Aviation safety investigations & reports

Boeing 737-376, VH-TAZ, Mackay QLD, 9 August 1990

Investigation number:
199003410
Status: Completed
Investigation completed

Summary

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The operator submitted an ICAO format flight plan direct to the Civil Aviation Authority (CAA) telecommunications network on the evening prior to the flight. This flight plan took into account a temporary change of routes in the Mackay area due to decommissioning of the Mackay VHF omni-directional radio range (VOR). The operator also advised the CAA Mackay briefing office of the sectors to be flown by the crew who would obtain briefing at Mackay. When the crew arrived for briefing the Briefing Officer had a set of notams and flight sector sheets available for collection. The crew advised him that they would be using the plan submitted by their company. The sectors for the crew that day were Mackay - Rockhampton - Brisbane - Townsville - Brisbane. All legs were flown uneventfully until the Townsville - Brisbane sector. The clearance for the aircraft was to track Townsville - Bowen then planned route. Radar coverage from Townsville is lost at 90 nautical miles just prior to Bowen. The aircraft was flown from Bowen to Mackay with the next point being Corio instead of Bowen to Hamilton Island then to Corio. The error was detected when the Hamilton Island position report was requested by Townsville Control. The investigation disclosed that the crew did not read the Notams received at Mackay. Those Notams contained a typed note concerning amended routes around Mackay due to decommissioning of the Mackay VOR and readers were directed to a Brisbane FIR Notam number 3600. That Notam was not in the package given to the crew. In any event it had been superseded by Brisbane FIR Notam 3667 on 1 August and it was not given to the crew either. The company navigation officer is responsible for the routes flown by company aircraft. He had ensured that the flight plans relating to flights around Mackay took the amended routes into account. The pilots have two other sources of route data available. These are the flight planning books available at each CAA briefing office and the Flight Management Computer (FMC) sector details programmed into each aircraft. Neither of these were altered due to the effort required and the temporary nature of the changed routes. The only route effectively altered by the changes was the tracking of flights between Townsville and Hamilton Island instead of Townsville and Mackay. When the crew were checking the legs in the FMC on the ground at Townsville they used the sheet given to them by the Mackay briefing officer. Since this agreed with the FMC legs they had no reason to question the planned route. Had the flight plan been used as a check the different track would have been noted.

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General details
Date: 09 August 1990   Investigation status: Completed  
Time: 1232    
Location: Mackay    
State: Queensland   Occurrence type: Miscellaneous - Other  
Release date: 10 October 1990   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737  
Aircraft registration VH-TAZ  
Serial number 23491  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Townsville QLD  
Departure time 1209  
Destination Brisbane QLD