A QantasLink Dash 8 plane. GENERIC FILE PHOTO.
A QantasLink Dash 8 plane. GENERIC FILE PHOTO.

REVEALED: What led to scary Gladstone runway incident

An investigation has revealed why a QantasLink Dash 8 with 34 passengers on board was taxied onto the runway at Gladstone Airport in front of an approaching light aircraft in March last year.

The Australian Transport Safety Bureau (ATSB) on Tuesday released its findings from a probe into the early morning incident on March 17, 2020.

On that morning, the QantasLink Bombardier Dash 8 was being taxied for a scheduled flight from Gladstone Airport to Brisbane Airport.

There were two flight crew, two cabin crew and 34 passengers on board.

At the same time, an ATEC Faeta 321, with one instructor and student on board, was conducting circuit training at Gladstone Airport.

About 6.45am, the Faeta was on approach to conduct a "touch-and-go" on runway 10.

The Dash 8 entered and taxied along the runway in front of the Faeta.

The instructor on board the Faeta had to conduct a "go-around" to avoid an incident on the occupied runway.

The ATSB report reveals the events which contributed to the incident.

It states that about 6am on that day, the flight crew of the QantasLink Bombardier Dash 8-402 commenced pre-flight preparations for a 6.45am flight to Brisbane.

During those preparations, the crew twice started the aircraft's auxiliary power unit, which failed on both occasions when selecting "APU bleed air ON" to provide air-conditioning to the cabin.

The captain also had to review paperwork and brief cabin crew on arrangements for a "person in custody" and their police escort to travel on the flight.

After applying the Minimum Equipment List (MEL) to the APU, the flight crew undertook the remainder of their pre-flight checks, but missed setting the traffic collision avoidance system (TCAS)/transponder to "ON ALT" and selecting the Gladstone common terminal advisory frequency (CTAF) radio frequency.

The first officer identified the CTAF omission during the departure briefing, however incorrectly set the frequency to 126.7 MHz instead of 118.8 MHz, which was the correct frequency for the Gladstone CTAF.

"The ATSB's investigation found that the flight crew of the Dash 8 had inadvertently selected the incorrect radio frequency for the airport's CTAF and incorrect mode on the traffic collision avoidance system/transponder during the before start checks reducing the flight's crew situational awareness and mental model of traffic," said ATSB director of transport safety Stuart Macleod.

"The frequency selection error was further compounded by the flight crew not recognising the absence of the aerodrome frequency response unit reply when making radio calls on the incorrect frequency and the assumption they would be alerted to the presence of any transponder-equipped aircraft that were operating in the area."

This map shows the path of the Dash 8 at Gladstone Airport. Source: ATSB.
This map shows the path of the Dash 8 at Gladstone Airport. Source: ATSB.

About 6.45am, the Dash 8 was taxied onto the runway in front of the approaching light aircraft.

In response, the instructor on board the light aircraft commenced a "go-around" and attempted, unsuccessfully, to contact the Dash 8 crew on the Gladstone CTAF.

Shortly afterwards, the captain identified that the TCAS/transponder was not appropriately set and selected it to "ON ALT".

The TCAS subsequently presented the flight crew with a traffic advisory indicating climbing traffic, which was the light aircraft that the flight crew subsequently sighted climbing in an easterly direction overhead the airport.

Mr Macleod said the incident illustrated the "human factors implications" associated with the combination of increased workload and time pressures.

"Situations like this can result in degraded information processing, increased errors, the tunnelling of attention, and an increased reliance on familiar strategies or actions and probably resulted in the flight crew's omission of the two 'before start' checklist items and the selection of the incorrect frequency," he said.

"Flight crews can guard against similar situations by applying effective threat and error management strategies that recognise when such threats may arise and set in place suitable actions that minimise error potential.

"These actions include strict adherence to standard operating procedures and increased cross-checking of system inputs and mode changes."

As result of the incident, QantasLink has reviewed its operating procedures at non-controlled airports and introduced new requirements to contact air traffic control before entering the runway.

Read the ATSB's final report on this incident HERE.

 

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