? The question is why did it take 16 of the 44 total occurrences before it was made an issue, anyone of those events could have had the possibility of metal and bodies strewn across the landscape.

[rockarpee]

And how about the numerous non reported NON occurrences because 1 member of the crew managed to relay a STOP message to the PF. J2 became a part of my approach brief into Perth :O

[maggot]

And how about the numerous non reported NON occurrences because 1 member of the crew managed to relay a STOP message to the PF. J2 became a part of my approach brief into Perth :O
yeah it was frequently mentioned ime also

[Derfred]

Likewise. How many times does a potential life threatening “poor design” need to be pointed out before anything is done?

A lot, it seems.

[neville_nobody]

How many times does a potential life threatening “poor design” need to be pointed out before anything is done?



This is one of the worst things about "safety". You are not allowed to challenge the system. Quite often systems or airports are not design properly or corners cut to save money creating a safety hazard. When this is pointed out through safety reporting the safety department leaps to the defence of the system regardless to the obvious hazards. It isn't until there is a near disaster that the safety position is untenable and miraculously things get fixed.

[Lookleft]

Its a good point nev. Safety is driven by data and risk assessment. The old common sense rule has been replaced by quantitative evidence. A good example is the table in the report that shows the classification of ICAO runway incursion severity. Most of the incursions are in the lower risk category so Perth Airport could say there was nothing wrong with the position of J2 therefore money doesn't have to be spent to fix it. Once this incident put it into the significant risk category then the risk assessment matrix started to move into the red end of the likelihood and consequence box. Now the cost of potential litigation outweighed the cost of removing it The ridiculous part is all they had to do was alter the entry into J2 from runway 03 so that any aircraft had to slow to a normal taxi speed and the risk of incursion would be significantly reduced. Taxiway E2 off 05 in Adelaide shows how that could be achieved.

[gordonfvckingramsay]

This is one of the worst things about "safety". You are not allowed to challenge the system. Quite often systems or airports are not design properly or corners cut to save money creating a safety hazard. When this is pointed out through safety reporting the safety department leaps to the defence of the system regardless to the obvious hazards. It isn't until there is a near disaster that the safety position is untenable and miraculously things get fixed.

That is why as pilots, we should all slow down, knocking back the track shortening/high speed descent, throwing that extra ton of fuel, knocking back a duty extension, etc. Unless there is absolutely no reason not to. The answer should be NO unless there is clear evidence for a YES. You will always be blamed for poor safety design.

[sunnySA]

This is one of the worst things about "safety". You are not allowed to challenge the system. Quite often systems or airports are not design properly or corners cut to save money creating a safety hazard. When this is pointed out through safety reporting the safety department leaps to the defence of the system regardless to the obvious hazards. It isn't until there is a near disaster that the safety position is untenable and miraculously things get fixed.
Try working in air traffic control with Australia's #1 civil ANSP, system changes to Tower equipment are nearly impossible to make.

BTW, when I read this report I wonder what the SMC/Delivery/Supervisor was doing - 3 positions and poor prioritisation and what appears to be a lack of situational awareness involving a critical hot spot. Asking whether an aircraft is on frequency rather than issuing a safety alert seems rather odd, telling them they had crossed a stop bar also seems odd or is it just me?

The arrival would've heard the line-up clearance for the departure but I guess the arrival was task focussed. Surely a departure lining up on RWY 06 would be a threat when your landing on RWY 03.

And why the ADC didn't roll the arrival through to TWY Delta to assist the SMC or am I expecting too much?

[Square Bear]

Gordonf...

I agree totally.

A high speed descent below 10,000’ at say 320 kts to 5000’ vs 250 below 10000 will save around 1 minute:30 seconds. Never been one to see the point...burn more gas, increase the chance of getting out of shape, etc for what.

Only reasons I see for speed if you have been held up and need the speed to get down. In the normal event 250 kts gives a smidge extra time to finish the coffee thank you very much..

[morno]

Gordonf...

I agree totally.

A high speed descent below 10,000’ at say 320 kts to 5000’ vs 250 below 10000 will save around 1 minute:30 seconds. Never been one to see the point...burn more gas, increase the chance of getting out of shape, etc for what.

Only reasons I see for speed if you have been held up and need the speed to get down. In the normal event 250 kts gives a smidge extra time to finish the coffee thank you very much..

Depends, if you are told about it beforehand, you can plan for it and I see no reason to be getting out of shape.

Why do so many people make this job look so difficult, it’s not rocket science and doing a high speed descent should be a normal low risk task :ugh:

[Transition Layer]

Depends, if you are told about it beforehand, you can plan for it and I see no reason to be getting out of shape.

Why do so many people make this job look so difficult, it’s not rocket science and doing a high speed descent should be a normal low risk task :ugh:
The only risk I ever see during a high speed descent is clipping CTA steps (a by product of stupid Australian airspace design).

[gordonfvckingramsay]

Depends, if you are told about it beforehand, you can plan for it and I see no reason to be getting out of shape.

Why do so many people make this job look so difficult, it’s not rocket science and doing a high speed descent should be a normal low risk task :ugh:

Hence, and to quote myself, “The answer should be NO unless there is clear evidence for a YES”

I fly with a lot of pilots who have the opposite approach. They lack the ability to approach decision points with any critical thinking. For these types, TEM is either too hard or displays some level of weakness. They also fail to recognise that system is set up to point the finger at us. ATC, flight operations et al, will always say “they could have said NO, but they didn’t, not our fault.”

The thrust of my post was that people need to slow down, spend a few seconds thinking about the cost of the gains they seek. Believe me, you repent at leisure.

[morno]

Hence, and to quote myself, “The answer should be NO unless there is clear evidence for a YES”

I fly with a lot of pilots who have the opposite approach. They lack the ability to approach decision points with any critical thinking. For these types, TEM is either too hard or displays some level of weakness. They also fail to recognise that system is set up to point the finger at us. ATC, flight operations et al, will always say “they could have said NO, but they didn’t, not our fault.”

The thrust of my post was that people need to slow down, spend a few seconds thinking about the cost of the gains they seek. Believe me, you repent at leisure.

I agree with a lot of what you said, except the bit about the system being setup to point the finger at us.

In all my years of flying, I’ve never come across a blame system, and normally the ones who believe it is, have f***ed up somewhere along the line and went about it the wrong way. I’ve had my fair share of f**k ups, like all of us, but have never encountered any blame. I’ve always just acknowledged it, put my hand up and said I made a mistake, and it’s been put to bed pretty quickly, in some cases there’s even been acknowledgement that there’s something wrong and the threat has been fixed.

Paranoid, stress free flying is what makes you a more effective and efficient pilot. At least that’s how I fly, 20 years in.

[non_state_actor]

n all my years of flying, I’ve never come across a blame system, and normally the ones who believe it is, have f***ed up somewhere along the line and went about it the wrong way. I’ve had my fair share of f**k ups, like all of us, but have never encountered any blame. I’ve always just acknowledged it, put my hand up and said I made a mistake, and it’s been put to bed pretty quickly, in some cases there’s even been acknowledgement that there’s something wrong and the threat has been fixed.

That all depends on who you fly for. Certainly some companies are just as you say whilst others are out to nail the PIC at any opportunity.