Jandakot Airport: ATSB finds alert instructor helped prevent ‘serious outcome’ after instruction not followed

An alert flying instructor helped prevent tragedy at Jandakot Airport after an incoming plane cut off an aircraft preparing to land, an investigation by the Australian Transport Safety Bureau has found. The investigation was launched after an incident on June 12 when a student pilot was returning to Jandakot after a solo navigation flight in a twin-engine Piper PA-44 Seminole. At the same time, a single-engine Cessna 172 was approaching the airport from the training area. Air traffic control directed the pilot of the faster Seminole to overtake the Cessna as they approached the circuit. However, when the Seminole did not pass the Cessna prior to joining the circuit, ATC amended the instruction, telling the Seminole to “follow the Cessna”. “The Seminole pilot did not identify this final part of the amended instruction, likely due to receiving an unexpected cockpit traffic alert at the time the approach clearance was issued,” ATSB director of transport safety Stuart Macleod said. The pilot of the PA-44 continued to overtake the C172 as per the previous instruction by accelerating, descending and turning inside it, reducing the distance between the two. ATC warned the C172 that the PA-44 had “cut them off”. The PA-44 thought the separation between the two aircraft “did look a bit odd” but did not question the controller. The instructor in the C172 was concerned that the PA-44 pilot may not have understood ATC and ensured they maintained visual contact with the PA-44 throughout the incident. “The situation awareness maintained by the instructor in the C172 ensured that adequate separation was maintained between the two aircraft as the situation developed, possibly preventing a more serious outcome,” the ATSB report said. It found that although it was a key element of the revised approach clearance, the PA-44 pilot’s read back of ATC’s instructions was incomplete. “This was not corrected by the controller as the Manual of Air Traffic Services did not explicitly require sequencing instructions to be read back,” Mr Macleod said. “This was a missed opportunity to resolve the situation and, more generally, provided no assurance that this safety critical aspect had been correctly understood.” The PA-44 pilot said they had always previously been required to read back the complete sequencing instruction. As they did not get another prompt to read back, they did not think they had incorrectly heard the instruction. Airservices Australia will now investigate changing the Manual of Air Traffic Services and the Aeronautical Information Publication reference to include the instruction “follow” in the list of items requiring read back. “Sequencing of aircraft is a safety critical component of assuring separation and needs to be unambiguous for all,” the ATSB report said. “For flight crew, they should seek confirmation from controllers if they are unsure of what is required of them or if the picture doesn’t look right. “Similarly, if there is any doubt, ATC should confirm that pilots have a correct understanding of sequencing requirements.”