What happened
During the initial preparations for the day's first flight, the crew of VH-LQJ experienced several unexpected challenges prior to their scheduled 0645 departure. Unanticipated events, including an APU failure and administrative tasks regarding person in custody paperwork, created significant distractions. These interruptions occurred within a limited timeframe, resulting in heightened workload and time pressure for the captain and first officer.
While managing these pressures, the crew failed to complete two specific 'before start' checklist items. This included the failure to select the correct frequency on VHF COM 2 and the omission of the TCAS/transponder selection. Because the crew was monitoring the incorrect CTAF, they did not notice the lack of an AFRU reply, leading them to believe no other traffic was nearby. Consequently, the crew taxied VH-LQJ onto the runway directly in front of aircraft 24-8279. The instructor on board 24-8279 was forced to perform a go-around to prevent a collision.
The investigation
The investigation focused on the breakdown in situational awareness experienced by the crew of VH-LQJ. Investigators examined how the combination of time pressure and technical distractions led to a degraded mental model of the surrounding airspace. The investigation looked into the specific errors regarding radio frequency selection and the failure to activate the necessary transponder modes, which prevented the crew from receiving electronic alerts regarding nearby traffic.
Findings
- The flight crew's situational awareness was significantly compromised by increased workload and time pressures during pre-flight activities.
- The crew failed to identify the presence of aircraft 24-8279 during their visual scan of the intersection.
- The error in radio frequency selection was not caught because the crew did not recognize the absence of expected radio replies.
- The failure to set the TCAS/transponder meant the crew relied solely on visual identification, which was ineffective due to their degraded state of awareness.