ATR 72 lines up and starts take-off on incorrect runway, Australia : 財團法人中華民國台灣飛行安全基金會

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ATR 72 lines up and starts take-off on incorrect runway, Australia

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admin - News | 2020-12-16 07:06:55

Date:	25-SEP-2019
Time:	19:00 LT
Type:	ATR 72-600 (72-212A)
Owner/operator:	Virgin Australia Airlines
Registration:	VH-VPJ
C/n / msn:	1169
Fatalities:	Fatalities: 0 / Occupants: 55
Other fatalities:	0
Aircraft damage:	None
Category:	Incident
Location:	Canberra Airport (CBR/YSCB) - Australia
Phase:	Take off
Nature:	Passenger - Scheduled
Departure airport:	Canberra Airport, ACT (CBR/YSCB)
Destination airport:	Sydney-Kingsford Smith International Airport, NSW (SYD/YSSY)
Investigating agency:	ATSB

Narrative:
On the evening of 25 September 2019, the flight crew of an ATR 72 aircraft, registered VH-VPJ and operated by Virgin Australia Airlines, received a clearance to line‑up on runway 35 from intersection ‘Golf’ at Canberra Airport, Australia. While taxiing to the runway, the flight crew inadvertently lined-up on runway 30. Almost immediately after commencing the take-off roll, and at about the same time air traffic control instructed them to ‘stop’, the flight crew rejected the take‑off. The aircraft was re‑positioned for a departure from runway 35.
The ATSB found that the flight crew elected to depart from intersection ‘Golf’ for runway 35. Due to the close proximity of the aircraft’s parking bay to the ‘Golf’ runway holding point, the selection of this intersection reduced the distance, and therefore the amount of time available for the flight crew to complete their pre-departure checks. After passing through the holding point, the captain taxied the aircraft onto runway 30, following the lead-on lights for that runway, while the first officer’s attention was focussed on completing procedures and checklists. This likely resulted in the flight crew having reduced awareness of the runway environment and aircraft orientation.
The lead-on lights to runway 30 were active with the taxiway lighting and the lead-on lights to runway 35 were activated when the holding point stop bar at intersection ‘Golf’ was turned off by air traffic control. Therefore, both runway lead-on lights were active. This increased the risk of an aircraft being manoeuvred onto the incorrect runway, particularly at night and/or in low visibility conditions. In this case, the captain, who recalled being focused on the lead-on lights, followed the first set of lights that led to runway 30.
The ATSB also established that Virgin Australia Airlines’ ATR72 Before take-off procedure did not specify when ‘ready [for take-off]’ was to be communicated to air traffic control. This increased the risk of procedures and checklists being completed while the aircraft was taxiing onto the runway, at a time when monitoring was critical. Virgin Australia Airlines’ procedures applicable to all the aircraft in their fleet did not include a runway verification check using external cues, including runway markings, signs and/or lights.

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