B738, Perth Western Australia, 2010

Summary: 

On 24 February 2010, a Garuda Boeing 737-800 misunderstood the runway exit instruction issued during their landing roll at Perth and turned onto an intersecting active runway. An expeditious exit from this runway followed and no actual conflict resulted. The phraseology used by air traffic control was open to incorrect interpretation by the flight crew and led to their premature turn off the landing runway despite a prior briefing on exit options.

Event Details
When: 
24/02/2010
Event Type: 
Day/Night: 
Day
Flight Conditions: 
On Ground - Normal Visibility

19264

Flight Details
Aircraft: 
Operator: 
Type of Flight: 
Public Transport (Passenger)
Actual Destination: 
Take-off Commenced: 
Yes
Flight Airborne: 
Yes
Flight Completed: 
Yes
Phase of Flight: 
Taxi
Location
Location - Airport
Airport: 
AGC
Tag(s): 
Phraseology
HF
Tag(s): 
Inappropriate ATC Communication, Ineffective Monitoring
RI
Tag(s): 
Accepted ATC Clearance not followed, Incursion after Landing, Intersecting Runways
Outcome
Damage or injury: 
Yes
Non-aircraft damage: 
Yes
Non-occupant Casualties: 
No
Off Airport Landing: 
Yes
Ditching: 
Yes
Causal Factor Group(s)
Group(s): 
Aircraft Operation, Air Traffic Management
Safety Recommendation(s)
Group(s): 
None Made
Investigation Type
Type: 
Independent

Description

On 24 February 2010, a Boeing 737-800 being operated by Garuda on a scheduled passenger flight from Denpasar, Indonesia to Perth failed to follow the runway exit instruction given by ATC after a daylight landing in normal visibility on runway 03 at destination and instead turned right directly onto intersecting active runway 06. ATC then instructed an expeditious exit of this runway to the right via taxiway S and no actual conflict occurred.

Investigation

An Investigation was carried out by the Australian Transport Safety Bureau (ATSB). It was established that no runway exit instructions had been given to the aircraft prior to touchdown and that an instruction to “take taxiway November, second on your right now’ had been issued as the aircraft decelerated on the landing roll prior to taxiway ‘P’.

Perth Aerodrome layout. Source: Final report

It was noted that the flight crew briefing for the approach and landing had identified taxiways P and N as the first and second exits from the landing runway.

The Final Report AO-2010-011 of the Investigation was published on 29 June 2010

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