No fatalities

2018-04-30: Airbus A321-231 (VH-VWQ) — Jetstar Airways — Melbourne Airport, Victoria

Melbourne Airport, Victoria

On April 30, 2018, an Airbus A321-231 (registration VH-VWQ) operated by Jetstar Airways was involved in an aviation accident near Melbourne Airport, Victoria. No fatalities were reported. Investigators recorded the probable cause as: This finding should not be read as apportioning blame or liability to any particular organisation or individual. The surface movement controller’s workload during handover probably contributed to him forgetting the taxiing instruction he had issued to VH-VWQ. This summary draws on records from the Australian Transport Safety Bureau (ATSB); 8 related events involving the same aircraft type or operator are linked below.

Sourcesthe Australian Transport Safety Bureau (ATSB)Primary reportUpdated 1779788977Data APIEditorial standards
Aircraft registered VH-VWQ
Aircraft registered VH-VWQ. Photo: Bidgee / CC BY-SA 3.0 au, via Wikimedia Commons

A controller forgot a taxi clearance during handover due to high workload from peak traffic, recent takeover, and taxiway works, leading to a potential conflict between aircraft VWQ and VZB.

Controller Workload Factors

The controller's workload was increased by several factors: a high volume of traffic during the morning peak period, having recently taken over active traffic control from a trainee, and ongoing taxiway works. These demands elevated the task load on the controller.

Handover and Memory Lapse

After commencing a handover to a relieving controller, the controller forgot that he had issued a clearance to aircraft VWQ to taxi through intersection A/T, mistakenly believing he had instructed the crew to hold short of T. He subsequently cleared aircraft VZB through the same intersection, creating a potential conflict. High workload situations are likely to reduce memory performance. The workload and distraction associated with the handover probably contributed to the delay in detecting this conflict. When the conflict was detected, other radio transmissions further delayed the controller in instructing the VWQ flight crew to give way to VZB until after avoiding action had already been taken.

Managing Workload During Handover

Workload experienced by a controller at a given time is subjective, making it difficult to assess the increase that can be managed before error rates rise. Implementing strategies to reduce the risk and consequences of errors due to high workload is important. A widely accepted strategy is to delay handover until a suitable lull in traffic. In this occurrence, there had been five minutes of almost continuous radio communications followed by a 30-second lull before the controller started the handover. After completing some checklist items, the controller delayed detailing the traffic to the relieving controller. Had the handover been delayed until a longer lull could be expected, it may have reduced the risk of error. However, without any prompt to record taxiing instructions, the controller remained reliant on remembering the issued clearance limits.