Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.
The ATSB is satisfied that the amendments to the Volume A1: Operating Policies and Procedures and Boeing 737-NG Flight Crew Operations Manual will increase the opportunity for flight crew to detect errors.
In particular, the requirement to reference both internal and external cues, and verbally identify and verify the runway, will provide a specific opportunity for flight crew to confirm the correct runway and take-off position before they lead to unintended consequences.
Virgin Australia Airlines advised they will be amending their Operating Policies and Procedures manual to include reference to external cues, including runway signs and the localiser.
In addition, the Flight Crew Operating Manual for the Boeing 737 will also include the following steps:
• Both flight crew are required to verify the intended take-off position with the TOLD [take-off and landing data] card.
• Both flight crew are required to verify the runway and runway take-off position are correct. The pilot flying references the runway signage and/or runway markings, and the pilot monitoring verifies the position and verbalise that it has been ‘checked’.
• Prior to commencing the take-off roll, verify that the aircraft heading agrees with the runway heading.
The ATSB considers that the proposed inclusion of a runway verification procedure, which would require Virgin Australia Airlines flight crew to review the take-off runway and refer to internal and external cues to check the aircraft is lined-up on the correct runway, will address the safety issue.
On 14 June 2023, Virgin Australia advised the ATSB that they had updated Volume A1: Operating Policies and Procedures stating that, prior to entering the runway for take-off, the flight crew must:
Verify correct runway and runway take-off positioning using both external cues (e.g. runway signage, runway markings, runway lighting, and aircraft orientation) and internal cues (e.g. FliteDeck Pro Airport Moving Map/airport chart, LOC, aircraft position and orientation on the navigation display relative to the departure runway etc).
Further, the Boeing 737-NG Flight Crew Operations Manual was also updated requiring flight crews, when approaching the take-off position, to verify that the runway and runway take-off position were correct. The captain was required to verbalise the reference runway signage or markings and the first officer was to verify and acknowledge that this was the correct position.
