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ASN Wikibase Occurrence # 210405
Last updated: 30 November 2020
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Time:14:42 LT
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-838 (WL)
Registration: VH-XZM
C/n / msn: 44574/5018
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Perth Airport, WA (PER/YPPH) -   Australia
Phase: Taxi
Nature:Passenger - Scheduled
Departure airport:Sydney-Kingsford Smith International Airport, NSW (SYD/YSSY)
Destination airport:Perth Airport, WA (PER/YPPH)
Investigating agency: ATSB
A serious runway incursion incident occurred at Perth Airport, Australia on 28 April 2018, involving two Qantas Boeing 737-800 aircraft.
VH-XZM (QF567 from Sydney) landed on runway 03 and exited the runway on taxiway Juliet 2 (J2). The flight crew was required to hold short of runway 06. The aircraft passed the holding point, and stopped just past the holding point.
VH-VZL (QF582 to Sydney), another Boeing 737, was departing on runway 06 and had commenced its take-off roll. The controller instructed the flight crew to stop immediately. The flight crew conducted a rejected take-off and the aircraft stopped on the runway near taxiway J2. They were then instructed to vacate the runway at taxiway Alpha (A).

The area where the incident occurred is annotated on the En Route Supplement Australia (ERSA) as a runway incursion ‘hot spot’. The holding point on taxiway J2 prior to runway 06 is marked with a runway stop bar.

Contributing factors:
- The captain developed an incorrect mental model of the exit taxiways off runway 03, believing the aircraft would not have to cross runway 06 after exiting on either of the potential taxiways (J2 or D). As a result, the captain did not expect to cross a runway holding point or stop bar and, upon seeing the stop bar was illuminated, incorrectly thought that it must only apply to
aircraft coming from the other direction.
- During the approach phase, the captain's workload as pilot monitoring was increased due to the first officer's low level of experience and air traffic control's request for a high-speed descent. This workload contributed to the omission of routine secondary tasks, such as requesting a taxiway D exit from the tower and pre-setting the surface movement control frequency.
- After vacating runway 03, the first officer focused inside the flight deck for a period of time to select the surface movement control frequency, instead of performing the more safety criticaltask of monitoring the aircraft's taxi path as it approached a known runway incursion hot spot.
- When approaching the holding point for runway 06, the captain briefly focused inside the flight deck to gain an understanding for the delay in changing to the next frequency. This reduced the time available to notice the holding point signs and lights ahead.
The captain taxied passed the runway 06 holding point (with an illuminated stop bar) without an air traffic control clearance.
- After taxiing passed the illuminated stop bar, the captain was distracted by the presence of another aircraft on the apron. This focused the captain’s attention on the distant apron area, reducing the likelihood of visually identifying the runway immediately in front of the aircraft.
- During the approach briefing, the flight crew discussed taxiway J2 and taxiway D, but the flight crew did not discuss the potential threat of the hot spot associated with taxiway J2.
- Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed. [Safety issue]
- Although some aerodrome navigational charts in Australia had identified hot spot locations, they generally provided limited explanatory information to enhance flight crew understanding or awareness of why the hot spot was there and what actions they could take to mitigate the associated risk.
- The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient to effectively reduce the risk of a runway incursion. [Safety issue]
- Although the flight crew of VH-VZL taking off on runway 06 were provided with an instruction to stop immediately to reject their take-off, no safety alert or instruction was provided to the flight crew of VH-XZM during the period between when the controllers received a stop bar violation alert (1442:04) and the captain applied the brakes at 1442:19.

Other factors that increased risk:
- Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combinedroles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation alert or runway incursion alert at their workstation. [Safety issue]

AIP Australia aerodrome chart:

Accident investigation:
Investigating agency: ATSB
Status: Investigation completed
Duration: 2 years and 5 months
Download report: Final report


Photo of VH-XZM courtesy

Adelaide - International (YPAD / ADL)
5 February 2020; (c) Gavin Hughes

Revision history:

04-May-2018 16:05 harro Added
04-May-2018 18:24 harro Updated [Source]
03-Oct-2020 09:27 harro Updated [Narrative, Category, Accident report, Photo]

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