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The ATSB's final report into the terrain proximity caution incident to the south-south-east of Canberra at 0544 am on 24 July 2004 has found that the flight crew of the Boeing 737 were affected by fatigue and they misinterpreted the instrument approach chart and entered incorrect data into the flight management computer.

The aircraft was being operated on an overnight service from Perth to Canberra, when it proceeded beyond the limits of the Church Creek Holding pattern, 10.9 NM south of Canberra. In doing so the crew manoeuvred the aircraft closer to terrain than intended. As a consequence the aircraft received a 'Caution Terrain' message from the aircraft's enhanced ground proximity warning system.

The crew had commenced a right turn back to the north towards Canberra shortly before the 'Caution Terrain' message. They then climbed the aircraft to a higher altitude.

The flight crew's fatigue was partly the result of an airconditioning fault that led to hot cockpit conditions from Perth to Canberra. Normal air traffic assistance was unavailable in Canberra until 40 minutes after the scheduled 0530 am opening time.

The aircraft operator has amended its procedures to require a higher altitude for aircraft holding to the south of Canberra and the chart publisher is amending charts to reduce the likelihood of misinterpretation.

The ATSB initiated a category 3 investigation, which was subsequently noted on the ATSB website in early August. The Bureau released a preliminary report on this occurrence on 22 September 2004.

The final ATSB investigation report ( Aviation Safety Investigation Report 200402747) can be downloaded from the website, or obtained from the ATSB by telephoning (02) 6274 6478 or 1800 020 616.

Media contact: 1800 020 616
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Last update 01 April 2011