Several safety actions have been made or are planned in response to a close proximity event that occurred between two 737 aircraft at Sydney Airport last year, an Australian Transport Safety Bureau final report details.
On 29 April 2023, a Qantas-operated Boeing 737 was lined up to take off from Sydney’s runway 16L, while a second Qantas 737 was on approach to land on the same runway.
The Australian Transport Safety Bureau (ATSB) has now released its final report detailing the event and the subsequent actions taken to enhance aviation safety protocols.
Incident Overview
On April 29, 2023, a potentially hazardous situation unfolded as a Qantas-operated Boeing 737-838 registered VH-VZM prepared for takeoff from Sydney’s runway 16L while another Qantas 737-838 registered VH-VZW was on final approach to land on the same runway.
Shortly after VH-VZM commenced the take-off roll, the aerodrome controller identified the spacing between the 2 aircraft had reduced to a distance that could result in compromised runway separation.
In response to the imminent risk, the controller instructed the approaching aircraft VH-VZW to initiate a go-around and discontinue its approach.
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However, amidst the high workload and a momentary delay caused by an inadvertent interjection, the crew of the second aircraft misinterpreted the controller’s directive.
This misinterpretation led them to maintain the runway heading instead of executing the prescribed left turn, resulting in a critical reduction in separation between the two aircraft.
During the missed approach, the separation between the 2 aircraft reduced to 0.8 NM (1.5 km) horizontally and 330 ft vertically as they climbed away from the runway.
Post-Incident Safety Measures
Following the incident, Airservices Australia, the air traffic services provider, initiated several safety enhancements in collaboration with the ATSB.
These measures aim to fortify the resilience of the aviation system and mitigate the likelihood of similar incidents in the future. Among the proposed actions outlined in the final report are:
Enhanced Analysis of Landing Runway Occupancy Times
Airservices Australia commits to conducting a thorough analysis of landing runway occupancy times at Sydney Airport and potentially other major airports.
This analysis will determine expected runway occupancy times under various aircraft types and operational conditions, facilitating better traffic management and coordination.
Implementation of Defensive Controlling Techniques
To bolster air traffic control procedures, defensive controlling techniques will be integrated to improve situational awareness and responsiveness during critical phases of flight, such as go-arounds.
These techniques will empower controllers to effectively manage traffic flow and maintain adequate separation between aircraft.
Assurance Review of Go-Around Scenarios
An assurance review of go-around procedures at Sydney Airport involving a second aircraft requiring controller intervention will be conducted.
This review aims to identify and address any deficiencies in existing protocols, ensuring swift and decisive actions in similar situations in the future.
Expansion of Compromised Separation Training
Night-time go-around scenarios will be incorporated into compromised separation training to prepare controllers and flight crews for challenging conditions during low visibility periods.
This expanded training regimen will enhance overall operational safety and preparedness in complex airspace environments.
A full copy of the ATSB final report can be accessed here.
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