Aviation safety investigations & reports

Loss of separation Boeing 767, N601EV and a Boeing 747, 9M-MPD, 9 km S Bindook, NSW, 21 September 1998

Investigation number:
199803921
Status: Completed
Investigation completed

Summary

Air traffic control had issued the crew of a foreign Boeing 767 (B767) with an instruction to hold at Bindook. Although the published holding procedure required a left pattern, the crew turned the aircraft for a right pattern. The right turn subsequently placed the aircraft into conflict with a Boeing 747, which was being radar vectored to the south of Bindook. Separation was reduced to approximately 700 ft vertically, and 4 NM laterally. The required separation standard was 1,000 ft, or 5 NM.

An investigation revealed that the crew did not locate the holding pattern on the Jeppesen terminal chart. The depiction of the holding pattern was difficult to distinguish from other markings on the chart and the pattern was not displayed on the appropriate Standard Arrival Route (STAR) chart. In addition, the holding pattern was not loaded in the aircraft's flight management computer database. The Captain of the B767 reported that in the USA, where a holding pattern is not displayed, or in the absence of other information, a "default" right hand pattern is to be flown. There is no such procedure in Australia. As a result, the Captain elected to fly a right hand pattern without checking with air traffic control for holding pattern information.

Safety Action

Local Safety Action

The airline has issued a fleet notice to B767 crews, reminding pilots to be more vigilant when flying into Sydney, and alerting them to the inadequacy of holding information.

BASI Safety Action

As a result of this occurrence, the Bureau of Air Safety Investigation is currently investigating a perceived safety deficiency.

The deficiency relates to the depiction of holding patterns on en-route charts, the appropriateness of the use of non-standard holding patterns, and associated radiotelephony phraseology.

Any safety output issued as a result of this analysis will be published in the Bureau's Quarterly Safety Deficiency Report.

General details
Date: 21 September 1998   Investigation status: Completed  
Time: 0822 hours EST    
Location   (show map): 9 km S Bindook    
State: New South Wales   Occurrence type: Loss of separation  
Release date: 17 August 1999   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer The Boeing Company  
Aircraft model 767  
Aircraft registration N601EV  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Taipei, TAIWAN  
Destination Sydney, NSW  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer The Boeing Company  
Aircraft model 747  
Aircraft registration 9M-MPD  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Melbourne, VIC  
Destination Sydney, NSW  
Last update 13 May 2014