What happened
An incident occurred involving two aircraft, VH-ZRH and VH-ITF, which led to a potential runway conflict. While the flight crew of VH-ZRH was preparing to use the runway, they entered the active area without realizing that the pilot of VH-ITF had already begun a takeoff roll. The pilot of VH-ITF observed the movement of VH-ZRH and was able to promptly abort the takeoff to avoid a collision.
The investigation
Investigators examined the situational awareness of both crews and found that while Melbourne Centre had provided traffic information, the pilots did not correctly interpret the traffic picture. Specifically, the crew of VH-Z/RH operated under the mistaken belief that VH-ITF had already departed the area. Although air traffic control communications indicated that VH-ITF was still taxiing at Carnarvon, the crew did not verify this, instead allowing their prior expectations to override the provided data.
On the other hand, the pilot of VH-ITF was aware of the presence of VH-ZRH but assumed the other aircraft would hold short of the runway. Because the pilot believed no conflict existed, they did not initiate direct radio contact with the other crew to clarify intentions.
Findings
- The flight crew of VH-ZRH performed an ineffective visual scan of the runway threshold prior to entry.
- Expectation bias played a significant role, as the crew's belief that the other aircraft had departed likely prevented them from identifying VH-ITF during their lookout.
- Both crews maintained an incorrect understanding of each other's positions and intentions.
- A lack of direct communication between the two flight crews prevented the resolution of the potential conflict through verbal clarification.