Aviation safety investigations & reports

British Aerospace Plc 3201 , VH-XFC 9 km NNE of Brisbane, 28 July 1999

Investigation number:
199903602
Status: Completed
Investigation completed

Summary

There were three aircraft in the approach sequence to land on runway 19 at Brisbane: a British Aerospace 146 (BAe 146), VH-JJS, on final at 2 NM; a British Aerospace Jetstream 3200 (Jetstream), VH-XFC, on right base at 6.5 NM with approximately 8 track-miles to touchdown; and a Fairchild SA226 Metroliner (Metroliner), VH-TFQ, on an oblique left base at 6.5 NM with approximately 10.5 track-miles to touchdown. Analysis of recorded voice data confirmed that the approach controller advised the crew of the Metroliner that they were number 3 in the sequence and that the Jetstream was number 2. Subsequent to that advice, the controller advised the Metroliner crew that the aircraft they were to follow was at 11 o'clock, 10 NM at 1600 ft. They were instructed to report when they could see that aircraft. The crew responded "Traffic sighted". The crew of the Metroliner was then assigned responsibility for separation from the Jetstream by being cleared to manoeuvre as required to make a visual approach and to "follow the Jetstream". In the same transmission, the crew were cautioned about the BAe 146 "on a very short final runway 19" and instructed to contact the tower.

When the crew transferred to the tower frequency, the aerodrome controller realised that the Metroliner was following the wrong aircraft, the BAe 146, and could be in conflict with the Jetstream. The controller instructed the Metroliner crew to orbit their aircraft on left base to increase its separation with the Jetstream. Analysis of recorded radar data indicated that separation between the Metroliner and the Jetstream had reduced to 1.2 NM when they were at the same level.

The crew of the Metroliner did not recall being cautioned about the 146. The aircraft they had sighted and followed was not the Jetstream but the BAe 146, which resulted in the breakdown of separation.

The Manual of Air Traffic Services (MATS) stated in MATS 4-5-1, paragraph 7:

"Correct identification of the aircraft from which separation must be maintained is essential".

Paragraph 10 stated:

"The traffic information provided shall contain as much as is necessary of the following to assist the pilot in identifying the other aircraft:
  1. type, and description if unfamiliar;
  2. level;
  3. position information either by clock reference, bearing and distance, relation to a geographical point, reported position and estimate, or position in circuit;
  4. intentions, or direction in flight."

Analysis of the radar data indicated that at the time the crew was asked to report sighting the aircraft, the BAe 146 was in the Metroliner's 11 o'clock relative position at 6.8 NM and displayed an oblique, side profile. The position of the Jetstream was more to the Metroliner's 12 o'clock relative position, at 9.8 NM and displayed a head-on profile.

Analysis

Notwithstanding the different profiles of the two aircraft, type identification of either aircraft would have been virtually impossible to determine at the ranges of the aircraft, that is beyond 6.8 NM. This is because contrast, which is the difference between the brightness of the aircraft against the brightness of the background, reduces with increasing range. Further, target identification would have been hampered by contour interaction. This phenomenon occurs where the outline of a target aircraft interacts with the contours present in the background. This is a particular problem at lower altitudes where aircraft appear against complex backgrounds.

When the crew of the Metroliner was instructed to report when they could see the other aircraft at 11 o'clock, the BAe 146 was the only aircraft discernible to them. With its side profile, the BAe 146 was at the extreme limit of visual acuity and could easily have been mistaken for a Jetstream, particularly as no other aircraft was in their field of vision. The Jetstream, with its head-on profile and greater range, would have been impossible to see at 9.8 NM. Moreover, because its actual position was not correctly described to the crew, they were looking for the Jetstream in the wrong place.

The approach controller may have realised that there was potential for mis-identification of the two aircraft. This is suggested by his action of cautioning the Metroliner crew about the BAe 146 that was on short final. However, the controller did not provide additional information that would have provided an assurance that the pilot was following the correct aircraft.

The identification of the potential conflict and action taken by the aerodrome controller was timely and appropriate. The vigilance and prompt action of the aerodrome controller acted as a safety defence to reduce the possibility of collision between the aircraft.

Significant Factors

  1. The approach controller used the "sight and follow procedure" in an inappropriate circumstance. That is, the controller transferred the responsibility for separation to the pilot in a situation where the positive application of a separation standard may have been more appropriate.
  2. The approach controller requested the crew of the Metroliner to sight the Jetstream in circumstances where a positive sighting may have been improbable.
  3. The crew of the Metroliner sighted and followed the BAe 146 rather than the Jetstream

Safety Action

Local safety action

The Airservices Australia investigator made the following recommendations:

"The MORETON GROUP Leader to include the application of the "Sight & Follow" procedure as a specific subject in all future Refresher Training programs with case studies for analysis. (e.g. the practicality of sighting traffic same level eleven o'clock at ten miles in a period of high cockpit workload.)

Consideration given to include in MATS 4-5-1 para 10 specific reference to "---their number in the landing sequence ----" and not limit this reference to same page, para 15, second sentence under the title of Visual Separation by Aerodrome Controllers."

Australian Transport Safety Bureau safety action

As a result of this occurrence the Australian Transport Safety Bureau (formerly BASI) is currently investigating a safety deficiency. The deficiency relates to the training provided to Airservices Australia's approach controllers, in particular human factors awareness training on the limitations of human performance.

General details
Date: 28 July 1999   Investigation status: Completed  
Time: 0935 hours EST    
Location   (show map): 9 km NNE Brisbane, Aero    
State: Queensland   Occurrence type: Loss of separation  
Release date: 12 May 2000   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer British Aerospace PLC  
Aircraft model 3200  
Aircraft registration VH-XFC  
Serial number 949  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Roma, QLD  
Destination Brisbane, QLD  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Fairchild Industries Inc  
Aircraft model SA226  
Aircraft registration VH-TFQ  
Serial number TC-395  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Coolangatta, QLD  
Destination Brisbane, QLD  

Aircraft 3 details

Aircraft 3 details
Aircraft manufacturer British Aerospace PLC  
Aircraft model BAe 146  
Aircraft registration VH-JJS  
Serial number E2093  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Unknown  
Destination Brisbane, QLD  
Last update 13 May 2014