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On 13 October 2010, a Boeing 717-200 (717), registered VH-NXD, was being operated by Cobham Aviation Services Australia, on a scheduled passenger flight from Perth to Kalgoorlie, Western Australia. On board were 97 passengers, three cabin crew and two flight crew.

During the approach to land on runway 29 at Kalgoorlie Airport, the stickshaker activated. The copilot, who was the pilot flying, reduced the aircraft's pitch angle and continued the turn onto final. About a minute later, the approach was no longer stabilised and the flight crew conducted a go-around. On the second approach to land and after turning onto final, the copilot noted that the aircraft was below the required profile. As the copilot increased the aircraft's pitch attitude, the stickshaker activated for about 2 seconds. Following recovery actions, a go-around was conducted. The third approach was conducted by the pilot in command at an airspeed that was about 15 kts higher than the previous approaches.

The investigation found that the stickshaker activations were primarily a result of an incorrect approach speed. The approach speed generated by the flight management system (FMS) was based on a landing weight that was 9,415 kg less than the aircraft's actual weight. Prior to departure, the flight crew had inadvertently entered the aircraft's operating weight in lieu of the aircraft's zero fuel weight (ZFW) into the FMS. The data entry error also influenced the aircraft's take-off weight (TOW) in the FMS. The error went unnoticed and did not manifest as an operational problem until the approach into Kalgoorlie.

The investigation identified several organisational issues that had the potential to adversely affect the safety of future operations. Those issues related to the format of the aircraft load sheet, the verification check by the flight crew of the TOW against the load sheet and the lack of an independent validation check of the FMS-generated landing weight. In response, the operator has made a number of enhancements to the format of the 717 load sheet, the FMS weight data entry and verification procedures, the weight validation checks and the 717 simulator training in respect of recovery from stickshaker activation.

The application of correct operating data is a foundational and critical element of flight safety. In January 2011, the ATSB released a research report titled Take-off performance calculation and entry errors: A global perspective.

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Safety issues

AO-2010-081-SI-01 - AO-2010-081-SI-02 - AO-2010-081-SI-03 - AO-2010-081-SI-04 -  

Load Sheet layout

The presentation on the aircraft load sheet of the zero fuel weight immediately below the operating weight, increased the risk of selecting the inapropriate figure for flight management system data entry.
Safety issue details
Issue number:AO-2010-081-SI-01
Who it affects:
Status:Adequately addressed


 

Take-off weight check procedure

The operator's procedure for confirming the validity of the flight management system generated take-off weight did not place sufficient emphasis on the check against the load sheet.

Safety issue details
Issue number:AO-2010-081-SI-02
Status:Adequately addressed


 

Validation of landing weight

The operators procedures did not include a validation check of the landing weight generated by the flight management system which resulted in lack of assurance that the approach and landing speeds were valid.
Safety issue details
Issue number:AO-2010-081-SI-03
Who it affects:
Status:Adequately addressed


 

Recurrent training

The operators recurrent simulator training did not address the recovery from a stall or stick shaker activation such that the ongoing competency of their flight crew was not assured.
Safety issue details
Issue number:AO-2010-081-SI-04
Who it affects:
Status:Adequately addressed

 
General details
Date: 13 October 2010 Investigation status: Completed 
Time: 1313 WST  
Location   (show map):Kalgoorlie Airport Investigation type: Occurrence Investigation 
State: Western Australia Occurrence type: Stall warning 
Release date: 09 February 2012 Occurrence class: Operational 
Report status: Final Occurrence category: Serious Incident 
 Highest injury level: None 
 
Aircraft details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 717 
Aircraft registration: VH-NXD 
Serial number: 55062 
Operator: Cobham Aviation 
Type of operation: Air Transport High Capacity 
Damage to aircraft: Nil 
Departure point:Perth, WA
Destination:Kalgoorlie, WA
 
 
 
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Last update 18 April 2018