LEVEL 3 Final report

Based on the investigation authority's final report.

Date
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Occurrence
Runway incursion and near collision
Location
Runway 14, Mackay Airport, Queensland
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Operator
Sharp Airlines
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Aircraft
Fairchild Industries SA227-DC
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Registration
VH-HPE
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Route
Mackay to Brisbane, scheduled freight
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People aboard
1 pilot; no passengers
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Casualties
No injuries; no aircraft damage
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Topics
Operational risk assessment, Runway incursion, Radio communication, Situational awareness, Electronic-device distraction

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Photographs and geographic context

Cockpit radio controls in a representative photograph

Representative cockpit radio photograph credited on the official report cover to Chris Leipelt, Public Domain.

Photo: Chris Leipelt, Public domain, as explicitly credited by the ATSB

Image info

Generic cockpit context, not VH-HPE and not a photograph of the occurrence. The report does not specify when the photograph was taken.

Image source

Embedded cover JPEG extracted from the report; retained without cropping. Responsive WebP copies resized without cropping.

Geographic context

Geographical orientation for Sharp Airlines 161: runway near collision at MackayMackay departure; Brisbane intended destination. Schematic approximate airport markers, not a recorded flight track or navigation chart. Route names are documented in the report.12NORTH UP / SCHEMATIC / NOT A RECORDED FLIGHT TRACK
  1. Mackay departure
  2. Brisbane intended destination
Schematic approximate airport markers, not a recorded flight track or navigation chart. Route names are documented in the report. Basemap: Natural Earth, public domain.
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What happened

A runway inspection vehicle escaped onto a taxiway about five seconds before a departing cargo aircraft rotated nearby. Radio clarity and incomplete visual checks left neither participant aware of the conflict.

Read the full incident Follow what happened, from the flight to the investigation findings.

What investigators concluded

ATSB found poor radio broadcasts, lack of runway confirmation after an unidentified light, and incomplete scanning and listening by the vehicle driver contributed. Separate safety issues concerned electronic-device guidance and formal assessment of non-controlled-airport hazards.

Evidence behind this explanation

The full incident

1,611 words / about 8 minutes to read. Based on the investigation records cited below.

The departure that slipped beyond tower hours

On the evening of 12 November 2025, a Sharp Airlines Fairchild SA227-DC was due to fly scheduled freight from Mackay to Brisbane. The aircraft, registered VH-HPE, carried a single pilot and no passengers. Its planned departure was 19:55 local time, but the flight plan had been inadvertently cancelled. The pilot had to resolve the problem with Mackay Tower and resubmit details. The resulting delay of around thirty minutes changed the setting for the departure: by the time the aircraft was ready, the tower had closed.

Mackay was then operating on a common traffic advisory frequency, or CTAF. Rather than receiving runway instructions from a tower controller, pilots and authorised vehicle drivers used radio broadcasts and visual checks to coordinate their movements. The pilot selected the Mackay CTAF on the aircraft's second communications radio and kept Brisbane Centre on the first. That division let the pilot monitor local movements and obtain air traffic information, but it also meant two streams of broadcasts could be heard during the preparation for takeoff.

At the same time an airport safety officer was waiting in a vehicle, callsign Car 1, near the runway. The driver intended to inspect the runway after another scheduled aircraft had departed and before a later arrival. Sharp's delay made its departure less consistent with the driver's expectations. No accident had yet occurred, but the pilot and driver were about to use the same runway without sharing an accurate picture of each other's position. The investigation would trace that breakdown through radio clarity, visual attention, electronic-device use and organisational procedures.

Sources for this section

Two people, two incomplete pictures

The aircraft taxied from the western general aviation apron towards runway 14. A review of the recordings found that the pilot's taxi broadcast was barely audible. It also contained incorrect information, including a wrong flight number and holding point, and did not identify Mackay at the start. The pilot later broadcast that the aircraft was entering and backtracking the runway. That call was also difficult to hear. Meanwhile, Car 1 remained at the Bravo holding point for about five minutes while the aircraft moved to the departure threshold.

