ATSB report into runway incursion at Perth Airport
 

This was released on 1 October 2020.

Investigation AO-2018-032

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!

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.

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.

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

:confused:

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!

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.

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?).

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.

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.

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

Thanks Beer Baron

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.

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

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?

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.

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.