Private Flight Pilot’s Expectation Bias with Procedures Likely Led to Runway Incursion: ATSB Investigation
The ATSB (Australian Transport Safety Bureau) conducted an investigation into a runway incursion involving a private flight operated by Beech Aircraft Corp. 58, registration VH-NSK at Bankstown Airport, NSW on 26 October, 2021.
On October 26, 2021, a Beech Aircraft Corp. 58, registered VH-NSK, operated by Little Wings Limited, was prepared for a private flight from Bankstown Airport, New South Wales. The purpose of the flight was to test the stall warning system following maintenance. The pilot was the sole person on board.
The aircraft for a private flight was cleared to enter and line up on runway 29 right (29R) however, the pilot crossed the runway and entered occupied runway 29 centre (29C) without a clearance. As the pilot was cleared to take-off, the controller identified the error and instructed the pilot to hold position on the runway. At the same time, the pilot detected an Embraer 190, which was conducting high power engine runs on the upwind end of runway 29C and did not commence the take‑off.
What the ATSB found
The ATSB found that the pilot typically departed Bankstown from the centre runway, under the instrument flight rules procedures. This likely created an expectation that they were using this runway, despite reading back the correct runway to the controller. This resulted in them crossing runway 29R and entering runway 29C without a clearance.
Additionally, while the air traffic controller watched the aircraft enter 29R, due to subsequent focused attention on two helicopters in the vicinity of the airport, they did not identify its continued movement on to the occupied runway 29C.
What is the safety message from the private flight incident?
This incident illustrates the importance of pilots focusing on the specific instructions given by air traffic controllers. In 2012, the United States Federal Aviation Administration Safety Team (FAASTeam) released notice NOT4214 Pilot safety tip – Expectation bias stating that “analysis of runway incursion data shows that expectation bias is one of the most common causal factors for pilot deviations.”
The notice went on to say that pilots ‘need to understand that expectation bias often affects the verbal transmission of information. When issued instructions by air traffic control, pilots should “focus on listening and repeat to yourself exactly what is said in your head — and then apply that information actively.” In October 2016, Airservices Australia released A pilot’s guide to Runway Safety. This guide focused on seven important areas in surface operations and identified safety measures to help reduce the errors that lead to runway incursions.
Runway incursions remain an ongoing safety concern globally. In addition, Airservices Australia have released specific guidance for pilots flying at Bankstown Airport Tips for flying at Bankstown, along with tips for flying at other metropolitan airports: Moorabbin, Parafield, Jandakot and Archerfield.
Image source/credit: ATSB, “Runway incursion involving Beech Aircraft Corp. 58, VH NSK Bankstown Airport, New South Wales, on October 26, 2021.”
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