The driver heard the preceding aircraft's departure call but did not see Sharp enter and backtrack the runway. The driver had opened a runway-inspection form on a company-issued iPad before entering. The ATSB found evidence that the form was opened one second before Sharp's lining-up call on the Brisbane Centre frequency. It considered distraction from the device possible, while also accounting for the driver's expectation that Sharp would not be departing at that time. The finding does not require inventing exactly where the driver was looking at every instant.

At 20:29:45, Sharp's pilot told Brisbane Centre that the aircraft was lining up on runway 14 at Mackay. That transmission was audible despite the wrong flight number. A little later the pilot broadcast on the CTAF that the aircraft was rolling, then worked through a six-item line-up checklist. During the checklist a flash of light appeared at the other end of the runway. The pilot paused to identify it but could not determine its source. Having lost track of which checklist items were complete, the pilot restarted the checklist instead of confirming on the radio whether something was on the runway.

Sources for this section

A vehicle on the runway as takeoff began

At 20:30:21, as the aircraft's engine power increased, Car 1's driver broadcast that the vehicle was entering runway 14. Recordings showed that this transmission was of good quality. The pilot did not hear it. Around twenty seconds later the vehicle crossed the holding point, and about ten seconds after that the aircraft began moving. The driver was now inspecting the runway while the aircraft accelerated towards the same area. Neither had identified the conflict before entering this stage of the sequence.

The driver subsequently saw a light but initially wondered whether it belonged to a vehicle on a road behind the runway threshold. That uncertainty was not resolved with a radio call. As the inspection vehicle approached the area between the Bravo and Juliet taxiways, the driver recognised the approaching aircraft. CCTV showed a noticeable increase in the vehicle's speed. The driver moved towards the runway edge, accelerated and headed for the Juliet exit. The conflict had moved from a planning and communication problem to an immediate physical escape.

The pilot reported seeing two lights as the aircraft passed approximately 100 knots. They blended with the runway edge lights and were hard to distinguish. The pilot only realised they were vehicle headlights as rotation approached and the vehicle was leaving the runway. About five seconds after Car 1 exited, the aircraft rotated adjacent to that taxiway. The aircraft then departed without contact or damage, and the pilot and driver exchanged clear radio calls about what had happened. There were no injuries, but this was a near collision during a high-speed takeoff, rather than routine low-speed contact on an apron.

Sources for this section

Why the broadcasts did not provide protection

The ATSB examined recordings from the airport and rescue-service receivers, Brisbane Centre communications, the aircraft's flight data recorder and CCTV. The cockpit voice recording was not obtained because it would have been overwritten. Those sources supported the sequence of calls and movements but did not provide an uninterrupted recording of everything heard or said inside the cockpit. The investigation therefore combined physical recordings with the pilot's and driver's accounts, qualifying conclusions where the evidence did not settle them.

The Metroliner had two VHF antennas: one on top of the aircraft and one underneath. The second radio used the underside antenna. Broadcasts made from the ground using that radio were difficult to understand, while those made after the aircraft became airborne were clear. The ATSB concluded that the ground-facing antenna reduced signal strength through shielding by the aircraft. Rapid speech and non-standard phraseology added to the problem. No fault was subsequently reported with the second radio or its antenna, so the findings did not reduce the incident to a broken radio.

The driver's entering-runway broadcast was clearly recorded, yet that did not establish that it reached the pilot with the same clarity. Reception through the lower antenna was likely reduced, and concurrent traffic on the Brisbane Centre frequency added another stream of information. The pilot confirmed being able to hear both frequencies simultaneously. On the driver's side, transmissions were present but lacked clear, expected cues identifying Mackay. The investigation explains that poor clarity, competing attention and expectation could make relevant information fail to register. It retains 'likely' and 'possibly' because the actual processing of each call cannot be directly reconstructed.

