QantasLink Dash 8 Lined Up on Runway Lights at Mildura

The Australian Transport Safety Bureau (ATSB) has released its final report, ATSB investigation AO-2025-008, into a serious incident involving a QantasLink Dash 8 at Mildura Airport. The investigation details how the aircraft inadvertently lined up with and struck runway edge lights during a take-off in dark conditions. The findings highlight the critical role of human factors, particularly crew distraction during pre-flight checks, in the Mildura Airport misaligned take-off.

The incident, which occurred on February 25, 2025, involved a QantasLink De Havilland Canada (DHC) DHC-8-315, registration VH-TQM. During the take-off roll before first light, the flight crew misaligned the aircraft with the runway, causing it to contact and damage five runway edge lights. The crew, unaware of the full extent of the misalignment, continued the flight to Melbourne, where they conducted a low pass for a visual inspection before landing without further incident.

Investigation Findings

According to the ATSB, a key contributing factor was the flight crew's focus on conducting internal checks while turning onto the runway. This diverted their attention from crucial external visual cues needed for correct alignment in the low-light environment. ATSB Director of Transport Safety, Kerri Hughes, emphasized this point, stating that dark ambient conditions consistently reduce visual cues and that pilots must carefully consider the timing of checks when external monitoring is critical.

The investigation also noted that the captain returned a positive result for an unprescribed medication above the permitted threshold. However, an assessment by an independent forensic pharmacologist, cited in the report, concluded that impairment was not expected given the dosage and time elapsed. The ATSB determined that the medication was unlikely to have been a contributing factor to the incident.

During the subsequent low pass at Melbourne to check for damage, the aircraft descended to a minimum of 134 feet above the ground, which was below the crew's briefed minimum safe altitude of 200 feet. This deviation was also noted in the final report as a procedural issue.

A Pattern of Misaligned Take-offs

The QantasLink Dash 8 incident is not an isolated event. The ATSB report places it within a broader context of similar occurrences across Australia. The bureau referenced its investigation (AO-2023-027) into three separate misaligned take-offs at Perth Airport between June 2023 and April 2024, all of which occurred before first light. This pattern suggests a systemic risk associated with night operations where runway lighting can be misinterpreted without sufficient external vigilance.

Historical precedents also exist for the specific operator and aircraft type. On February 11, 2009, a QantasLink DHC-8 at Townsville Airport also struck a runway edge light after the captain misaligned the aircraft during the take-off roll, as detailed in ATSB investigation AO-2009-007. These recurring events underscore the challenges crews face in maintaining situational awareness during ground operations in low visibility.

Operator and Airport Response

In response to the findings, QantasLink has taken concrete safety actions. The airline updated its Flight Crew Operating Manual (FCOM) and issued a safety alert to all pilots. According to the ATSB, the new procedure explicitly prohibits the conduct of checks during runway end turns, ensuring crews can dedicate their full attention to aligning the aircraft. This change directly addresses the primary contributing factor identified in the investigation. QantasLink flight crews will also undergo enhanced human factors and non-technical skills training.

Mildura Airport has also implemented changes, updating supporting documentation for the runway 09 starter extension to improve flight crew awareness of the airfield's layout.

Fleet Modernization Context

The incident involved a DHC-8-315, part of an older fleet that QantasLink is actively replacing. According to a Qantas Group fleet update, the airline is phasing out its 19 Q200 and Q300 aircraft in favor of a more unified and efficient fleet of DHC-8-400s, commercially known as the Q400. The airline is adding 14 additional Q400s, which will bring its total Q400 fleet to 45. This move is aimed at improving reliability and reducing operational complexity.

DHC-8-300 vs DHC-8-400 (Q400): Key Specifications

What Comes Next

The safety actions taken by QantasLink and Mildura Airport are now in effect. The broader fleet transition is ongoing, with the Qantas Group confirming that the complete phase-out of the older Q200 and Q300 turboprop fleet is expected by the end of 2026. The investigation by the ATSB under the Transport Safety Investigation Act 2003 is now closed.

Why This Matters

This incident serves as a critical case study on the persistence of human factors challenges in modern aviation. It underscores that even routine procedures like lining up for take-off can present significant risks without strict adherence to sterile cockpit principles and maintaining situational awareness. For the industry, it reinforces the need for continuous training on threats present in low-visibility ground operations and highlights how procedural drift can lead to serious safety events.