00:01An incident that occurred only three hours after another incident that we've picked up
00:05to investigate, and this occurred last Sunday at around 10 o'clock.
00:08We know that a Virgin 737 was given clearance to take off using the long runway at Sydney
00:15Airport.
00:15Now, just as they're beginning their take off role and applying power, they've noticed
00:20a Qantas 737 crossing the runway.
00:23Now, it had also been given clearance to cross the runway.
00:26So, whilst these two planes didn't come close, they were really about 1,000 metres apart,
00:32so action was taken and the appropriate time by the crew on the Virgin flight, and indeed
00:38air traffic control realised the situation and cancelled the clearance for take off.
00:44It is concerning that it occurred at all, and that's why we've picked it up.
00:48We're adding this to the other two investigations that we've started over the last two weeks,
00:52and we really want to understand why these mistakes happened in the first place.
00:56In all cases, appropriate action was taken by the pilots on board in all three instances,
01:03and indeed by traffic control, but it doesn't underscore the importance that they shouldn't
01:09have been put in this situation in the first place.
01:11So, is this latest incident a case of bad luck, if there could ever be termed bad luck in
01:16an airport, or bad management?
01:18Oh, look, it's not bad luck.
01:21Airport operations and commercial aviation is a very tight, regulated industry, and there
01:28are multiple layers of defence to make sure that it's safe.
01:31Now, when one of those layers of defence is compromised, as we've seen in these three
01:36instances, then we need to understand why. So, it's certainly not a case of bad luck.
01:41Something has gone wrong. We need to understand the circumstances that allowed it to go wrong.
01:46But most importantly, what's the strengthening? What's the recommendations to make sure that
01:52this doesn't happen again? But as I'll say, in all instances, appropriate action was taken
01:58by the crews on board the aircraft on all three occurrences.
02:02OK. I'd like to touch on a couple of things there. This incident happened last Sunday,
02:05as you just mentioned, a few hours after the other one. When did ATSB find out about it,
02:09and why the delay in the Australian public finding out about it?
02:13Look, we only found out about this around lunchtime yesterday. Now, there was a delay,
02:18and once we'd got the initial indication, then we made it known that we were investigating
02:23a couple of hours later. We want to understand why there was a delay
02:27in the reporting to us. Now, we do work closely with airlines, with air services,
02:32around reporting guidelines. So, look, we don't know exactly why there was a delay. We do think
02:38that initial indications that it was probably classified initially as a training incident
02:44and not a reportable incident. Now, why that's the case, we don't know. But we know that some training
02:49and supervision was being undertaken in the tower at the time. But, however, notwithstanding that,
02:57we need to understand that was there a breakdown in that communication and how do we strengthen it
03:02to make sure that we're not delayed in these notifications in the future.
03:05So, if there is an issue around the training in the tower at the time,
03:09you will investigate that, as you've just mentioned. But do you think there really should
03:13be training in the air traffic control tower at any time?
03:16Well, look, training, and I think the Head of Air Services has stated just very recently that
03:22this is a significant ramp-up time for them, post-COVID, around bringing on new controllers.
03:27Now, that involves a myriad of training, from classroom training to simulation training,
03:33and then introduction into the live environments as well. So, look, we don't know the full circumstances
03:38around the supervision and training, but it is very normal in most workplaces for training to
03:43graduate up to a live environment to then, obviously, progressing to full qualifications.
03:49Exactly who was involved at this stage and whether that even played a role, we're yet to ascertain.
03:55We need to understand all of the circumstances surrounding what's occurred before we make any,
04:02I guess, recommendations as to what needs to be strengthened.
04:05Sure. I guess what might be on a lot of travellers' minds right now, three serious safety incidents
04:10at Sydney Airport in as many weeks. Is it safe to travel through Sydney Airport right now?
04:15My job is to investigate these things when they've gone wrong. I will say, in all three instances,
04:22there was a layer of defence that kicked in and prevented an escalation. Now, we find in a lot of
04:29our
04:29investigations, it's very rarely one single point of failure. For it to progress through to an actual
04:35accident, multiple things need to go wrong. In all three cases here, there was a line of defence
04:41that prevented an escalation. And that line of defence was actually multiple lines of defence,
04:47in that we had air crews on board the aircrafts, identifying the situation and taking action.
04:52But we also had air traffic control in the case of the two Qantas planes that came in close proximity.
04:59It was also recognised by air traffic control, orbit after when it perhaps should have been. But equally,
05:07in this one, this latest one that was reported to us, air traffic control cancelled the take-off
05:13clearance around the same time as the pilot on board realised that there was a potential conflict.
05:18So, given the regularity of these safety issues, will the ATSB expedite its investigations? I believe
05:26two months is the timeframe that we've been given. Is that too long while thousands of people continue
05:31to travel through Sydney Airport? Look, we pick up around 80 investigations a year. We've got around
05:3780 active investigations. We get around 8,000 notifications. Keeping in mind, aviation is an
05:43incredibly important part to all of Australia, regional Australia and our major cities. We expedite
05:50things as best we can, but equally, we make sure we get it right. So, we spend the time to
05:55get all of the
05:56evidence, to analyse it and to make sure that our reports actually lead to safety improvements.
06:01Of those 80 investigations... So, we will get something out.
06:03Sorry to interrupt, Angus. Of those 80 investigations that you've got in a year,
06:07how do these last three rank? Are they numbers one, two and three?
06:10Look, they sit alongside a number of very significant investigations, but I will say
06:16that fair-paying passengers, particularly high-capacity, what we'd say RPT, is amongst our
06:23highest priority. So, look, we do put a lot of effort into these, but we make sure we get it
06:28right,
06:28so that when our report comes out, it actually leads to improvements. And that's why Australia has
06:34an aviation safety record that is really the envy of the world, because we take these things so
06:40seriously when there are, as you may say, either a near miss or even a, what has been effectively a
06:46managed situation. But it shouldn't have happened, and we need to make sure it doesn't happen in the
06:51future.
06:51Angus, just finally, on the incident that we're talking about now, we know that the Virgin Australia
06:55crew reduced thrust and the aircraft came to a stop on the runway when they realised that there was
07:02another plane in its path. I mean, pilots are being praised for their quick-thinking action here.
07:08They had been cleared for take-off. Are pilots doing the job of air traffic controllers?
07:13Look, I think in this case, you're absolutely right, the pilots should be praised. They identified that
07:19there was potentially an obstruction in this crossing aircraft, but that's part of the pilot's role as
07:24well. So, as I said, keeping aviation as safe as it is relies on multiple defences. Part of that,
07:31yes, of course, is air traffic control and the coordination, but it's also in electronic measures
07:37in the cockpit of the plane, it's to training and experience of pilots as well. There is a lot of
07:42things that make up safety in aviation. They all need to be working, and in this case, as I've said,
07:48and in the other two, there was that defence and well-trained pilots making appropriate actions
07:53that stopped an escalation of the situation.
07:57Angus Mitchell, ATSB Chief Commissioner, really appreciate you giving us your time this morning.
08:02You're welcome. Thank you.
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