Sources for this section

The checks that were missed

The investigation's contributing factors addressed both participants. The pilot did not confirm that the runway was clear after the unidentified flash of light. The driver did not scan for aircraft ground movements or maintain a constant radio listening watch before entering an occupied runway. Possible iPad distraction and the expectation of a different departure time contributed to the ATSB's explanation of the driver's incomplete awareness. Neither finding means the safety system was simply absent. Calls were made, lighting was visible and each person had procedures, but those protections did not establish shared awareness before takeoff.

The organisational findings were separate from those immediate actions. Mackay Airport had provided iPads to safety officers for useful operational purposes, including forms and movement information. It had not given specific guidance to prevent unintended consequences such as distraction. Sharp Airlines had identified hazards at uncontrolled airports, but had not formally assessed known hazards in its risk register as required by its safety management system. Discussions in safety meetings were not supported by minutes or a formal evaluation trail.

Those issues matter because correcting one person's broadcast would not necessarily correct the underlying process. A device can assist a runway inspection while competing with the visual and listening tasks needed to enter safely. Likewise, discussing a known hazard does not establish that its severity has been assessed, that mitigation is documented or that different crews understand the same precautions. The ATSB classified these as other factors that increased risk, including safety issues, rather than presenting them as individually proven causes of the vehicle and aircraft reaching the same runway.

Sources for this section

Actions recorded in the final report

Sharp Airlines investigated the occurrence and issued an advisory stressing effective radio communication. It reviewed its risk register and introduced a procedure to document discussion of hazards in safety meetings. In response to the draft report, it also assessed antenna placement and radio selection during operations at uncontrolled aerodromes and incorporated that detail into the register. The ATSB welcomed those measures and recorded the corresponding safety issue as closed and adequately addressed at the time of publication.

Mackay Airport updated human-factors training, reviewed runway and taxiway procedures and checked the radios in its airside vehicles. Tests confirmed that those vehicle radios were fully functional. The safety issue concerning electronic-device use was also recorded as closed and adequately addressed. The report's justification describes prohibiting electronic devices while in vehicles on manoeuvring areas, alongside additional human-factors training and annual refresher training. These are the actions and assessments recorded in the final report, not a statement that this page independently audited later airport operations.

The central sequence ended in seconds: the driver recognised the aircraft, accelerated to the runway exit, and the aircraft rotated shortly afterwards. The report supports that narrow temporal margin without establishing a precise closest separation in metres or an unavoidable crash if one action had been delayed. That distinction preserves both the seriousness of the occurrence and the limits of the evidence. A scheduled cargo flight, no injuries and no damage can still belong in a collection of significant airline close calls when official evidence documents a runway near collision at takeoff speed. Here the final investigation explains how ordinary tasks and incomplete cues aligned, and how the two organisations responded.

Sources for this section

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How the sequence developed

Follow the main stages, then open the evidence beneath each step.

  1. Late departure

    The flight departed after tower closure, using CTAF coordination.

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  2. Incomplete shared picture

    Poor broadcasts and missed checks left the runway conflict unrecognised.

    Read supporting evidence
  3. Vehicle entry

    The car inspected the runway while the aircraft began its takeoff.

    Read supporting evidence
  4. Escape before rotation

    The driver accelerated off the runway, with aircraft rotation about five seconds later.

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A simplified reading of the investigation findings. The sequence does not replace the full report or imply that every contributing factor is shown.

Sequence of events

All occurrence times are Australian Eastern Standard Time, UTC plus ten hours. Expand an event to see its evidence.

  1. 19:55 plannedFreight departure delayed

    An inadvertently cancelled flight plan delayed departure until after tower closure.

  2. 20:29:45Line-up broadcast
  3. 20:30:21Vehicle broadcast
  4. Takeoff rollConflict develops
  5. Vehicle escapeDriver accelerates
  6. About five seconds laterRotation

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Questions readers ask

Was this ordinary ground handling?

