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ATSB report into runway incursion at Perth Airport

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ATSB report into runway incursion at Perth Airport

Old 3rd Oct 2020, 22:17
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ATSB report into runway incursion at Perth Airport

This was released on 1 October 2020.

Investigation AO-2018-032
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Old 6th Oct 2020, 10:35
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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!
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Old 6th Oct 2020, 20:36
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Millions spent on stop bars around the country and these blokes manage to charge through them. Makes me wonder why they didnít stop to change frequencies.
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Old 6th Oct 2020, 21:08
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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.

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Old 6th Oct 2020, 21:49
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Youíd 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 4Ė5 months.

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Old 6th Oct 2020, 22:57
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Originally Posted by metrodashbrazconkie View Post
Millions spent on stop bars around the country and these blokes manage to charge through them. Makes me wonder why they didnít 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 donít think your scenario would have played out with hundreds of deaths. Still a massive f*ck up though!
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Old 6th Oct 2020, 23:13
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Must be about due for the usual Qantas propaganda to the effect that there was never any risk to safety...
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Old 7th Oct 2020, 00:26
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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.
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Old 7th Oct 2020, 13:39
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Iím curious, are FOís allowed to taxi in QF if thereís a tiller provided? If not, why not?

Iím aware that 737ís donít have tillers on the FOís side (or do some?).
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Old 7th Oct 2020, 20:48
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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.
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Old 7th Oct 2020, 20:56
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Originally Posted by galdian View Post
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.
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Old 7th Oct 2020, 21:25
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Originally Posted by morno View Post
Iím curious, are FOís allowed to taxi in QF if thereís a tiller provided? If not, why not?

Iím aware that 737ís donít have tillers on the FOís side (or do some?).
Yes QF F/Oís on all the other fleets taxi the aircraft. All the way to the NIGS at least.

No, none of our 737ís have a RHS tiller.
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Old 7th Oct 2020, 23:27
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Plenty of A/C pass each other less than 15M daily world wide! Humans fly planes, humans f**k up, it will happen again!
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Old 8th Oct 2020, 00:18
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Originally Posted by Beer Baron View Post
Yes QF F/Oís on all the other fleets taxi the aircraft. All the way to the NIGS at least.

No, none of our 737ís have a RHS tiller.
Thanks Beer Baron
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Old 8th Oct 2020, 05:53
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Originally Posted by Capt Fathom View Post
Youíd think Red STOP lights hard to ignore.
But vehicle drivers ignore them everyday! Just goes against the grain for most.


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.
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Old 9th Oct 2020, 11:53
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It's staggering that it takes 2 years and 5 months to put a report together into such an incident. Resourcing issue?
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Old 9th Oct 2020, 12:01
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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.
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Old 9th Oct 2020, 13:40
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Originally Posted by Icarus2001 View Post
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?
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Old 9th Oct 2020, 21:59
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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.
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Old 9th Oct 2020, 22:18
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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 ďThats what scares meĒ. Just because you can see the terminal doesnít mean you make a charge for it.
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