Aviation safety investigations & reports

British Aerospace Plc AVRO 146-RJ70A , VH-NJW

Investigation number:
Status: Completed
Investigation completed


Prior to departure from Sydney, the crew received a Norfolk Island weather forecast that indicated conditions should be suitable for a night visual approach. Consequently, just before descent, the pilot in command reviewed the visual approach procedures. During the descent, the Norfolk Island unicom service advised that there were rain showers in the area. Subsequently, the crew conducted a night visual approach in weather conditions where the visibility had reduced to approximately 8,000 m in drizzle and isolated low cloud. Sufficient fuel existed for the crew to divert to Noumea if necessary.

During the latter stages of the approach, the co-pilot assessed the in-flight weather as unsuitable for a night visual approach and assumed that the pilot in command shared this view. As the approach was continued, the co-pilot attempted on a number of occasions to communicate his concern to the pilot in command. However, the pilot in command initiated no significant rectifying action and continued the approach. When the runway lighting was sighted at approximately 2NM on final the visual approach slope indicator system (VASIS) indicated a three-lights fly-up. After the aircraft was safely landed, the pilot in command and co-pilot discussed the conduct of the approach. The pilot in command was somewhat surprised at the level of the co-pilot's concern.

An amended Norfolk Island terminal area forecast (TAF) had been issued during the time of the aircraft's approach, indicating a deterioration in the weather. However, due to the time required to complete normal processing procedures involved in relaying the information to the crew, they did not receive this update.

The operator reported that some deficiencies existed in aspects of crew coordination, and the pilot in command's knowledge of night visual approach procedures. The operator indicated that those issues would be addressed. The pilot in command subsequently commenced a substantial program of training, to be followed by a check before returning to line operations.

The pilot in command and co-pilot had flown together frequently for the preceding two years, both at Norfolk Island and at a previous basing in Australia. Since commencing employment with this operator, neither the pilot in command nor the co-pilot had received crew resource management (CRM) training, despite that being an assessable item of crew line and currency checks. The operator considered the occurrence to be an isolated human performance event. The safety regulator had not promulgated specific guidance regarding crew resource management training to operators engaged in multi-crew air transport operations.


Although the crew had briefed a night visual approach to Norfolk Island, the unicom advice regarding rain showers in the area was clearly inconsistent with the forecast they held. Investigation of the occurrence identified cockpit crew coordination deficiencies that included ineffective question-and-answer communications, and crewmembers performing tasks in isolation. The crew's performance during the approach might have been more effective had they acted in a manner consistent with recognised principles of crew resource management to ensure that all resources available to the crew were fully and effectively utilised. That the perceptions of the pilot in command and co-pilot were different was in itself an indication that there was a breakdown of communication and coordination between them.

The co-pilot believed that the pilot in command did not clearly communicate his approach intentions during the final approach phase. In effect, the co-pilot was left out of the pilot in command's decision-making loop. This generated a conflict in expectations between the pilot in command and co-pilot that was not resolved. As a result, and in view of the prevailing weather, the co-pilot became concerned for the safety of the operation.

The approach briefing was inadequate. As the crew had flown frequently together during the previous two years, they should have been very familiar with one another's usual practices. The pilot in command could have requested explicit feedback from the co-pilot to assess his understanding of the situation. The crew's familiarity with each other and their destination probably contributed to the brevity of the approach briefing.

The operator had not ensured a uniform standard of crew resource management across the company. Moreover, the safety regulator had not provided operators engaged in multi-crew air transport operations with specific guidance regarding crew resource management. Consequently, the operator was left to assess issues such as syllabus content, standard of training, qualifications of CRM assessors and frequency of assessment.

Significant Factors

  1. The pilot in command did not adequately convey his approach intentions to the co-pilot.
  2. The co-pilot, while concerned, did not adequately communicate his concerns to the pilot in command.

Safety Action

Local safety action

As a result of this investigation, the following safety actions were initiated by the operator:

  1. The operator advised that action would be taken to ensure a uniform standard of crew resource management across the company.
  2. The pilot in command was provided with additional training to address deficiencies in his knowledge of night visual approaches.

BASI safety action

As a result of investigations into a number of previous occurrences involving crew resource management issues, the Bureau issued interim recommendation IR950101 on 17 July 1995 to the Civil Aviation Safety Authority.

