Sydney Airport near-collision one of worst in 20 years, investigators say

A near-collision at Sydney Airport in July has been deemed one of the most severe runway conflicts since record-keeping began more than 20 years ago, air safety investigators say.

The Australian Transport Safety Bureau (ATSB) on Wednesday released four preliminary reports related to six incidents that occurred at Kingsford Smith Airport between July and August.

The reports do not make findings or recommendations, but outline the sequence of events and key operational context at the time of the incidents.

ATSB Commissioner Angus Mitchell said the first of the incidents, involving two Qantas aircraft in July, had been deemed a "Category A runway incursion".

He said the event was the most severe to occur in Sydney and was only the third such incident within Australia since ATSB records began in 2003.

"In all six incidents, safety defences operated in some form; air traffic controllers, pilots or ground crew acted to prevent more serious outcomes,"

Mr Mitchell said.

On July 27, a "breakdown of coordination" led an air traffic controller to clear a Boeing 737 carrying 157 people to cross a runway as a QantasLink Bombardier with 55 people onboard was landing.

The interim report said the air controller who issued the clearance had a "high predicted fatigue risk level" when a brief handover was given to another controller while they went on break.

"[The 737] had stopped before reaching the intersection of runway 34L and runway 25 but was within the runway surface area past the runway stop bars, resulting in a runway incursion," the report said.

"[The Bombardier] came to a stop prior to the runway 34L and 25 runway intersection. When both aircraft came to a stop, they were approximately 120 m apart."

The report also said that, the time of the occurrence, Sydney's air traffic control tower was operating with high predicted fatigue levels for four out of seven controllers.

"Whilst an elevated fatigue risk does not necessarily mean a controller was fatigued, or that fatigue affected performance, we are, however, examining the effectiveness of the measures that were in place to manage this pre-identified risk," Mr Mitchell said.

Mr Mitchell said roster modelling by Airservices Australia had predicted an "elevated fatigue risk" for staff on many of the days in which conflicts occurred between July 27 and August 25.

Mr Mitchell said while staff resourcing was not determined as the direct cause of the occurrences, the ATSB would investigate whether the practice of combining operational roles and an over-reliance on overtime to fill shifts were underlying factors.

Safety investigators broaden scope

On Wednesday, the ATSB also released a report comparing levels of similar occurrences across Australian airports between 2016 and 2026 to ascertain whether the incidents at Sydney Airport were localised or reflected a broader national trend.

Mr Mitchell said between July and August this year there had been 11 ground incidents reported at Sydney Airport, including the six currently under investigation.

Sydney also reported double the annual average of "information and procedural errors" compared to other major airports nationally, he said.

Mr Mitchell said "higher consequence incidents", such as runway incursions, taxiway collisions and losses of separation, had also increased post-COVID.

"Nationally, occurrence rates have remained steady over the past decade, at Sydney, however, ground conflictions attributed to ATC actions have increased since the COVID-19 recovery," he said. 

Mr Mitchell said challenges from COVID were still impacting operations, not only in Australia but globally.

"It's not just these incidents, we have seen those impacts at times with delays in flights [and] at times some of the stressors within the system and the flow on effects."

Still safe to fly

A spokesperson for Airservices Australia said in a statement it would review the interim reports and the findings once the investigations were concluded, but "safety remains our number one priority".

"We will continue to work with the ATSB on their investigations and we will work closely with CASA (Civil Aviation Safety Authority) and the ATSB in regard to any improvements that can be applied," the spokesperson said. 

A spokesperson for CASA said Australia's aviation network and Sydney Airport remained safe. 

"Having reviewed the ATSB's preliminary reports, CASA remains of the view that none of the incidents indicate and immediate safety risk. If action was needed, it would have been taken," the spokesperson said. 

"While the ATSB continues its investigation and analysis, CASA is undertaking a safety assurance review focusing on whether there are underlying operational or system issues that could affect safety." 

Federal Minister for Infrastructure and Transport, Catherine King, said the preliminary reports highlighted that every opportunity should be taken to improve aviation safety.

"Addressing operational and workforce challenges is critical to ensuring safe, reliable and resilient air traffic control services for the flying public," she said.

"This is why the government established the Sydney Airport Air Traffic Control Working Group, which brings together government, industry, workforce and regulatory stakeholders."

The final findings on the July 27 incident, as well as the two on August 9 and August 18, could take up to 12 months to be delivered.