Boeing Co 737-476, VH-TJQ

During the course of the investigation, it became known that hand-held checklists were being used for single-pilot operations in instrument meteorological conditions.

Consequently, the Bureau of Air Safety Investigation is investigating a perceived safety deficiency. The deficiency relates to the practice of single-pilot IFR flight crew using hand-held checklists during ILS approaches, with a possible loss of situational awareness associated with distraction.

Any safety output issued as a result of this analysis will be published in the Bureau's Quarterly Safety Deficiency Report.

The attention of the pilot under training was partially diverted from safely taxiing the aircraft due to his pre-occupation with a previous event.
The training captain did not provide a timely warning to the pilot under training that he had passed the correct taxiway and was approaching an active runway.

The task of taxiing the aircraft after landing was not particularly demanding. The night was fine and clear, there were no works in progress, and both pilots of the Metro were familiar with the airport layout. However, it was apparent that the attention of the pilot under training was partially diverted from taxiing the aircraft by his pre-occupation with how he had performed during the practice ILS approach. The result was that he then mistakenly believed the aircraft was still approaching the entry to taxiway Bravo, when in fact the aircraft had passed that point and was approaching runway 34L.

The training captain noticed that the aircraft had passed the entry to taxiway Bravo, and was about to query the pilot under training when he noticed the other aircraft landing on runway 34L. In hindsight, he should have alerted the pilot under training when it became apparent that the aircraft was not beginning to turn into taxiway Bravo.

Although it was reasonable to have expected the crew of the Metro to enter taxiway Bravo after correctly reading back their taxi clearance, the vigilance and prompt action of the tower controllers acted as a final safety defence to stop the aircraft from entering the runway.

A Fairchild SA227-AC (Metro) aircraft landed on runway 34R, with
an instruction to exit onto taxiway Tango 1 and taxi via taxiway
Juliet. The pilot contacted the surface movement controller (SMC)
while approaching a mandatory holding point on taxiway Juliet, and
was instructed to taxi via taxiway Bravo and hold short of runway
25. The pilot read the instruction back correctly. That instruction
required the pilot to continue ahead on taxiway Juliet, passing the
entry to taxiway Charlie before turning right into taxiway
Bravo.

The tower controllers subsequently observed the Metro taxiing
along taxiway Juliet, past the entry to taxiway Bravo, towards
runway 34L, which lay a short distance beyond taxiway Bravo. At
that time, a Boeing 737 (B737) was touching down on runway 34L. The
SMC instructed the pilot of the Metro to stop. As there was no
reply, the instruction was immediately repeated, and subsequently
acknowledged. The Metro was stopped at the edge of runway 34L,
beyond the runway holding point. The pilot of the B737 was also
instructed to stop immediately, but the aircraft was too close to
the taxiway Juliet intersection to comply. The B737 was steered to
the left of the runway centreline to increase separation from the
Metro, subsequently passing about 25 m in front of that aircraft,
at about 80 kts.

The occurrence happened at night in fine conditions; there were
no works taking place in the area; and all relevant taxiway lights,
runway holding point lights and movement area guidance signs were
reported by the air traffic controllers to have been functioning
normally. However, when subsequently interviewed, both pilots
asserted that the runway 34L holding point lights on taxiway Juliet
were not illuminated. Shortly after the incident an airport safety
officer had been requested to conduct an inspection of the ground
lighting in the occurrence area. All lighting, including the
holding point lights on taxiway Juliet protecting runway 34L, were
observed to be functioning normally.

An investigation established that the pilot flying the aircraft
was undergoing command training under the supervision of a training
captain. A practice Instrument Landing System (ILS) approach had
been flown, during which the pilot under training experienced
difficulties in maintaining the required flight tolerances. After
landing, the pilot correctly obtained and read back the taxi
clearance. However, he subsequently failed to notice that the
aircraft had passed taxiway Charlie and was approaching the
entrance to taxiway Bravo. Believing he was now approaching taxiway
Charlie, the pilot continued to taxi along taxiway Juliet,
expecting to see the entry to taxiway Bravo.

At about that point, the training captain, noticing that the
aircraft had just passed the entry to taxiway Bravo, looked towards
the pilot to ask where he was going, but immediately noticed the
lights of a landing aircraft on runway 34L. Concerned about the
proximity of the other aircraft, he immediately instructed the
pilot under training to stop, which coincided with similar
instructions from the SMC.

During discussions with the crew of the Metro, it became
apparent that, after landing, the pilot under training had been
concerned with his performance during the practice ILS approach,
and had initiated a brief discussion with the training captain at
about the time the aircraft had been taxiing along taxiway
Juliet.

Both pilots, who were very familiar with the layout of Sydney
Airport, also indicated that the movement area guidance signs
(MAGS) were somewhat confusing when indicating the entry to
taxiways. However, the pilot under training said that normally he
did not refer to the MAGS because of his familiarity with the
taxiway layout.