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Safety Action


This report highlights the potential safety benefits of the Flight Safety Foundation ALAR Tool Kit, especially in regard to the conduct of non-precision approaches.

Local safety action

The operator has advised that a review of processes has been carried out and new procedures are in place to ensure that a similar incident does not occur again. Some of the changes were reported to have been in the process of being introduced at the time of the accident.

Reported changes included the following:

  • Appointment of new personnel to key operational roles
  • Creation of a position of Flight Training Manager
  • Creation of a position of Quality Assurance Manager - Engineering
  • Review of Flight Manual Supplements
  • Rewriting of the Flight Operations Manual
  • Issue of a standing order to all pilots that a go-around is to be conducted anytime on approach below 1,000 ft above ground level, if the approach is not stabilised and the sink rate is in excess of 1,000 fpm
  • Reviewing the use of radio altimeter in non-precision approaches
  • Rewriting of the Check and Training Manual
  • Development of a Quick Action Handbook to cover emergency procedures

At the time of the occurrence, replacement aircraft for the Sydney-based aeromedical service were on order. Specifications for the new aircraft included an Enhanced Ground Proximity Warning System. Those aircraft are now in service.

Airservices Australia is reviewing the Manual of Air Traffic Services to clarify and remove the ambiguity relating to descent restrictions for pilots conducting instrument approaches in IMC.

Appendix A: Coffs Harbour Runway 21 GPS NPA Approach diagram
Published with permission of Jeppesen Sanderson, Inc. - NOT TO BE USED FOR NAVIGATION.

Appendix B: Elements of a Stabilised Approach

Note: A suggested definition or policy that might be considered by operators could be as follows: "All flights shall be stabilised by 1,000 feet height above touchdown (HAT) in instrument meteorological conditions (IMC) and by 500 feet HAT in visual meteorological conditions (VMC)." An approach is considered stabilised when all of the following criteria are met:

  1. The aircraft is on the correct flight path
  2. Only small changes in heading and pitch are required to maintain that path
  3. The aircraft speed is not more than Vref + 20 knots indicated airspeed (KIAS) and not less than Vref
  4. The aircraft is in the proper landing configuration (approach configuration for small twins)
  5. Sink rate is maximum 1,000 feet per minute; if an approach requires a sink rate greater than 1,000 feet per minute, a special briefing is to be performed
  6. Power setting appropriate for configuration and not below the minimum power for approach as defined by the aircraft operations manual
  7. All briefings and checklists have been performed
  8. Specific types of approaches are considered stabilised if they also fulfil the following:
    • Instrument landing system (ILS) approaches - must be flown within one dot of the glideslope or localiser; a category II or III approach must be flown within the expanded localiser band.
    • Visual approaches - wings must be level on final when the aircraft reaches 500 feet HAT.
    • Circling approaches - wings must be level on final when aircraft reaches 300 feet HAT
  9. Unique approaches such as the 'old' Hong Kong airport, and the DCA (Washington, D.C.) river visual approach to Runway 18 require a special briefing

Source: Flight Safety Foundation Approach-and-Landing Accident Reduction Task Force.


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