Aviation safety investigations & reports

Saab Aircraft AB SF-340B, VH-KDQ

Investigation number:
199901070
Status: Completed
Investigation completed

Summary

A Saab SF-340B (Saab) was conducting a scheduled passenger service from Canberra to Sydney and had been assigned descent to 7,000 ft by the Approach South radar controller in order to maintain the minimum vertical separation standard of 1,000 ft, between the Saab and a Piper Chieftain. The Chieftain was ahead in the approach sequence and had been assigned descent to 6,000 ft. The two aircraft were separated laterally by distances greater than the minimum radar separation standard of 3 NM, but their respective tracks were converging.

The controller requested the Saab crew to expedite descent to 7,000 ft. That instruction was read back by the pilot in command, however, the readback was indistinct. The controller repeated the request "Expedite descent to 7,000 ft". The pilot in command acknowledged that transmission with the aircraft's callsign. Shortly after, the controller observed that the altitude readout for the Saab was indicating that the aircraft was descending through 7,000 ft. The controller queried the Saab crew to confirm that they were maintaining 7,000 ft, then instructed the crew to turn left onto a heading of 360 degrees due to the traffic ahead. As the crew responded to that instruction, the lateral and vertical separation between the Saab and the Chieftain reduced to 1.5 NM and 500 ft respectively.

The traffic sequence had been busy, with the controller endeavouring to change the landing sequence by placing the Saab ahead of the Chieftain. The controller was required to monitor the lateral and vertical separation between a number of aircraft as two standard arrival routes converged. As a consequence, the controller was required to establish vertical separation to ensure separation was maintained between all aircraft as they approached an area of lateral conflict.

All radio transmissions between the controller and the Saab were recorded. A review of the recorded information indicated that the altitudes assigned by the controller, and the readbacks from the Saab crew, were clear and distinct except for the response to the controller's initial request to expedite descent. The Saab crew were unable to explain why they were not alerted to the possibility of an incorrect altitude following the controller's reiteration of the request to expedite descent to 7,000 ft.

The Aeronautical Information Publication GEN 3.4-10 paragraph 4.4 details readback requirements for flight crew. For other than a route clearance, "the key elements of clearances, instructions or information must be read back ensuring sufficient detail is included to clearly indicate compliance". A level instruction must be read back. In this occurrence, the controller did not expect a readback of the altitude, because the previously assigned altitude had not changed. The indistinct response from the Saab crew caused the controller to doubt that his request had been understood, so he repeated the request. When that transmission was acknowledged by the pilot in command, the controller believed that the crew now understood his request to expedite descent to 7,000 ft.

The Saab crew believed that an altitude clearance of 6,000 ft had been issued between the time the controller assigned them 7,000 ft, and when the controller requested that they expedite descent to 7,000 ft. However, the recorded transmissions did not include any reference to 6,000 ft directed to, or received from, the Saab crew during that period.

General details
Date: 17 March 1999   Investigation status: Completed  
Time: 0839 hours ESuT    
Location   (show map): 28 km WSW Sydney, (VOR)    
State: New South Wales   Occurrence type: Loss of separation  
Release date: 27 April 1999   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer S.A.A.B. Aircraft Co  
Aircraft model 340  
Aircraft registration VH-KDQ  
Serial number 340B-325  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Canberra,, ACT  
Destination Sydney, NSW  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-31  
Aircraft registration VH-JVD  
Serial number 31-7852041  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Shepparton, VIC  
Destination Sydney, NSW  
Last update 13 May 2014