ASN Wikibase Occurrence # 228046
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| Date: | Monday 5 August 2019 |
| Time: | 18:32 |
| Type: |  Airbus A330-202 |
| Owner/operator: | Qantas |
| Registration: | VH-EBJ |
| MSN: | 940 |
| Year of manufacture: | 2008 |
| Engine model: | GE CF6-80E1A4 |
| Fatalities: | Fatalities: 0 / Occupants: 163 |
| Aircraft damage: | None |
| Category: | Incident |
| Location: | near Sydney Int Airport, NSW -
 Australia
|
| Phase: | Take off |
| Nature: | Passenger - Scheduled |
| Departure airport: | Sydney-Kingsford Smith International Airport, NSW (SYD/YSSY) |
| Melbourne-Tullamarine Airport, VIC (MEL/YMML) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
A loss of separation occurred involving an Airbus A330-202 (flight QF459, registered VH-EBJ) and a Boeing 737-800 (QF545, registered VH-VZO), near Sydney Airport, Australia.
VH-EBJ was lined up ready for departure on runway 34R and VH-VZO was on final approach to runway 34R. After the previous landing aircraft had cleared the runway, the air traffic controller cleared VH-EBJ for immediate take-off. Shortly after, the flight crew of VH-VZO were issued a late instruction to go around as the runway separation standard could not be assured.
The controller instructed the flight crew of VH-VZO to turn on to an easterly heading and climb to provide separation with VH-EBJ as that aircraft became airborne. However, the turn instruction provided to the flight crew of VH-VZO conflicted with the departure track of VH-EBJ, which was on a standard instrument departure.
The flight crew of VH-EBJ subsequently received a traffic collision avoidance system traffic alert.
In the early stages of the respective procedures, the separation between the aircraft reduced to about 0.42 NM (800 m) laterally and about 508 ft vertically.
Contributing factors:
- The 737 flight crew did not maintain the aircraft’s speed within the specified range during the first part of final approach, and did not advise air traffic control of this non-compliance as required by the approach procedure.
- The spacing between the landing Dash 8 and the following 737 on approach reduced to less than 5 NM without the required coordination between the approach controller and aerodrome controller position prior to transfer.
- The trainee aerodrome controller’s judgement of the spacing between the Dash 8 and 737 was likely affected by incomplete appreciation of their initial spacing and speed difference. As a result, the A330 was instructed to line up and was then issued a clearance for an immediate take-off without sufficient spacing to prevent a runway separation issue or go-around. Because the respective departure and missed approach procedures both involved climbing from a low level and tracking to the east, this led to a compromised separation situation.
- After initiating the missed approach, the 737 flight crew inadvertently continued on the runway heading above the mandatory 600 ft turn beyond the missed approach point, and did not turn until instructed by the trainee aerodrome controller. As a consequence, the flight path of the 737 was closer to that of the A330’s departure track than it would have been if the turn had been commenced at the required height.
- Although the trainee aerodrome controller’s instruction for the 737 to initiate the turn reduced the collision risk, the extension of the turn to 100° did not mitigate the short-term effect of the delayed and relatively large-radius turn of the 737, or modify the A330’s projected flight path. Further, the aerodrome controller did not issue the 737’s turn instruction using the phrase required for avoiding action or issue a safety alert to either flight crew.
- After the missed approach was initiated, the on-the-job training instructor’s prompts to the trainee aerodrome controller were at the lower level of the prompting hierarchy and did not reflect the potential criticality of the situation or elicit an effective response.
- The Airservices Australia MARUB SIX standard instrument departure and the missed approach procedure for runway 34R directed aircraft onto outbound tracks that did not sufficiently assure separation between aircraft following the procedures concurrently. (Safety issue)
- Although Airservices Australia applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally. (Safety issue)
Accident investigation:
 |
|
Sources:
https://www.atsb.gov.au/publications/investigation_reports/2019/aair/ao-2019-041/
Location
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 09-Aug-2019 06:46 | harro | Added |
| 10-Jun-2022 08:38 | Ron Averes | Updated [Location] |
| 12-Oct-2023 06:14 | harro | Updated [[Location]] |
| 30-Oct-2023 12:10 | harro | Updated [[[Location]]] |
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