No. It was a documented runway near collision during a scheduled cargo aircraft takeoff, with the driver taking immediate escape action.

Was a broken radio identified?

The report states no faults were found after the incident; antenna shielding, speech and phraseology explained poor ground transmissions.

Does five seconds give the exact collision margin?

No. It is the recorded interval between vehicle exit and nearby aircraft rotation, not a measured closest separation or a deterministic collision prediction.

What the evidence can and cannot establish

Safety follow-up

Actions and recommendations are described at the dates of the cited records. A recommendation is not proof of implementation.

Classifications, with reasons

These labels organise the evidence. They are not a ranking of causes. A shared label means a shared research topic, not an identical mechanism.

Initiating eventRunway incursion

A vehicle entered the occupied runway during the cargo departure.

Official contributing factorRadio communication

Rapid speech, non-standard phraseology and the lower antenna reduced clarity.

Official contributing factorSituational awareness

The pilot did not confirm the runway was clear and the driver did not maintain scanning and a listening watch.

Risk findingOperational risk assessment

Known non-controlled-airport hazards had not been formally assessed as the SMS required.

Risk findingElectronic-device distraction

The driver may have been distracted; absent device-use guidance was a separate organisational safety issue.

Read alongside

These comparisons connect specific research topics. Shared circumstances do not establish identical causes. Evidence from both investigations is provided below.

Air Canada Flight 624

Both investigations illustrate why incomplete cues can matter close to a runway. Mackay involved an unseen vehicle during takeoff and radio coordination; Air Canada 624 involved an approach below the intended path and collision with terrain. The common research question is cue interpretation, not a shared accident cause.

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TSB final reportComparison final-report findings | Printed page 74 | PDF page 82Find this passage in evidence search

Further investigation records

Explore the records below for additional context. They open on the publisher's site and are not all included in our report search. Source reuse terms apply.

  • Official final report

    ATSB / investigation and safety issues

    Adopted investigation, original page references and report-era safety actions.

  • Authority occurrence record

    ATSB / investigation and safety issues

    Authority report record and source provenance.

Sources and transparency

Prepared 7 October 2026 from the cited final investigation. Unpublished; editorial approval and independent expert review have not been completed.

Source limitations

No exact closest distance is established. Cockpit voice recording was overwritten; interpretations of attention and reception retain likely or possible wording. No injury or aircraft damage occurred.

Runway incursion and near collision involving Fairchild SA227-DC, VH-HPE, and an airport safety vehicle, at Mackay Airport, Queensland, on 12 November 2025

ATSB
Official final report; cached original bytes and complete extraction checked 7 October 2026

Official report PDF, hosted by atsb.gov.au

Open source document

Retrieved 5 October 2026. 33 PDF pages. 973,579 bytes.

File fingerprint (SHA-256). It identifies the exact version of the report this page was checked against.

92283c7fa6073ebe2ad00414b9b9327cd3072d69cac74a64fa731429d08d34fa

Source used for original commentary and short verification snippets; illustrations not reused unless separately licensed. Source terms / provenance.

Aviation Investigation Report A15H0002: Collision with terrain, Air Canada, Airbus Industrie A320-211, C-FTJP, 29 March 2015

Transportation Safety Board of Canada
Final report, released 18 May 2017; current E-1 edition, ISBN 978-0-660-09980-4

Official report PDF, hosted by tsb.gc.ca

Open source document · Alternate source location

Retrieved 3 October 2026. 96 PDF pages. 1,551,525 bytes.

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7c8ef0f2ae38bcd22e9d5292caabb7a8224fc9e5fa96de7d08ec2ae4e9ba873c

Non-commercial excerpts, attributed to the TSB and linked to the original version. No TSB endorsement. Third-party illustrations excluded. The TSB terms page was unavailable during the final link check.

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Editorial record

Kevin Murphy writes the incident accounts on AirlineIncidents.com, out of a long interest in aviation safety and the lessons each investigation leaves behind.

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