The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority (CASA) require operators involved in multi-crew air transport operations to ensure that pilots have received effective training in crew resource management (CRM) principles. To this end, the CASA should publish a timetable for the phased introduction of CRM training to ensure that:

  1. CRM principles are made an integral part of the operator's recurrent check and training program and where practicable, such training should be integrated with simulator LOFT exercises;
  2. the CASA provides operators and/or CRM course providers with an approved course syllabus based on international best practice;
  3. such training integrates cabin crew into appropriate aspects of the program; and
  4. the effectiveness of each course is assessed to the satisfaction of the CASA".

The following response was received from the Civil Aviation Safety Authority on 8 September 1995:

"I refer to your Interim Recommendation No IR950101 concerning the B747-312 accident at Sydney on 19 October 1994.

CASA fully endorses the principles of and accepts the benefits flowing from CRM and similar training as well as strongly encouraging such training for flight crew, cabin crew and other operating crew. However, CASA is not fully convinced that mandating CRM or similar training, particularly for high and low capacity RPT operations, will necessarily prevent or reduce the incidence of such accidents in the future.

Nonetheless, CASA is willing to further investigate CRM training including the position taken by leading overseas regulatory authorities in this regard, particularly in relation to high and low capacity RPT operations. To this end, CASA intends to consider the issue as part of a major project to commence in the latter part of 1995. This project is to review all aspects of RPT operations conducted under CAR 217 in relation to Training and Checking organisations and is the first major review of such operations to be carried out for some time.

CASA undertakes to advise BASI of the outcome of that review in relation to CRM and similar training".



The following response was received from the Civil Aviation Safety Authority on 26 February 1997, and stated in part:

"I refer to BASI Interim Recommendation IR950101 and the Civil Aviation Safety Authority responses of September 1995 and January 1996.

My purpose in writing is to provide you with a formal update on the CASA position on this recommendation. I understand that the CASA General Manager Flying Operations informally conveyed this position to Director BASI earlier this year and sought from him copies of up to date material on crew resource management (CRM) training acquired by BASI at a recent Orient Airlines Association seminar. The CASA position for publication is shown in the quotes below."

"After further review along the lines indicated in our response of 8 September 1995, CASA agrees that regulations should be introduced requiring operators engaged in multi-crew air transport operations to have effective crew resource management training programs.

This is one of the tasks being actioned by the Air Transport Technical Committee of CASA's Regulatory Framework Program. The crew training project team working under that committee, which includes representatives from industry, is also considering introduction of other best practice initiatives such as the Advanced Qualification Program (AQP) introduced by the FAA and the New Zealand CAA. Introduction of any new legislation on these matters is of course subject to requirements for appropriate consultation with industry. The RFP has a timetable to complete and publish a new set of Civil Aviation Safety Regulations (CASRs) and associated advisory material by the end of 1998. However, where possible new CASRs will be introduced progressively before that date."


"I would also like to take this opportunity to invite BASI to provide a human factors qualified observer/adviser to assist the project team developing the CRM/AQP regulations and advisory material."

Response classification: CLOSED - ACCEPTED

CASA has since issued a Notice of Proposed Rulemaking (NPRM9809RP) on regulations relating to passenger and crew-member safety. Whilst all aircraft operators and crew members will be affected to some degree by the NPRM, the principal thrust of the proposed changes is to "upgrade safety with respect to the carriage of fare-paying passengers in aircraft requiring the carriage of cabin crew". This implies that the NPRM is largely directed toward multi-crew operations in passenger-carrying aircraft. Section 121.YY of the NPRM refers to crew-member emergency procedures training. Each operator will be required to conduct initial and ongoing CRM training for each crew-member position required for a particular aircraft type.

On 16 September 1999 the Bureau received the following advice from CASA regarding CRM training and the date of introduction of CASR Part 121A:

"It is not anticipated that new Part 121A will be effective before 1 January 2002. However, CASA is aware of the importance of CRM training for crew members and will be issuing a policy that will require operators to conduct such training. This policy will be issued in advance of the introduction of the new regulations and is expected to be in place by 1 July 2000."

The Bureau is currently monitoring implementation of IR950101.

General details
Date: 08 July 1998   Investigation status: Completed  
Time: 1200 hours UTC    
Location   (show map): 9 km WNW Norfolk Island, Aero.    
State: New South Wales    
Release date: 01 October 1999   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer British Aerospace PLC  
Aircraft model AVRO 146  
Aircraft registration VH-NJW  
Serial number E1223  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Destination Norfolk Island  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 4415.0 11100
Last update 13 May 2014