A light aircraft’s runway incursion which led to a 737 airliner conducting a go-around, highlights the importance of pilots being aware of the most up-to-date information for the airports they are operating from, and to not hesitate to ask ATC for assistance, an Australian Transport Safety Bureau final report details.
On 7 May 2023, a pilot was preparing for a solo training flight from Sunshine Coast Airport to Wellcamp Airport, Queensland, in a Diamond DA 40 single-engine aircraft.
After requesting a departure to the south-west, the pilot was instructed by air traffic control (ATC) to taxi via taxiway Foxtrot to holding point Foxtrot runway 31.
“Taxiway Foxtrot is the repurposed southern end of the decommissioned runway 18/36 at Sunshine Coast, and as such intercepts runway 13/31 at an oblique angle,” said ATSB Director Transport Safety Stuart Macleod.
“Due to this angle, the holding point for that taxiway is about 140 m from the intersection with the runway, to ensure aircraft at that holding point remain outside the runway strip.
“Additionally, a pilot in the left seat of an aircraft needs to scan for landing aircraft at an angle of 125–130⁰ from directly ahead, outside the normal field of view.”
The Diamond pilot, who was familiar with the runway configurations at Sunshine Coast Airport but was using taxiway Foxtrot for the first time, initially stopped short at the correct holding point, but incorrectly assessed they were holding at a taxiway intermediate holding position.
“This error was reinforced when the pilot received ATC instruction to ‘hold short runway 31’ – a required change in terminology from ATC which led the pilot to believe there was an additional holding point closer to the runway.”
Despite being unsure of this belief, the pilot did not ask ATC for clarification, and crossed the holding point. At about the same time, a Boeing 737 was on final to land on runway 31.
When the Diamond was about 74 m beyond the holding point, the driver of a nearby safety car alerted ATC, and the controller immediately instructed the 737, which was now on late final about 250 ft above the runway, to conduct a go around.
The Diamond stopped on the taxiway, and the 737 went around, later landing without incident.
“Runway incursions, and other runway separation issues, are among the most significant risks to safe aviation operations, and are a key global safety priority,” Mr Macleod said.
“This incident highlights that pilots should study the most up to date information, and should never hesitate to ask ATC for clarification if they are unsure or confused about instructions.”
The ATSB’s final report details a range of safety actions taken as a result of the incident, by the training operator, Flight Training Adelaide, as well as Sunshine Coast Airport, and the Civil Aviation Safety Authority (CASA).
Actions have included the installation of mandatory instruction markings at Foxtrot, to further improve the visual characteristics of the holding position markings.
CASA has provided clarity around the runway shading on ERSA and DAP diagrams, and upgraded the Sunshine Coast manoeuvring map to accurately reflect the airport layout.
Finally, following an internal investigation, the training operator has taken a range of safety actions, including a flight instructor meeting to communicate the importance of students understanding the signs, markings, lights and phraseology, particularly when at a controlled aerodrome.
“We acknowledge the safety actions taken by all relevant parties in this incident, all with the aim of reducing the likelihood of a reoccurrence,” Mr Macleod concluded.